Injuries

Achilles Tendinopathy

Nov 8, 2019

What is Achilles Tendinopathy?

A tendon is a tough band of connective tissue that connects muscle to bone and can become irritated with repetitive movements. The Achilles tendon is one of the longest tendons in the human body and spans from the heel bone to the calf muscles (Gastrocnemius & Soleus).

Achilles Tendinopathy is a chronic overuse injury affecting the Achilles tendon. It is an activity-limiting syndrome characterised by inflammation of the tendon and the presence of pain. The Achilles tendon has a high injury rate with repetitive, loaded movements such as running or jumping, and is almost always related to sport. This seems unusual considering the Achilles tendon is one of the longest and strongest tendons in the human body.

The Achilles tendon also has an avascular zone of about 2-6cm, which means it has very little blood supply. This makes it highly susceptible to injury – be it a tendinopathy or even full rupture.

How did I get it?

The nature of Achilles Tendinopathy is chronic, meaning that it occurs as a result of excessive, repetitive demands placed on the tendon by the muscle over time. It is said that runners have a 30 times greater risk of tendinopathy than sedentary individuals and this may be because the force of running on the body is eight times greater than that of body mass (yes, the human body is a powerful thing).

So, how did this injury actually happen? Answering ‘yes’ to any of these questions may give you an idea:

  • Are you a runner or are you involved in an activity or sport that requires repetitive jumping or running?
  • Have you increased your load or intensity of activity recently?
  • Have you just recently picked up running or another new or unfamiliar activity?
  • Have you recently returned to loading after a layoff period for another lower limb injury?

You should look out for the following signs and symptoms to help you determine whether or not your injury is Achilles tendon related:

  • Localised pain at the back of the foot just above the heel bone
  • Noticeable inflammation (swelling) or redness at the Achilles tendon
  • Tightness of the calf muscles
  • Pain with constricting shoes
  • Pain during activity or hours after activity in the form of a dull ache
  • Morning stiffness

How can I effectively prevent Achilles Tendinopathy?

Crucial to the prevention of Achilles Tendinopathy, is understanding what phase of prevention you fall into. In the acute setting, emphasis is drawn to reducing pain and inflammation, enabling the individual with movement. In the chronic phase the focus is shifted to support the damaged structure through bracing and activation of surrounding musculature.

In addition to the phases, you must understand the mechanics of the joint and the amount of activity that you are doing. Usually incorrect bodily mechanics either in isolation or coupled with a high activity load will require modification. Activity modification incorporates the inter-play between load, intensity and recovery. Not allowing the Gastrocnemius-Soleus complex enough time to recover, accelerates the risk of Achilles Tendinopathy. Stretching has been regarded as means of passive recovery of the damaged structure allowing the tendon and muscle fibres to assume a lengthened, relaxed state.

It is usually in acute phase that you should seek physical therapy to place the tissue under the correct stresses and rehabilitation, thus enhancing time to recovery and peak performance. Consultation with your Physician, Physiotherapist or Biokineticist is ideally the way forward once recognizing the signs and symptoms of Achilles Tendinopathy.

How can I treat it?

With regards to comprehensive treatment, the following components should be addressed:

  1. Eccentric loading of the Gastrocnemius-Soleus complex as documented in the Alfredson protocol for calf raises
  2. Isolated activation and strengthening of muscles surrounding the damaged area
  3. Kinetic chain activation and strengthening
  4. Non-conservative operative in the event of no improvement with conservative therapy

1.Alfredson protocol

Double leg eccentric calf-raises

Calf raise

Single leg eccentric calf raises

Calf raise Calf Raise

2. Activation and isolation strengthening

Side lying abduction

Side lying abduction Side lying abduction

Pelvic bridging

Pelvic bridging Pelvic bridging

3. Kinetic Chain Activation

Lunge to calf raise   Lunge to calf raise

Summary

Achilles tendinopathy is related to repetitive loading on the calf muscles. Recognising the signs and symptoms associated with the condition such as pain and swelling is the first step in treatment. Subject to identifying the associated signs and symptoms, one should seek physical therapy advice and adhere to a strict rehabilitation protocol.

Prepared by the Binokinetics team at the Sports Science Institute of South Africa (SSISA)


SSISA’s Biokinetics practice has a special focus on Orthopaedic & Neurological Rehabilitation, using scientific and evidence-based exercise programmes geared to improve function, performance and quality of life. The team also offer an intensive running programme for athletes of all levels to improve their abilities. Read more about SSISA Biokinetics


Please note that information found in these articles does not constitute medical advice. If you are experiencing an injury or condition of any kind, it is always advisable to contact a medical professional for advice on your specific symptoms.


References

  • Longe, J. (2005). Gale Encyclopedia of Alternative Medicine. USA: Thompson Gale.
  • Scott, A., Huisman, E. & Khan, K. (2011). Conservative Treatment of Chronic Achilles Tendinopathy. Canadian Medical Association Journal, 183(10):1159-1165.
  • Prentice, W.E. (2010). Essentials of Athletic Injury Management. New York: McGraw-Hill.
  • Wilson, J.J., & Best, T.M. (2005). Common Overuse Tendon Problems: A Review and Recommendations for Treatment. American Academy of Family Physicians, 72(5): 811-818.
  • Images: https://www.epfootandankle.com/achilles-tendonitis.html; https://www.active.com/running/articles/how-to-treat-and-prevent-running-injuries-achilles-tendonitis
  • Alfredson, H., & Cook, J. (2007). A treatment algorithm for managing Achilles tendinopathy: new treatment options. British journal of sports medicine, 41(4), 211-216.
  • Chimenti, R. L., Cychosz, C. C., Hall, M. M., & Phisitkul, P. (2017). Current concepts review update: insertional Achilles Tendinopathy. Foot & ankle international, 38(10), 1160-1169.
  • Roche, A. J., & Calder, J. D. F. (2013). Achilles tendinopathy: a review of the current concepts of treatment. Bone Joint J, 95(10), 1299-1307.
  • Murphy, M. C., Travers, M. J., Chivers, P., Debenham, J. R., Docking, S. I., Rio, E. K., & Gibson, W. (2019). Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. British journal of sports medicine, 53(17), 1070-1077.

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