Achilles Tendinopathy

What is a tendon and what is its function?

A tendon is a connective tissue that attaches muscle to bone. The primary function of a tendon is to both absorb and transmit force much like a spring. In the body we call this spring like mechanism a Stretch Shorten Cycle (SSC) which is an important component of basic human movements such as walking, running and jumping.

What is tendonitis?

Tendons are thick connective tissues that attach muscle to bones. Tendonitis is rhe common name for ‘inflamed’ tendons (itis = inflammation in latin). Tendonitis is one of a handful of pathologies related to tendon pain. Tendinopathy is considered the umbrella term for a family of tendon related pain such as;

• Tendonitis (inflamed tendon)
• Tenosynovitis (inflamed sheath surrounding the tendon)
• Tendinosis (degeneration of the collagen within the tendon)

However, as there is a range of different types of tendon type injuries, the preferred term is simply tendon pain.

Tendonitis can occur in any tendon in the body but for this article we will focus our attention to the Achilles tendon

What is Achilles tendinitis?

The Achilles tendon is the tendon that attaches the calf to the heel bone. The primary role of this tendon is to absorb and transmit force during regular movement and exercise. Achilles tendonitis can be located typically in 2 regions;

1. The middle of the tendon, called a mid-portion tendinitis (More common)
2. At the heel bone, called an insertional tendinitis.

Achilles tendonitis commonly affects those who engage in regular weight bearing exercise (running, field based sports etc) but can also affect those who live a sedentary lifestyle.

The achilles tendon can progress through different stages as described by Cook Et Al.These stages are;

• Reactive
• Dysrepair
• Degenerative

The symptoms and signs are significantly impacted by load modification and tolerance to load.

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Symptoms of Achilles tendonitis

Typically Achilles tendonitis presents as;

• Localised tendon pain along the length of the tendon or directly on the heel bone.
• Symptoms are often worse in the morning or after being stationary.
• Associated dysfunction such as loss of strength, inability to jump or impaired function in activities like walking and running How is Achilles tendonitis diagnosed? Achilles tendonitis does not necessarily require imaging or special testing to diagnose. This can be diagnosed via a thorough history and physical examination by your Sports Chiropractor or

healthcare practitioner. Occasionally and MRI or an Ultrasound may be used to rule out another pathology to confirm a diagnosis or to seek a deeper understanding of the tendonitis.

Causes of Achilles tendonitis

What is very important in the development of achilles tendon pain are changes in loading, which have been shown to be a key contributing factor to the cause of achilles tendonitis.

Typically there is not just a singular cause of achilles tendonitis, there are usually a combination of factors coming together to cause the symptoms.The causes of achilles tendon pain can generally be broken down into two categoriesIntrinsic Contributors

Intrinsic Contributors
a. Non-Modifiable;

i. Age
ii. Gender
iii. Previous history of achilles or related injury
iv. Recent injuries
v. Use and exposure to steroids and other drugs
b. Modifiable;
i. Weight ii. Strength
iii. Endurance
iv. Elasticity
v. Foot alignment and pronation
vi. Reduced Ankle range of motion

2. Extrinsic Contributors

a. Footwear
b. Change in exercise load**
c. Change in general activity levels
d. Change in training surfaces

What are the best treatments for Achilles tendinitis?

The best evidence currently for the management of tendon pain is exercise interventions, education and activity modification. As the tendon is sensitive to loading, naturally it typically responds best to these interventions.

Hands on therapies including massage and dry needling, shock wave therapy and injections (cortisone and PRP) are commonly utilized to aid in the management of tendon pain and may be effective for short term pain relief, however, the evidence for the long term resolution of tendon pain and return to normal exercise and physical tasks from these interventions are not strong.

Exercises and exercise programs for Achilles tendinitis

There are many different types of exercises for Achilles tendon pain and different types of exercise protocols, however, there does not appear to be a singular best exercise or program. What is important when utilizing specific exercises are these 3 points;

1. Exercises need to be progressively and safely overloaded.
2. Monitor the response to the exercise within 24hrs.
3. Avoid significantly provocative exercises

Utilizing different types of contractions such as isometric, eccentric and concentric exercises may be beneficial and gradually including high and fast movements such as hopping and skipping may be used when the tendon can tolerate it

Other considerations

Tendon pain is complex and there does appear to be a cognitive and/or neurological component to these issues. Addressing areas of your health such as stress, anxiety, depression and nutrition is very important. Looking after your mental health by resting, spending time with loved ones and getting adequate sleep can play an important role in the recovery of the tendon pain. In short, maintaining a healthy and active lifestyle is very important to consider when coping with tendon pain.

DOWNLOAD OUR ‘WHAT TO KNOW, WHAT TO DO’ PDF FOR ACHILLES TENDINOPATHY BELOW

References:

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Malliaras, P., Barton, C. J., Reeves, N. D., Langberg, H., Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and Patellar Tendinopathy Loading Programmes A Systematic Review Comparing Clinical Outcomes and Identifying Potential Mechanisms for Effectiveness. Springer, 43(4), 267–286. https://doi.org/10.1007/s40279-013-0019-z

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Malliaras, P., l’Esport, S. O.-A. M. de, & 2017, undefined. (n.d.). Potential risk factors leading to tendinopathy. Elsevier. Retrieved May 8, 2021, from https://www.sciencedirect.com/science/article/pii/S1886658117300269

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Benjamin, M., Moriggl, B., Brenner, E., Emery, P., McGonagle, D., & Redman, S. (2004). The “enthesis organ” concept: Why enthesopathies may not present as focal insertional disorders. Arthritis and Rheumatism, 50(10), 3306–3313. https://doi.org/10.1002/art.20566

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