Keywords: Achilles tendinopathy, proteoglycans , collagen, matrix, Physiotherapy, Special tests, Differential Diagnosis, Exercises, Injection.
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Achilles tendinopathy is the most frequently occurring tendinous lesion in the sports setting (Maffulli et al, 1998) and is characterised by pain in the tendon, generally at the start and end of exercise (Vega et al, 2008). The pathogenesis of tendinopathies remains unclear (Abate et al 2009) however is thought to occur in three stages; injury, failed healing, clinical presentation (Fu el al, 2010). Tendinopathies are predominatly described as tendinosis, which presents as disorientation of collagen, focal necrosis, and increased prominence of vascular spaces (Khan et al, 1999). This can often be palpated as thickening or nodules within the tendon (Vaga et al, 2007). Acute inflammatory changes in the tendon sheath have also been documented and terms such as tenosynovitis, para- tenonitis, and peritendinitis have been used (Woo et al, 2007).
Overuse, repetitive strain or mechanical overload to tendons are considered as primary trigger of symptomatic tendinopathy in various regions however pathology is noted in both athletic and non athletic populations (Fu et al, 2010; Almekinders and Temple, 1998;Rolf and Movin, 1997; Astrom, 1998).
Clinically Relevant Anatomy
It is estimated that achilles tendonosis accounts for around 11% of all running injuries. The Achilles tendon is the large tendon at the back of the ankle. It connects the large calf muscles (Gastrocnemius and Soleus) to the heel bone (calcaneus) and provides the power in the push off phase of the gait cycle (walking and running).
Achilles tendonitis is often now being referred to as achilles tendinopathy. This is because it is no longer thought to be an inflammatory condition. On investigation, the main finding is usually degenerated tissue with a loss of normal fibre structure.
Achilles tendonosis can be either acute, meaning occurring over a period of a few days, following an increase in training, or chronic which occurs over a longer period of time. In addition to being either chronic or acute, the condition can also be either at the attachment point to the heel or in the mid-portion of the tendon (typically around 4cm above the heel). Healing of the achilles tendon is often slow, due to its poor blood supply.
Characteristics and Clinical presentation
- Gradual onset of achilles pain at the back of the ankle, just above the heel bone.
- This develops over a period of days.
- Pain at the onset of exercise which fades as the exercise progresses.
- Pain eases with rest.
- Tenderness on palpation.
- Chronic achilles tendonosis may follow on from acute tendonitis if it goes untreated or is not allow sufficient rest. Chronic achilles tendonitis is a difficult condition to treat, particularly in older athletes who appear to suffer more often.
- Gradual onset of achilles pain over a period of weeks, or even months.
- Pain with all exercise, which is constant throughout.
- Pain in the tendon when walking especially up hill or up stairs.
- Pain and stiffness in the Achilles tendon especially in the morning or after rest.
- There may be nodules or lumps in the achilles tendon, particularly 2-4cm above the heel.
- Tenderness on palpation.
- Swelling or thickening over the Achilles tendon.
- There may be redness over the skin.
- You can sometimes feel a creaking when you press your fingers into the tendon and move the ankle.
Achilles tendonosis is an overuse injury. Too much too soon is the basic cause of overuse injuries, however other factors can contribute to developing the condition.
- Increase in activity (either distance, speed or hills).
- Less recovery time between activities.
- Change of footwear or training surface.
- Weak calf muscles.
- Decreased range of motion at the ankle joint, usually cause by tight calf muscles.
- Running up hills – the achilles tendon has to stretch more than normal on every stride. This is fine for a while but will mean the tendon will fatigue sooner than normal.
- Overpronation or feet which roll in when running can place an increased strain on the achilles tendon. As the foot rolls in (flattens) the lower leg also rotates inwards which places twisting stresses on the tendon.
- Wearing high heels constantly shortens the tendon and calf muscles. When exercising in flat running shoes, the tendon is stretched beyond its normal range which places an ‘abnormal’ strain on the tendon.
- Achilles tendon rupture
- Plantar fascitis
- Ankle sprain
- Calf Sprain
- Syndesmosis Sprain
- Morning stiffness/pain, a palpable nodule and pain on tendon loading are suggested clinical markers for tendinopathies (Cook and Purdam, 2008).
- A history of overload and repetitive strain of the Achilles tendon also fits the diagnosis of an Achilles tendinopathy.
- A positive arc sign and palpation test (high specificity = 0.83)
- Thickening of the tendon suggests pathological changes in the tendon, which can be categorised into ‘clinical presentation (Fu et al, 2010).
General advice for patient
- Relative Rest
- Apply cold therapy (if acute episode).
- Wear a heel pad to raise the heel and take some of the strain off the achilles tendon. This should only be a temporary measure while the achilles tendon is healing.
- Make sure you have the right running shoes for your foot type and the sport.
- See a sports injury professional who can advise on treatment and rehabilitation.
Healthcare professional or Physiotherapy management
- Prescribe anti-inflammatory medication such as ibuprofen.
- Identify the causes and prescribe orthotics or a change in training methods.
- Tape the back of the leg to support the tendon.
- Use ultrasound treatment.
- Apply sports massage techniques.
- Eccentric loading programme
- Prescribe a rehabilitation programme.
- Some might give a steroid injection however an injection directly into the tendon is not recommended. Some specialists believe this can increase the risk of a total rupture.
- Scan with an MRI or Ultrasound to identify .
- Achilles tendonosis surgery may be performed if conservative treatment fails.
- If you look after this injury early enough you should make a good recovery. It is important you rehabilitate the tendon properly after it has recovered or the injury will return. If you ignore the early warning signs and do not look after this injury then it may become chronic which is very difficult to treat.
Aims of physiotherapy and surgery
- Encourage parallel alignment of collagen.
- Reduce fibrotic adhesions
- Restore normal vascularization
- Stimulate viable cells in order to enhance the healing process
Rolf (1997) and Benazzo (2000)
- Deep transverse frictions to break down adhesions.
- Eccentric loading to encourage parallel aligment of collagen.
- Ultrasound to increase activity of the cell membranes and enhance the healing process. ONLY to be used if associated tenosynovitis or retrocalcaneal bursitis.
- Eccentric loading to encourage the reverse of neovascularisation (Ohberg and Alfredson, 2004).
- Stimulation of the three gates (Bilateral LI 4 and left LIV 3) was used to encourage supraspinal effects such as diffuse noxious inhibitory controls (DNIC), beta endorphin mediated descending pain inhibitory pathways (Sterner-Victorin et al, 2002) and increase blood flow to the hypothalamus and the dPAG (Lewith et al, 2005) which are important regions for acupuncture analgesia (Zhao, 2008).
- BL 27 was chosen as a segmental points because it lies in the same dermatome as the affected tissue. Acupuncture has previously been effective for the modulation of pain via the pain gate mechanism (Carlsson, 2002) which involves stimulation of A-beta nerves that communicate with the dorsal horn of the spinal cord, brain stem and PAG, triggering descending inhibitory pathways in the shape of endogenous opioid mechanisms (Kaptchuck, 2002; Longbottom, 2010)
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