Achilles Tendinopathy - what is it and what are the best treatment options?
Achilles tendinopathy (aka tendinitis) is a degenerative condition of the Achilles tendon, which is the tendon that connects the calf muscle onto the heel bone of the foot. Its primary role is to generate propulsive force for walking, running and jumping, it does so by pulling on the heel bone which causes plantarflexion of the ankle lifting you up onto your tip toes.
Achilles tendinopathy is a degenerative condition that occurs due to repetitive strain, it is actually a failed healing response of the body which often occurs due to a sudden increase in activities (repetitive strain) of the lower limb such as running, walking, or jumping. It is most commonly associated with runner’s; approximately 33% of all adult runners over the age of 40 will experience Achilles tendinopathy at some point in their running career.
Healthy tendons have no direct nerve supply. However, chronic Achilles tendinopathy causes the formation of small holes within the tendon which allow veins and nerves to then infiltrate. This is one plausible theory as to why people develop chronic tendinopathy, which generally leads to increased pain sensitivity, and increases the difficulty in its resolution.
Statistics
Approximately 6% of the general population experiences Achilles tendon pain at some point in their lifetime
65% of all Achilles tendinopathies diagnosed in a general practice setting are not sport related
A study out of the Netherlands found mid-portion Achilles tendinopathy in the general population at 1.85 per 1000 people
Elite long-distance runners have a lifetime risk of 52%
3–5% of Achilles injuries in runners can be career ending
Insertional vs Non-insertional Achilles Tendinopathy
There are two types of Achilles tendinopathy: Insertional Achilles tendinopathy, and Non-insertional (mid-portion) Achilles tendinopathy. It is important to highlight the difference between the two because they have slightly different presentations and treatments.
Insertional Achilles tendinopathy is when the tendon degeneration is located at the furthest attachment of the tendon onto the heel. This type of tendinopathy is less common accounting for approximately 40% of all Achilles tendinopathy cases, however, it is slightly more difficulty to treat and resolve.
Non-insertional Achilles tendinopathy is when the part of the Achilles affected is at least 3-6cm away from its attachment point on the heel bone. This type of Achilles tendinopathy is more common (approximately 60% of cases) and tends to respond a little better to conservative treatment.
Management
There are many forms of treatment for Achilles tendinopathy, for the sake of this article we are going to only discuss non-invasive (non-surgical) forms of treatment. There are many non-invasive treatments, unfortunately many that are still used have little or no clinical evidence of their effectiveness. Fortunately, there are several treatments that have robust clinical evidence of their effectiveness, so we are going to discuss on those ones. Achilles tendinopathy can cause sufferers to decrease their physical activity level, with a potentially negative effect on their overall health and general well-being, so psychological factors such as pain catastrophising or kinesiophobia (excessive, irrational and debilitating fear of physical movement) many need to be addressed as well.
Exercise
Exercise that mechanically loads the Achilles tendon is the regarded as the gold standard of treatment for Achilles tendinopathy, meaning it has demonstrated the highest level of evidence for its effectiveness. Eccentric exercise (loading a muscle while it actively lengthens) is believed to counteract the failed healing (degeneration) which underlies tendinopathy, by promoting collagen fiber cross-linkage formation within the tendon. Most studies looking at exercise for Achilles tendinopathy show some level of positive therapeutic effect, and no studies have reported adverse effects.
Stretching and strengthening of the calf muscles and Achilles tendon help preserve lower limb function, restore normal ankle joint mobility and decrease the strain on the Achilles tendon.
Extracorporeal Shock Wave Therapy
Extracorporeal shockwave therapy is a treatment using powerful acoustic pulses which carries high energy to painful soft tissues of the body related to acute or chronic musculoskeletal conditions. The energy promotes repair and regenerative processes of bones, tendons, muscles, and other soft tissues.
Here are some of the pros and cons of shock wave therapy:
Pros
Gives immediate relief
One treatment can provide pain and healing effects up to 3 months later
No adverse events post treatment
Relatively inexpensive treatment
Shock wave therapy can be combined with other therapies, often yielding superior outcomes
Cons
Is a mild to moderately painful procedure
Possible transient post-therapy skin reddening but no bruising
Need to use contact gel on the skin
Need to find a practitioner that has a shock wave machine
A study by Rompe et al. (2007) compared and eccentric loading group to a radial shock wave therapy group, and a control group. Four months after completion of radial shock wave therapy (3 sessions): 52% of patients suffering from non-insertional Achilles tendinopathy and 64% of patients with chronic insertional Achilles tendinopathy reported “complete recovery” or “marked improvement.”
Two years later, Rompe et al. (2009) conducted another study that looked at combining eccentric loading and radial shock wave therapy (3 sessions) which increased the proportion of “completely recovered” or “much improved” patients to 82%.
Laser Therapy
There are two main categories of laser therapy. The first is called low level laser therapy (LLLT or cold laser). It is called cold laser because the effects are photochemical (like photosynthesis in plants) and biochemical, it does not generate heat like other forms of laser therapy. It creates therapeutic effects in three distinct ways.
Growth factor response within cells and tissue as a result of increased ATP and protein synthesis. Improved cell proliferation, change in cell membrane permeability to calcium up-take.
Pain relief as a result of increased endorphin release; increased serotonin; suppression of nociceptor (pain sensing nerves) action.
Strengthening the immune system response via increased levels of lymphocyte activity and through a mechanism termed photomodulation of blood.
Lasers with a power output greater than 0.5 Watts are termed high-powered laser. This form of laser therapy does generate heat on the surface of the skin due to their higher power density (irradiance), so some precautions need to be adhered to in order to avoid side effects, however, it is accepted as a very safe therapy. Most of the heat is generated below the skin level and therefore focuses the heat to the target tissues and limits heating the superficial skin tissue.
Soft tissue therapy
Soft tissue treatment has been used for thousands of years and has loads of research to back up its effectiveness. However, not all practitioners have the same level of skill and therefore results can very greatly. Nonetheless, when performed by an experienced and skilled practitioner soft tissue therapy can result in mild to moderately positive therapeutic effects for Achilles tendinopathy. The downside is that it can be an unpleasant treatment in terms of pain. The upside is that it is very safe (when all possible contra-indications are excluded such as use of blood thinners, blood coagulation diseases such as haemophilia, or deep vein thrombosis) and the effects are generally felt straight after the treatment.
Kinesiology Taping
Kinesiology taping (aka kinesiotape or K-tape) if you haven’t heard of it then you’ve most likely seen professional athletes wearing it. It has been around since the mid-1970s but became popular in the 1990s. There are now many brands of kinesio tape – they are all forms of dynamic tape which is basically tape that stretches and moves with the body, kind of like Lycra. The tape is purported to have various therapeutic effects such as pain relief, decreased swelling, improved blood flow, improved muscle function, and can improve joint stability.
There are only a few studies on kinesiotape for Achilles tendinopathy, the two studies I found concluded that kinesiotape had no clinical effects. However, one of the studies showed a decrease in pain for the first 24 hours after application. Nonetheless, I have found K-tape to be a helpful adjunct to conservative therapy as patients often are a bit sore after manual therapy so any decrease in their pain is welcomed. NB: K-tape is contraindicated for patients with malignancy (cancer), infection, cellulitis, open wounds, DVTs and previous allergic reactions to K-tape (there is a hypoallergenic form of K-tape that can be used in these situations).
Foot Orthotics
If foot alignment is abnormal, foot orthoses that place the back of the foot (hindfoot) in neutral may help. Also, a heel lift of 12-15mm is commonly used along with other interventions to manage Achilles tendon pain. Orthotics correction can alter the biomechanics of the foot and ankle and may relieve heel pain. In runners orthotics have been used with up to 75% success. It is not always necessary to go out and spend several hundred dollars on custom orthotics, for most people a simple prefabricated orthotic under $100 will do the trick.
Prevention
Who needs a cure when you can prevent a condition from every happening? Well, to effectively prevent Achilles tendinopathy, perpetual overloading at an early stage needs to be addressed. The problem with early detection is that the first symptom is often pain that limits sport participation. This is usually preceded by weeks or months of minor pain, morning stiffness, which often go ignored by the patient and clinician as long as the patient can continue to perform their desire activity. The earlier the injury is detected, the shorter the expected time for full recovery.
If you struggle with achilles tendinopathy, get in touch to discuss how we can help.
References
Longo, U. G., Ronga, M., & Maffulli, N. (2018). Achilles tendinopathy. Sports medicine and arthroscopy review, 26(1), 16-30.
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.
Kearney, R. S., Parsons, N., Metcalfe, D., & Costa, M. L. (2015). Injection therapies for Achilles tendinopathy. Cochrane Database of Systematic Reviews, (5).
Riley, G. (2008). Tendinopathy—from basic science to treatment. Nature clinical practice Rheumatology, 4(2), 82-89.
de Jonge, S., Van den Berg, C., de Vos, R. J., Van Der Heide, H. J. L., Weir, A., Verhaar, J. A. N., ... & Tol, J. L. (2011). Incidence of midportion Achilles tendinopathy in the general population. British journal of sports medicine, 45(13), 1026-1028.
McLauchlan, G., & Handoll, H. H. (2001). Interventions for treating acute and chronic Achilles tendinitis. Cochrane database of systematic reviews, (2).
Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current clinical concepts: conservative management of Achilles tendinopathy. Journal of athletic training, 55(5), 438-447.