Achilles Tendinopathy

Achilles Tendinopathy is a relatively common presentation in both active and inactive populations, although more common in sporting populations.
The term Achilles Tendinopathy may encompass symptoms of any disorder related to the Achilles tendon.
The most common painful areas
• Mid-portion of the tendon
• Insertional area, were the tendon meets the bone.

Signs and Symptoms
The most common presentation is a slow onset discomfort and pain around the mid-portion of the Achilles while walking or running.
• The tendon may feel stiffness first thing in the morning and at the beginning of exercise but gets less during activity and may worsen when you cool down.
• Feeling pain or stiffness, the next morning after activity.
• The calf muscles may feel stiff with a lack of strength.
• You may notice a slight lump at the mi-portion of the Achilles.
• The tendon may be painful to touch.

The Achilles Tendon
The Achilles tendon is a load-bearing tendon originating from the gastrocnemius and soleus muscles and inserting at the (calcaneus) heel bone.
The Achilles tendon is extremely strong and can withstand the multitude of our regular daily activities including the demands of sport such as climbing, running and jumping.
Tendons are simple structures their main function is to transmit tensile loads from muscle to bone.
The special characteristics of the Achilles tendon, is that it has an energy-storage capacity and will thicken to adapt with repeated loading.
As long as the functional demands don’t exceed our ability to compensate, we remain uninjured.

What causes Achilles Tendinopathy?
The body has an amazing ability to adapt to increased activity and steady loading. But a sudden change in terrain or the increase in activity such as frequency, intensity or duration may tip the scales making the tendon vulnerable to injury.
The body tissues are constantly being challenged, strained and broken down with activity.
During rest the body repairs any damage and can make the tissues stronger.
But if the body is challenged faster than it can repair, the tissues fail to adapt, finally tipping the scales towards degeneration leading to symptoms of pain and discomfort.

Muscle strength (research findings)
Research by the S. O’Neill group in the UK found that runners with Achilles Tendinopathy had less endurance in both their calf muscles (plantar-flexors) compared to the control group.
Also the symptomatic side in the tendinopathy group was weaker than the non-affected side; therefore the contralateral side should not be used as a normal measure of endurance.
There is also mounting evidence that bi-lateral weakness in hip abductor and external rotator muscles may be linked to mid portion Achilles tendinopathy.
A recent study by Bramah et al, investigating (kinetics) or the underlying body alignment and mechanics as a possible cause specific running injuries.
Their research group compared the different kinematics between injured and non-injured runners.
The injured runners demonstrated:
Greater contralateral hip drop.
Forward trunk-lean at midstance.
An increase in forward extended knee and dorsiflexed ankle on initial contact.
Contralateral hip drop appeared to be the most important identifiable variable associated with running injuries.

Other Possible Causes of Heel Pain
• Lumbar referred pain
• Plantaris Tendinopathy
• Sural nerve referred pain
• Soleus/ gastrocnemius strain
• Lower limb trigger points
• Inflamed paratendon
• Insertional Tendinopathy
• Posterior impingement
• Retrocalcaneal bursa
• Metabolic disorders
• Tibialis posterior/ Flexor halluces longus Tendinopathy

Physical Examination
This should include a full history and risk factors leading to the event.
• Observation
• Functional kinetic chain assessment
• Palpation/ Localization of pain
• Load response: strength and endurance

Pain management
Specific loading to gastrocnemius and soleus muscles
Ensure the tendon meets the functional and loading demands required for sport and daily life.
Tendons don’t get better with rest

C Bramah, SJ Preece, N Gill, L Herrington et al. 2018. Is There a Pathological Gait Associated With Common Soft Tissue Running Injuries? The American Journal of Sports Medicine. 46 (12) 3023-3031

Brukner & Khan’s. Clinical Sports Medicine 5th Ed. 2017, Vol 1 Injuries. 865-888J L Cook, C R Purdam. 2013. The challenge of managing tendinopathy in competing athletes.

B Habets, HW Smits, FJG Backx, REH Van Cingel, BMA Huisstede. 2017.Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achilles tendinopathy: A cross-sectional study. Physical Therapy in Sport (25) 55-61

BJSMC Pizzolato, DG Lloyd, MH Zheng, TF Besier, VB Shim. 2018. Finding the sweet spot via personalized Achilles tendon training: the future is within reach. BJSM

S O’Neill, P Watson, S Barry. 2014. Plantarflexor muscle power deficits in runners with Achilles Tendinopathy. BJSM Vol 48 issue Suppl 2

M M AL-Uzri, S O’Neill 2014. The effect of eccentric exercises on plantar-flexor power in healthy individuals. BJSM Vol 48 issue Suppl 2.

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