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What is achilles tendinopathy?

achilles tendon

Achilles tendinopathy is a condition that can cause pain, swelling and weakness of the achilles tendon. The achilles tendon joins your heel bone to your calf muscles.

Is thought to be caused by repeated stress on the tendon which leads to weakening and fraying of the tendon fibres. As the tendon tries to heal itself it can become thickened and can form nodules or a lump in the tendon. 

It can affect the mid portion of the tendon, typically 4cm above the heel. This is called non-insertional achilles tendinopathy.

 

Haglund deformityIt may also affect the tendon at its attachment to the heel . This is called insertional achilles tendinopathy. Inesertional achilles tendinopathy may also be associated with a prominent bump of bone at the back of the heel, which is known as a Haglund deformity. 

How common is achilles tendinopathy?

Achilles tendinopathy is one of the most common ligament problems in sportsmen and women. It is most common in people aged 35-50, especially if people return to sport after several years of relative inactivity. It may also occur in non-athletic people.

Being overweight, diabetic or having tight calf muscles can increase your chance of developing achilles tendinopathy.

 

What are the symptoms and signs of achilles tendinopathy?

  • Morning stiffness and 'start-up pain'.
  • Tender swelling over the achilles tendon.
  • Pain during or after exercise.
  • Rarely the tendon may completely rupture, often with an audible bang.

Initial treatment

Rest

Acute injuries require rest. This may involve reducing the level of your normal training regime or functional activities. Continuing to exercise in an uncontrolled manner on a painful Achilles tendon will increase damaged and make the problem more difficult to treat. It is advisable to avoid any high impact activities or sports until your pain subsides. Modifying your activity will help to reduce pain, allow inflammation to settle and minimise stresses on the tendon.

heel raise

Ice

During the initial stages of injury, ice treatment can be useful in managing pain and swelling. Apply a pack of frozen peas or an ice pack wrapped in a damp cloth to the tendon. Always check the skin following ice application for any skin burns. Leave this on for no more than 10 minutes, repeat up to 4 times per day or after exercise. Apply ice following any physical activity.

Orthotics

The use of a heel pad raises the heel and reduces strain on the Achilles tendon. 

Pain relief

Paracetamol and Non Steroidal Anti-Inflammatory (NSAIDs) such as ibuprofen can help relieve pain. Care should be taken with NSAIDS, and you should limit use to no more than 14 days. Prolonged use of NSAIDs may impede tissue healing long term as well as cause stomach irritation or kidney damage. Please consult your GP regarding NSAIDs use.

Physiotherapy and exercises

Physiotherapists can offer a range of treatments including stretching, strengthening exercises, soft tissue massage, gait analysis and orthotics as well as more advanced techniques such as ultrasound therapy. In many cases however, simple exercises and stretches which can be done at home will speed your recovery. 

Eccentric exercise programme

Eccentric exercises focus on stretching a tendon whilst the muscle is contracting. This improves blood flow through the tendon and speeds healing.

Exercise 1: 

  • Stand on a step, using the wall or a bannister for support.
  • The from of your feet should be on the step, the back of your feet overhanging the edge.
  • Stand on both feet.
  • Use your GOOD leg to raise up onto your tiptoes.
  • Transfer your weight over onto your BAD leg lifting your GOOD leg off the step.
  • Slowly lower yourself down. 
  • Aim for 3 sets of 30 repetitions, 3 times a day

Exercise 2:  

  • Very similar to exercise 1, but with the knee bent.
  • Use your GOOD leg to raise up onto your tiptoes.
  • Transfer your weight over onto your BAD leg lifting your GOOD leg off the step.
  • Bend your knee.
  • Slowly lower yourself down. 
  • Aim for 3 sets of 30 repetitions, 3 times a day

During an eccentric exercise programme, you may experience an increase in pain for up to eight weeks. This will reduce as you continue with the exercises. If, during an exercise, you have severe pain, stop and try to return to it the following day.

Stretching programme

In addition to eccentric exercises, you should also stretch the calf muscles and achilles tendon. There are two stretches to do, each targeting different muscles in the calf.

1. Gastrocnemius stretch

  • Stand against a wall with feet parallel, the injured leg behind the good leg.
  • Bend the front knee forward with knee over the toes.
  • Keep the back leg straight, keeping the heel in contact with the floor.
  • Lean into the wall.

 

2. Soleus stretch 

  • Same position as above, but with the back leg slightly bent at the knee
  • Lean forwards, keeping the heel in contact with the ground.

 

The role of surgery for achilles tendinopathy

Most cases will respond well to a structured exercise programme. 

In some cases, surgery is required. There are three operations which may help, dependent on the type of tendinopathy which you have, and the amount of tendon which is involved.

1. Debridement of non-insertional achilles tendinopathy

The inflamed lining of the tendon is removed, and the tendon itself split in the line of its fibres. Any dead or torn tissue is removed. If large amounts of achilles tendon are removed and the remaining tendon is very weak, a tendon transfer may be required. This involves re-routing an adjacent tendon into the heel bone to augment the achilles tendon.

2. Debridement of insertional achilles tendinopathy

The tendon is detached from its insertion point into the heel bone, and any dead or damaged tissue removed. If there is a Haglund deformity this can be removed at the same time. The tendon is then reattached to the bone using bone anchors. The tendon must be protected in a plaster cast whilst it heals.

3. Osteotomy of the heel bone

If there is a large Haglund deformity and this is causing inflammation of the fluid-filled bursa beneath the achilles tendon, the heel bone can be re-aligned using an osteotomy. The bone is cut and a small wedge of bone removed to alter the angle of pull of the achilles and decompress the bursa. This requires six weeks in plaster whilst the bone heals.

Surgery for achilles tendinopathy requires long recovery times and has a high complication rate, including blood clots, infection and wound healing problems. It should only be undertaken as a last resort once all non-operative treatments have been exhausted.

For further information about achilles tendinopathy or for a consultation with Mr Willmott, please contact his secretary on 01424 834115, or by emailing This email address is being protected from spambots. You need JavaScript enabled to view it.

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