Two thirds of runners complain they suffer from Achilles tendon pain. Lauren Gowland reviews the best ways to treat it
Achilles tendon injuries afflict runners about 10 times more frequently than non-athletes of the same age.
From Achilles tenosynovitis, Achilles tendinitis, Achilles tendinosis, Achilles rupture to Achilles tendinopathies, most of us have experienced the pain of them at some point in our careers. But what causes them and how do we treat and avoid them?
The Achilles tendon is the thickest tendon in the human body. It attaches the plantaris, gastrocnemius and soleus muscle to the posterior tuberosity of the calcaneus serving its main function to plantar flex the foot.
It is surrounded by a connective tissue sheath also known as a paratendon. This structure is highly vascular and allows the tendon to glide more easily with movement. All conditions are treatable, but with varying degrees of success. With the correct diagnosis and appropriate management measures put in place, recovery will usually take around three months.
But since the treatment options available are so vastly controversial, the risks and benefits of each option need to be thoroughly assessed and matched to each individual case before a final decision is made, so make sure you consult a medical expert if you are plagued by the problem.
In the meantime, here’s a guide that might help you.
Achilles tenosynovitis
This is inflammation of the sheath surrounding the tendon. It commonly causes fibrosis and scarring within the sheath restricting the range of motion of the Achilles tendon. Symptoms experienced with this condition include pain, tender swelling around the Achilles and crepitus on movement of the ankle joint.
Causes for this condition relate to having a tight calf and Achilles complex, changing the volume of training completed or changing the type of footwear being worn.
What to do: Management options for Achilles tenosynovitis can be divided into short and long term plans. Firstly, rest from the aggravating sport. Secondly, at the time of the injury, ice and compression should be applied for about 10-15 minutes every hour for 3-4 hours. This will ease pain along with reducing swelling and inflammation.
Non-Steroidal Anti-Inflammatory Drugs may be given for a few days to a week to reduce inflammation also. Longer term management of Alfredson’s eccentric heel drops (see below), massage and a change in footwear is recommended.
Achilles tendinopathy
This is an umbrella term for clinical conditions in and surrounding the tendon. Medically speaking, tendinopathy is due to non-inflammatory, intra-tendinous collagen degeneration with fibre disorientation and thinning.
Under examination, the overall bulk of the Achilles tendon will increase while its overall strength will decrease. There two types of tendinopathy – insertional, where the Achilles joins to the calcaneus – and non-insertional, occurring approximately two to six centimetres from this point. Symptoms include increasing pain, stiffness around the tendon.
What to try: Heat and light walking are known to improve the symptoms whereas strenuous activity is likely to exacerbate them.
There are three main response stages. Firstly, reactive tendinopathy is a short-term response whereby the Achilles thickens and stiffens in an attempt to reduce the load being placed upon it. The tendon disrepair is due to delineation of the tendon fibres.
Finally, in the degenerative tendinopathy stage, which is more common in older athletes, due to chronic overloading, collagen becomes disorganised and the matrix begins to break down. Increased vascularity and neuronal ingrowth contribute to this stage.
Achilles tendinitis
Achilles tendinitis is inflammation of the Achilles tendon itself. There are two main locations where this occurs: firstly, at the insertion point where the tendon attaches to the calcaneus and secondly, at the mid-point of the tendon. In both cases the damaged tendon fibres may calcify providing symptoms of stiffness and pain.
There are many theories about what triggers it including overuse of the Achilles, muscle imbalance or weakness, decreased blood supply and tensile strength with aging or even malalignment such as hyper-pronation.
The tenocytes themselves produce Substance P and prostaglandin E2, inflammatory mediators, in response to increased loading. This subsequently leads to delineation of the tendon fibres.
What to try: There have been numerous studies conducted to determine the best treatment for Achilles tendinitis, but the outcome remains unclear. According to the National Institute for Health and Care Excellence (NICE), first line management
for Achilles tendinopathies includes rest; stopping the precipitating sport that caused the injury.
Provide analgesia for the pain itself. Non-Steroidal Anti Inflammatory Drugs (NSAIDs) are advised for an acute injury but longer term paracetamol would be preferable due to the lower risk of side effects.
In terms of easing symptoms, the application of ice packs or cold compresses to the area immediately after the injury will be of some benefit.
Achilles tendinopathy
A total of 66% of Achilles tendon problems occur in runners and it is down to characteristically chronic overuse of the Achilles tendon while training. Other causes of tendinopathy include extreme overloading such as rapid increase in training volume, poorly fitting footwear, change in running surface or excessive pronation of the foot. There’s also a genetic link with Achilles tendinopathy.
What to try: The treatment of Achilles tendinopathies is multifactorial and highly controversial. Initial approaches would be the same as recommended for Achilles tendinosis. Evidence suggests that eccentric rehabilitation programmes promote the most effective outcomes. The Achilles responds to this type of exercise as the fibres of the tendon are reorganised to deal with a higher load.
You could also try orthotic devices that marginally lift the heel or support the arch with the aim of reducing the strain on the tendon while it heals.
HOW TO DO THE HEEL DROP
One of the recommended exercise programmes based on eccentric heel drops was devised in 1998 by Dr Hakan Alfredson, a Swedish sports medicine doctor. It is known as “Alfredson’s heel drop protocol” and the exercise regimen comprises three sets of 15 heel drops twice daily for 12 weeks.
The exact technique to perform these exercises involves the patient standing on a step with both heels overhanging. The patient lifts the injured heel off the step and raises the good heel to plantarflex the foot, still on the step.
Secondly, the weight is transferred onto the injured foot in the plantar flexed position, over the edge of the step.
Finally, to complete the exercise, the heel is slowly lowered over the edge of the step over approximately 10 seconds until the foot is in the dorsiflexed position. A variation is to bend the injured leg. This puts more weight through the tendon to strengthen it further.
WHAT ELSE TO TRY
Vary where you run: For example, run on grass or trail instead of road to reduce the load put through the Achilles tendon. Similarly, reassess the choice of footwear.
Change your footwear: Many runners who suffer with Achilles tendinopathies have a hyper-pronated running style. This is the movement of the subtalar joint into eversion, dorsiflexion and abduction. Finding a supportive shoe to help counteract some of this movement will reduce the susceptibility to such injuries.
Avoid steroid jabs: NICE does not support the use of steroid injections as a recognised treatment for Achilles tendinopathies as there’s an increased risk of tendon atrophy or rupture.
Try shock wave therapy: With this treatment, acoustic shockwaves are passed through the skin and directed at the Achilles tendon with the aim of boosting blood flow to the area and promoting regrowth of the tendon in a linear fashion.
Look for lasers: Low level laser therapy is thought to increase collagen production and reduce blood flow in new vessels. It’s best used as adjuncts to eccentric Achilles exercises.
Surgery as a last resort: Rarely, resistant Achilles tendinopathy may require open surgery to excise fibrous adhesions and degenerative nodules. Surgical methods are of main benefit in acute rupture as opposed to tendinopathies. Younger athletes with full rupture are more likely to benefit from surgical repair as risk of re-rupture is reduced. With a possible future sporting career the benefits of surgery are likely to outweigh any risk.
» Lauren Gowland is a fifth-year medical student at Lancaster Medical School and a member of Blackpool, Wyre and Fylde AC
