What is it?
The term tendinopathy refers to a pathological state of a tendon. A tendon may become inflamed, thickened or suffer tears as a consequence of trauma, overuse or a combination of both. There are different stages of tendinopathy relating to the structural form of the tendon. Two common terms used to describe these stages are tendinitis and tendinosis.
Achilles tendinopathy is a pathological state of the Achilles tendon. The Achilles tendon is the tissue that connects the calf muscle in the back of the leg to the heel bone. This musculo-tendinous unit functions to allow us to lift the heel and propel our body weight forward during gait.
Achilles tendinitis is inflammation of the Achilles tendon. When the tendon becomes irritated by excess loads during our activities, microscopic disruptions of the fibres occur within the tendon. Inflammation results and may gather in and round the tendon resulting in pain. This inflammatory response to overload usually represents the early stages of the condition.
Over time, if the tendon continues to encounter microscopic degradation, the inflammatory phase often ceases and the tendon begins to lose its structure and tensile resistance. The strong fibres of the tendon are replaced by a less functional tissue. This is called tendinosis, a chronic stage of tendinopathy.
How did I get it?
Achilles tendinitis/tendinosis is caused by overuse or overload of the tendon. Both extrinsic and intrinsic factors may combine to overload the tendon. Examples of extrinsic factors are training schedules, footwear, and running surfaces, while intrinsic factors include ankle stiffness, foot structure and strength. A combination of a poor training schedule with insufficient recovery time and a lack of strength may be one such combination that leads to Achilles tendinopathy.
What does it feel like?
Many cases of tendinopathy are actually not painful and often the condition goes unnoticed for some time. For those that do experience symptoms, the usual presentation is one of pain or stiffness after rest. Commonly the first few steps in the morning after sleep are tender in the area just above the heel. This then reduces after the area “warms up.” The same pattern is often described by those doing sport with a slight tenderness and stiffness during warm up, ease of the symptoms during play and then resumption of the pain and stiffness after cooling down.
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How is it diagnosed?
A history of the symptoms is usually enough to diagnose the condition. Palpation may reveal swelling or discrepancies over the tendon with associated pain and thickening. MRI and ultrasound are useful in advanced cases or when pain is significant to help differentiate between tendinosis of tears of the tendon.
How do I fix it?
- Rest or modification of training programs is a good start to allow heeling to take place
- Icing the area of pain is advantageous regardless of the stage of the condition.
- Orthotic modifications to shoes to unload the tendon are particularly useful in the early stages to reduce pain and swelling.
- Tears frequently are immobilised in a cam walking boot.
- Stretching can be useful for tight muscles but may be counterproductive during poor tissue quality.
- After the condition improves a slow strengthening program of the calf musculature will help recovery.
Will I need surgery?
In the case or a ruptured tendon, surgery results in good repair and reduced re-rupture rates. Conservative repair of the tendon is often successful but re-rupture rates are higher and strength deficits may be greater.
If the tendinosis is severe and involves over 50% of the tendon then there may also be a case for surgery. This would be considered after conservative therapy approaches have not been successful.
How do I stop it coming back?
Achilles tendinopathy can take considerable time to repair and often intermittently returns. The best way to stop it from coming back is to strengthen the tendon in a functional way that will replicate the stresses that are going to occur throughout your activities. The tendon needs time to adapt to new tasks so give yourself ample time to build strength before you start some new activity. Footwear and foot structure assessment are important and should be sort before taking up any new activity.