Achilles Tendonitis

Achilles Tendonitis treatment and information

A tendon is a band, made of connective tissue, connecting a muscle to the bone. A tendon can be “stretched”, “strained” or even torn, but not “sprained” (you use this terminology for a ligament, as opposed to “strained” which is specific to a muscle or tendon).

The Achilles tendon (or calcaneal tendon) is located in the posterior (back) aspect of the lower leg, attaching the gastrocnemius, soleus and plantaris muscles to the calcaneus bone. This group of muscles serves in the plantar flexion of the foot (bringing the front foot towards the ground) and flexion of the knee. The Achilles tendon is the thickest in the human body (Doral et al., 2010).

Tendons have different functions depending on their location: they can be “positioning” or “energy storing”, the latter being the case of the Achilles tendon for example (Thorpe et al., 2013). Energy storing tendons store and recover energy during a specific motion, such as during the human stride. An imbalance in this storing/recovering system can lead to the tendon’s irritation, or worse, a tear which can be partial or full.

A tendonitis (or tendinopathy) can have various causes and can happen in different contexts. An irritation of the Achilles tendon can happen due to overloading, repetitive strain, or even a trauma, which can lead to a full rupture of the tendon. The most common context leading to Achilles tendonitis is usually running, and multiple factors can explain it: return to activity after a period of inactivity, postural imbalance leading to a stress of the posterior chain muscles of the leg (glutei, hamstrings and calves), poor shoewear support, or restricted foot mobility.

We commonly separate the muscle group of the lower limb in two chains: posterior and anterior. The posterior group is composed of the gluteals, hamstrings and calves, whereas the anterior is composed of the hip flexors, quadriceps and tibialis muscles. A healthy balance in the loading and activation of these chains will be key to preserving the integrity of the muscles and their tendons.

In the case of an inflammation of the tendon, swelling, redness of the area or even a sensation of heat can be observed around the back of the affected heel. More commonly, an irritation of the Achilles tendon will present with pain, exacerbated by activity (such as running) or loading of the calf group muscles. The painful area is usually not precisely located, vaguely described affecting the heel area. The discomfort is commonly present in the first steps made by the patient when waking up in the morning, and will be relieved with rest.

While the signs and symptoms described by the patient will help in the diagnosis of an Achilles tendonitis and lead the physical examination, the only way to get a precise and clear medical diagnosis is through imaging.

The best devices to visualise soft tissues like tendons will be MRI and ultrasound machines. They will give a very detailed image of the integrity of the Achilles tendon, and in the case of an ultrasound, will even show a real-time image of this structure in motion, which will help understanding the mechanism leading to the symptoms described by the patient. An X-Ray won’t visualise the soft tissues, such as muscles, ligaments, tendons, but will highlight other structures more dense such as bones. Therefore, an X-Ray will help rule out other conditions that could create similar symptoms, but won’t be effective diagnosing a tendonitis.

Untreated and with repetitive activity designed to stress the tendon, such as running or jumping (especially if wearing an inappropriate shoewear that is poorly supporting the foot, and/or on a concrete surface), the symptoms of the Achilles tendonitis may take a few weeks or even months before feeling better. With the appropriate self care and even treatment options (as listed below), the symptoms may only take 2 to 3 weeks before dissipating. However, it is always recommended to consult a specialist to avoid a repetition of these inflammations.

There are many options to treat Achilles tendonitis: you can manage it yourself or you can see a practitioner.

Where the use of heat is helpful to treat muscle tightness, here ice would be more beneficial as it will be an effective tool to calm down the inflammatory process on the tendon. Because of the potential skin reactions when in direct contact with heat or ice, it is always recommended to use a tissue or a thin cloth wrapped around the source of cold before applying it on the sore area. An application on the painful locatio every 3 to 4 hours, for not more than 15-20 mins at a time should be enough.

Rest is also recommended in the first 2-3 days following the initial presentation of the symptoms, to reduce the pain level and minimise the stress applied to the tendon, but cannot be considered as a mid- or long-term solution as it won’t treat the reason leading to this irritation.

If after trying self management for a few weeks the symptoms persist, an examination and assessment by a specialist would be recommended. The first step for further medical referral would be to consult a GP, who could refer the patient to a physiotherapist or to an orthopaedic specialist. In some tendonitis cases, steroid injections may be recommended, providing a short term pain relief, but these can’t be performed in the case of Achilles tendonitis. The reason for it is because it may weaken the tendon and put it at risk of further damage.

Consulting an osteopath or physiotherapist in the treatment of an Achilles tendinopathy will provide the benefits of a comprehensive postural assessment, which will give you a clear and reasonable understanding of the mechanism leading to Achilles tendonitis. Treatment will aim to work globally on the lower extremity, not only the patient’s foot and ankle, but also the knee, hip, pelvis and further up in order to handle the cause of the symptoms and not only their presentation.

An appropriate loading of the tendon, associated with a comprehensive and reasonable plan of return to activity discussed with the patient will be key to enhance the healing process and avoid any risks of relapse.

When loading an irritated tendon, it’s preferable to do it with what is called an “isometric” contraction: the muscle is contracted, but not lengthened or shortened. The exercise can be done standing up, with the possibility to find your balance by placing one hand on an elevated support, such as a desk. Whilst a weight (potentially a dumbbell) is held in one hand, you stand on one leg on the front of your foot, tip-toes, and hold the position for 15-20 seconds. Repeat the exercise 5 times, with a 40 seconds break in between repetitions. This exercise can be done every day as a part of a muscle activation program, and specifically before any physical activity such as running or jumping.

Another type of exercise will be designed to stabilise the ankle and foot mobility. This will ensure the tendons and ligaments in the area are loaded appropriately, with a good absorption of the ground forces by the joints of the foot and ankle on each step of a run, or when landing after a jump.

The 4 key movements that will be reinforced with this exercise are the plantar flexion, the dorsiflexion, the inversion and eversion of the foot. With an elastic band pulling in the opposite direction of the movement done, either with a hand hold of the elastic or wrapped to a stable object, you will need to do the motion against the resistance, and then gradually release your traction for a return to a neutral position. Effectively, this exercise will allow a concentric (shortening) and eccentric (lengthening) contraction of the muscle targeted.

Finally, to plan carefully a return to activity, it is recommended to do lower impact type of runs, preferably on an even soft surface or grass if possible. Running for a smaller distance and at a slower pace in the first 10 days of the program. This will allow the tendon to heal, be strengthened, whilst still active.

Because all of the exercises quoted previously are designed to avoid further repetitions of the Achilles tendonitis, they can both be seen as rehab but also prehab tools: a good balance, stability of the ankles and enough mobility in the feet will keep the risk of tendonitis at a low level. This is why consulting a specialist, for routine check-ups will put the body in the best conditions to function optimally and avoid unnecessary stress!

Doral, M.N., Bozkurt, M., Turhan, E., Dönmez, G., Demirel, M., Kaya, D., Ateşok, K., Atay, Ö.A. and Maffulli, N., 2010. Achilles tendon rupture: physiotherapy and endoscopy-assisted surgical treatment of a common sports injury. Open access journal of sports medicine, 1, p.233.

Thorpe, C.T., Birch, H.L., Clegg, P.D. and Screen, H.R., 2013. The role of the non‐collagenous matrix in tendon function. International journal of experimental pathology, 94(4), pp.248-259.