Achilles tendinitis

Assess, Treat & Rehabilitate Achilles Tendinopathy

It is the strongest tendon of the body. The location of the Achilles tendon is at the back of the lower leg above the heel bone.

Achilles tendon attaches the calves as soleus and gastrocnemius to the calcaneus (heel bone). With the help of the Achilles tendon, you can go onto your tiptoes.

The function of the Achilles tendon is to transmit the forces to the foot from the calf muscles. It transmits this force when a person pushes his foot off the ground for running or jumping. Achilles tendon helps in controlling the position of the ankle when the feet come back to the ground.

Irritation of the Achilles tendon is Achilles tendinopathy, this is a more accurate description than Achilles tendinitis.

The most common pain sensation of Achilles tendinopathy occurs behind the ankle and heel’s upper back while walking.

Achilles tendinopathy is prevalent among both inactive and active patients. But athletes with running sports experience about 50% more cases of Achilles tendinopathy.

The cause of Achilles tendinopathy is a repetitive activity or movement overuse. These can lead to sudden injury or trauma to the tendon. In severe cases, these repetitive traumas can also rupture the tendon. Achilles tendinopathy can also occur as a result of acute injury (single incident).

Several factors can contribute to the pathology of Achilles tendinopathy as:

• Obesity
• Inappropriate footwear (unable to transmit forces properly)
• A sudden change in the sports activity or exercise regimen
• Tightness of calf muscles
• Weakness of calf muscles
• Abnormal structure of feet
• Abnormal biomechanics of the feet

According to Cook and Purdum, this cohort of patients can be referred to as tendinopathy. This new strategy for approaching or dealing with tendon pain is Tendon Continuum.

This continuum model proposes three different staging’s of tendinopathy based on distributional changes.

These three stages are:

• Reactive tendinopathy
• Tendon disrepair
• Degenerative tendinopathy

Types of Achilles tendinopathy:

According to the tendon continuum, Achilles tendinopathy occurs in three stages:

• Reactive tendinopathy:

It is the first stage of the tendon continuum which causes a non-inflammatory (proliferative) cell-matrix response. It occurs due to result of tensile or compressive overload. At this stage, cells change their shape to manage more cytoplasmic organelles for increasing proteins.

Reactive tendinopathy is a short-term adaptation of the tendon which thickens it to:

• Increase stiffness
• Reduce stress

The imaging result shows swelling and thickness of the tendon due to several changes in proteins. The most common cause of this stage is direct tendon impact or sudden increase in stress. Tendon can completely reverse back in this condition.

• Tendon disrepair:

Suppose you do not allow the off-loading from the tendon after reactive tendinopathy. In that case, it can progress to the second stage.

There is an increase in the proliferation of proteins in the cell matrix. The increased protein accumulation can even separate the collagen structures within the cell matrix, which was intact in the first stage.

This protein segregation is visible with the help of ultrasound scans and MRI. In this stage, there is evidence of neural ingrowth or an increase in the tendon’s vascularity.

Tendon disrepair is a difficult stage to diagnose. You need to have an appropriate history, examination, and clinical evaluation in the most appropriate ways.

 This phase can occur due to frequent tendon overloading in phase one of the tendon continuum. Older (stiffer) tendons are more likely to develop this phase due to the lack of adaptability or flexibility.

• Degenerative tendinopathy:

The final phase of the tendon continuum is degenerative tendinopathy. In this phase, the prognosis of the injury is poor or nearly irreversible.

In this phase, the following changes occur in cell-matrix:

• Cell death in certain areas
• Exhaustion of the tenocytes
• The general disorganization of the cells and proteins in the cell-matrix

On scanning or imaging, you can see the signs of degeneration throughout the tendon. Tendon can have an increase in thickness, and you can palpate the nodular sections in the tendons.

Degenerative tendinopathy is more prevalent among older individuals.

Rehabilitation of Achilles tendinopathy:

The most effective treatment is Manaual Therapy Management (Osteopathy/Physiotherapy or rehabilitation.

A few vital points in Osteopathy/Physiotherapy treatment are:

• Adjustment in mechanical loading
• Management of modifiable risk factors
• Prognosis of the symptoms over time

Rehabilitation starts with the rest and icing of the tendon. You can also incorporate some pain killers in the initial states.

The most appropriate exercise for Achilles tendinopathy are:

• Stretching of calf muscles (gastrocnemius and soleus muscles)
• Eccentric exercises

In the initial days of eccentric exercises, there can be an increase in the intensity of pain.

The significant eccentric exercises are:

• Tiptoes on both of your legs while keeping the legs straight
• Tiptoes on both of your legs while keeping the knees bent
• Tiptoe on one of your legs while keeping it straight
• Tiptoes on one of your legs while keeping the knee bent
• Heel drop over the edge of a step while keeping your leg straight
• Heel drop over the edge of a step while keeping your knee bent

Perform all of these exercises at 15 repetitions and three sets twice a day.

Controlled tendon loading is another technique for the treatment of Achilles tendinopathy.

Three main exercises for it are:

• Isotonic loading
• Energy storage loading
• Isometric loading

Custom orthotics for Achilles tendinopathy:

Custom orthotics as foot insoles can help with Achilles tendinopathy. Professionals can guide you about the custom need of your condition.

Insoles can help in rectifying the excessive pronation due to tendinopathy. These orthotics will help in reducing the risk of tendon rupture.

A walking foot brace or Achilles tendinitis brace can help the ankle to retain its position. If your ankle stays in a controlled position during movements, it can reduce the risk of further damage.

Heel lifts can help the patient to keep his ankle into a plantarflexed position and reduce the strain.

Braces and lifts should form part of a plan to get you mobile and weight bearing, not a substitute for treatment and rehabilitation.

Takeaway:

Achilles tendinopathy is the condition of the Achilles tendon leading to a degeneration of the tendon. The leading cause of this condition is acute or repetitive injury. Athletes with running activities are more prone to this condition. The only treatment of Achilles tendinopathy is physical therapy or rehabilitation. Treatment includes rest, immobilization, gentle stretching, eccentric exercises, and controlled loading of the ankles. In case of severe damage, surgical interventions are introduced.

While exercises programs are effective, a proportion of patients who complete loading protocols (prescribed exercise) continue to experience symptoms at five years follow up. One of the potential explanations for this relates to the incomplete understanding of the mechanisms underpinning the injury and not identifying influencing factors such as movement patterns, previous injury along with muscle and joint dysfunction.

The Deansgate Osteopathic Clinic Approach To Resolving Achilles Tendinopathy

– Injury Assessment

– Full Body Assessment

– A Dynamic Gait Analysis

– Treatment

– Rehabilitation 

Injury Assessment

We include an assessment and give a diagnosis and provide you with a plan to treat and rehabilitate the injury.

Full Body Functional Assessment 

A comprehensive assessment of how you move examining strength, balance and coordination, a process to identify adaptive muscle and joint function which can lead to compensation patterns, injury, and performance loss in sports.

This also includes a Posture and spinal assessment, an optimum posture maximises how we use our body to perform not just sporting actions but everyday activities minimising the stress on the body, a major influence on our health and injuries.

Dynamic Gait Analysis

A Gait Analysis assesses the way you walk/run, our Footscan unit is a 8000 pressure sensor unit that provides precise data on your movement.

Using the latest innovative technology, the pressure plate analysis can identify abnormal foot pressures and movements during the gait cycle that are not visible, helping to diagnose lower limb conditions.

From a Gait Analysis we may recommend custom orthotics, these can be ordered and fitted as required by ourselves.

Custom Orthotics are foot supports use to balance foot movement, improve function and stability, most used to relieve foot or ankle pain, and other lower body conditions.  Although over-the-counter orthotics may be used to alleviate acute discomfort, the reality is they are more guess work and, improperly prescribed they can lead to pain and discomfort, and even cause serious injury!

Our Custom Orthotics are based on data from a Gait Analysis which provides the data for the only true 3D printed Custom Orthotics.

Report Of Findings

During the whole process we will discuss the examination and what each test and exercise tells us with a summary of findings. 

The findings help construct a treatment plan to maximise recovery and injury rehabilitation.

Plan of Action

Along with our report of findings we will provide a plan based on the information gathered combined with extensive clinical knowledge to get you back to loving the sports and activities you enjoy.

This can include treatment modules, exercise rehabilitation and custom orthotics 

If Achilles Tendinopathy is stopping you contact the clinic and let us help you get back to doing the things you love.

Gait Analysis & Assessment

References:

• Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports medicine and arthroscopy review. 2018 Mar 1;26(1):16-30.

• Maffulli N, Longo UG, Kadakia A, Spiezia F. Achilles tendinopathy. Foot and Ankle Surgery. 2020 Apr 1;26(3):240-9.

• Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed research international. 2016 Nov 3;2016.

• Jomaa G, Kwan CK, Fu SC, Ling SK, Chan KM, Yung PS, Rolf C. A systematic review of inflammatory cells and markers in human tendinopathy. BMC musculoskeletal disorders. 2020 Dec 1;21(1):78.

• Murphy M, Rio E, Debenham J, Docking S, Travers M, Gibson W. Evaluating the progress of mid-portion Achilles tendinopathy during rehabilitation: a review of outcome measures for muscle structure and function, tendon structure, and neural and pain associated mechanisms. International journal of sports physical therapy. 2018 Jun;13(3):537.

• Silvester M. Calf stretching in correct alignment. An important consideration in plantar fasciopathies. Journal of bodywork and movement therapies. 2017 Jan 1;21(1):212-5.

• McCormack JR, Underwood FB, Slaven EJ, Cappaert TA. Eccentric exercise versus eccentric exercise and soft tissue treatment (Astym) in the management of insertional Achilles tendinopathy: a randomized controlled trial. Sports health. 2016 May;8(3):230-7.

• Lee KK, Ling SK, Yung PS. Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift. BMC musculoskeletal disorders. 2019 Dec;20(1):1-2.

• Silbernagel KG Brorsson A Lundberg M.The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med. 2011;39(3):607-13.

   

• van der Plas A de Jonge S de Vos RJ, et al.A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214-8.

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