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Monday, March 20, 2017

Achilles tendinopathy- Symptoms, Causes & misconceptions

Today we’re going to talk through a very common injury that we see at Fix Physio- Achilles Tendinopathy.

What is the Achilles tendon?

The achilles tendon is one of the 2 main load bearing tendons in the lower limb along with the patella tendon of the knee. It is situated at the end of gastrocnemius (calf) muscle in the lower limb and attaches into the heel bone- the calcaneus. The term “Achilles” is associated with the Greek mythological warrior- Achilles and this tale suggests that his heel is the weakest and most vulnerable part of his otherwise indestructible body. This couldn’t be further from the truth in reality as the Achilles tendon is inherently one of the strongest tendons of the body- commonly coping with forces of 3787 Newtons during a hopping jump (fukashiro et al 1993).

The calf is comprised of 3 muscles, Gastrocnemius, Soleus & Plantaris. The achilles is the junction of all 3 of these and attaches the heel. The achilles is responsible for practically any activity that involves moving the foot from walking and running to jumping and standing on tip toe.

  • Gastrocnemius– crosses both the knee and the ankle and is responsible for flexing the knee and palntarflexing the ankle. The gastrocnemius is predominantly made up of fast twitch fibres so is responsible for explosive actions.
  • Soleus– crosses just the ankle and is responsible for plantar flexing the ankle- particularly in a bent knee position. The soleus is predominantly made up of slow twitch fibres and so is involved more in postural control and deceleration of landing leg during running.
  • Plantaris– the longest tendon in the human body and is absent in 8-12% of the population.The plantaris crosses the knee and the ankle and is responsible for weakly  plantar flexing the the ankle and flexing the knee. The plantaris muscle may also provide proprioceptive feedback information to the central nervous system regarding the position of the foot.
    The term “Tendinopathy” essentially means a dysfunction of the tendon.
    anatomyofthecalfmuscle2

Signs and symptoms

Achilles Tendinopathy is commonly sore, red, warm or swollen in one of two places within the tendon:

  1. The middle of the tendon itself and this commonly produces a palpable tender lump/ bump in the tendon body. Even when the pain symptoms of the tendinopathy have resolved, the bump may remain depending on the stage of the condition that the tendon had reached. achillestendonjpg_edited
  2. At the point where the tendon inserts into the heel bone and this is called an “insertional” Achilles tendinopathy. This is often due to a bony spur on the calcaneus rubbing against the tendon called a “Haglund’s deformity”. hadlundsdeformitybrandonpodiatrist

People who suffer from Achilles tendinopathy often complain of excruciating pain in the tendon on waking in the morning for the first 10-30 minutes. They also commonly complain that their achilles is painful at the start of exercise, gets easier during exercise then it is sore again after they stop exercising. In chronic cases the tendon be constantly painful with no reprieve in symptoms.

Finally, a crunching sound or feeling can sometimes be noticed when you use the Achilles.

What causes Achilles Tendinopathy? 

There are several factors which contribute to Achilles tendinopathy but the most important of which is that the Gastrocnemius/ Achilles tendon complex is not strong enough to cope with the amount of load that you are putting through it. We will take about what exercises to do to improve this strength in our next blog “Fix my Achilles injury”.

Other factors that contribute to Achilles tendinopathy are:

  1. Poor load management– this means that the person has done too much too soon. In particular, activities that require the tendon to store energy such as walking, jumping or hopping and loads that compress the tendon. Anybody that increases their training load by more than 10% from that of the previous week is far more at risk of injury than somebody that stays below the 10% load increase (Gabbett, 2016). This applies to all areas of the body and below is a good example of a runner doing “too much too soon”:Week 1: 2x 7.5km run + 1 x 15km run week 1 (30km cumulative km for the week)
    Week 2: 2 x 10km + 1x 20km run in week 2 (40km cumulative km for the week)This is a 33.33% increase in the weekly running load and this is highly likely to result in an injury somewhere in the body.
  2. Muscle imbalances/ joint stiffness higher up the chain– what we mean by this is that certain muscles up the leg, into the hips or in the lower back are weak or tight/ spasmed. Furthermore, certain joints up the leg, into the pelvis or in the lower back may be stiff.
  3. Poor footwear– Flat shoes or being bare foot usually irritates achilles tendinopathy and we recommend that somebody with this injury should either wear shoes with a small heel, running shoes that are raised at the heel compared to the toe or actually put a small heel raise of more than 6mm in your shoe. This works as it allows the achilles tendon to be taken off stretch.
    screenshot20131028at83442pm
    It is a common misconception that you should stretch an achilles tendinopathy- this can often make it worse. We also recommend that you have your shoes next to your bed and put them straight on in the morning. Finally, don’t go barefoot around the house- particularly on hard floors such as stone, wood or laminate.
  4.  Increased BMI– the more weight going through a sore achilles tendon, the more load an already weakened achilles tendon is going to have to cope with. If necessary, losing weight is a good option to speed up recovery of an Achilles tendinopathy.
  5.  Haglund’s deformity– as mentioned above.

Common misconceptions about Achilles tendinopathy treatment

  1. Tendinopathy improves with rest alone. We often hear patients say that they felt pain in their achilles so they rested it from the aggravating activity for 2-3 weeks and it felt better. However, when they went back to the aggravating activity- the pain instantly returned. Rest alone does not solve the problem, the best evidence is graded and specific exercise as prescribed by your physiotherapist.
  2.  Achilles Tendinopathy is caused by inflammation of the tendon. There is no good evidence to support this statement and biopsy studies of patients with Achilles Tendinopathy have shown no signs of inflammatory cells under a microscope. This is why the term Achilles “Tendonitis”- “itis” meaning inflammation, has been replaced by the term “Tendinopathy”.
  3. Stretching helps Achilles Tendinopathy. The best evidence for treatment of this injury is in load management. At best, stretching doesn’t help at all, at worst, stretching makes Achilles Tendinopathy worse. This is particularly true for patients who have the insertional tendinopathy as described above. Stretching can cause the achilles tendon to rub against the Haglund’s deformity and irritate the achilles.
  4. Massaging your painful achilles tendon is helpful. If the tendon is irritated, massage can actually increase your pain. However, massage of the attached muscle ie Gastrocnemius, Soleus or planters can be helpful (Jill Cooke).
  5. Achilles Tendinopathy is a prerequisite to achilles rupture. In actual fact most people who rupture a tendon have never had pain before, despite the tendon having substantial pathology in it (Jill Cooke)

So that was a little background information on the signs, symptoms, causes and common misconception of Achilles Tendinopathy. For the best way to manage this common and annoying injury, go to our next blog “Fix my Achilles injury” for advice on the best exercises and other treatment modalities to sort your injury out for good!

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