Achilles tendinopathy is an injury to the Achilles tendon due to repetitive use. In its literal sense, tendinopathy means a disease or disorder of the tendon.
A tendon is a strong, fibrous band that attaches the muscle to the bone. The Achilles tendon (calcaneal tendon) is the largest and strongest tendon in the body, and it connects the muscles of the calf to the heel bone of the foot (called the calcaneus).
This tendon is powerful and can endure great tensile forces. The Achilles tendon is responsible for raising the heel, which is essential in walking, running, jumping, stair negotiation and standing on tip-toe.
Why Is Tendinopathy Painful?
Achilles tendonitis as a form of tendinopathy is usually painful because of inflammation. The inflammation impinges on the nerves resulting in pain and tenderness in the affected area.
Individuals suffering from Achilles tendinosis do not always experience pain. It is not well-known why some people experience pain when they have tendinosis. Some studies suggest that the pain is due to the tangled formation of new nerves and blood vessels that are not as functional as they should be.
The major defining symptom of Achilles tendinopathy is a pain in the morning felt just above the heel bone. This is because the Achilles tendon remains in its relaxed, resting position during sleep. I
mmediately upon waking up, the tendon has to tolerate a full range of motion resulting in the stretching of the tendon as the affected individual takes their first step in the morning.
Symptoms of Achilles Tendinopathy?
- Pain and stiffness in the morning
- Thickening of the tendon
- Tenderness, swelling that is warm to touch
- Difficulty walking due to pain
Achilles tendinopathy is graded based on severity.
Table 1: Degree of severity
|Grades||Sign and Symptoms|
|Mild||Pain in the Achilles tendon during activity or immediately after activity, such as running|
|Moderate||Swelling or nodule formation|
|Severe||Pain caused by weight-bearing|
Rupture or tear of Achilles tendon (rare)
Is Achilles Tendinopathy Permanent?
Experts believe that the prognosis will be poor if the degeneration of the Achilles tendon is already extensive, especially if the cause is repetitive overuse.
This means that the injury is permanent and irreversible, and it may be difficult for the individual to return to his/her normal activities.
The degeneration may also be accompanied by adhesions in the paratenon which is the sheath that envelops the Achilles tendon. This results in poor flexibility and weakness of the Achilles tendon leading to further degeneration.
What Happens if Tendonitis Is Left Untreated?
Achilles tendonitis left untreated may result in repetitive injuries leading to scarring, permanent degeneration and tendinosis.
Continuous inflammation and pain decrease the tendon’s flexibility and make it very difficult to carry out normal day-to-day activities, thereby affecting the quality of life.
Repeated microtears may also result in partial or full tendon rupture or tear. This will require the individual to undergo a serious and more difficult treatment intervention such as surgery to repair the torn tendon.
What Is the Initial Treatment for Achilles Tendinopathy?
Initial treatment for Achilles tendinopathy includes:
- Resting the area and avoiding activities that cause pain. Individuals are advised to take 1-minute breaks for every 15 minutes of low-impact activity or 5-minute breaks for every 20 to 30 minutes of low-impact activity. The greater the extent of the injury, the more break or rest time needed. Generally, if the activity causes pain, it means that the load is too much for the tendon and the activity should be stopped.
- Use of arch support, taping or bracing can be helpful to improve the alignment of the foot – especially if the individual has a flat foot – and to prevent excessive load on the Achilles tendon.
- Non-steroidal anti-inflammatory drugs (NSAIDs) may be given to individuals with Achilles tendinitis. However, it may not be beneficial to individuals with tendinosis as some NSAIDs are thought to hinder collagen repair which will only aggravate the degeneration associated with tendinosis.
- Deep friction massage to prevent adhesions for tendonitis and to stimulate collagen production for tendinosis.
- Stretching and active movements are beneficial for individuals suffering from tendinopathy as long as it is done in a pain-free range.
- Physical therapy will help the individual manage the pain, facilitate flexibility and strengthening exercises and teach proper biomechanics and correct posture to prevent aggravation and reinjury.
What Happens if the Initial Treatment Fails?
If the initial treatment for tendinopathy is not successful, the individual should be reassessed to check for other causes and to evaluate if other treatment options may be needed.
If all conservative treatment has been done and is still ineffective, surgery may be needed to repair the tendon.
Should I Stretch With Achilles Tendinopathy?
Light stretching and moving the ankle in natural motions are beneficial as long as the movements do not cause pain. This will prevent unnecessary tightening of the Achilles muscle and nearby muscles while maintaining their functional strength.
Stretching and functional movements also increase blood circulation in the area, providing nutrients needed for healing and repair and preventing degeneration.
Is Heat Good For Tendinopathy?
Recent studies have shown that cryotherapy or application of ice in combination with proper exercise is more beneficial than heat or thermal therapy (warm compress increases blood circulation).
It is thought that the vasoconstriction or the narrowing of the blood vessels due to cryotherapy helps limit the abnormal formation of new blood vessels in the tendon.
It is advised to place ice on the affected area for 15 – 20 minutes several times a day and after performing exercise or activity. There should be at least a 45-minute gap in between the application of ice.
How Long Does Achilles Tendinopathy Take to Heal?
Achilles tendinopathy can take several days to months to heal depending on the severity and whether treatment was started when the injury was in the acute or chronic stage.
Achilles tendonitis usually heals in a few days and between six to nine weeks. Treatment is focused on reducing the inflammation, managing the pain, preventing re-injury and gradually returning to function.
Achilles tendinosis requires three to six months, extending up to nine months for individuals with severe degeneration. The focus of treatment is on breaking the cycle of reinjury, facilitating long-term repair, improving blood circulation for adequate healing and enhancing collagen production.
How Do You Prevent Achilles Tendinopathy?
The following things can be done to prevent Achilles tendinopathy:
- Activity or exercise should progress gradually. The duration and intensity of exercise should be increased slowly to ensure that the load and tensile forces that will act on the tendon are not excessive enough to cause an injury.
- Perform warm-up exercises to prepare the muscles and tendons of the body, especially when doing high-impact activities.
- Incorporate stretching and strengthening exercises in daily activities to ensure that the muscles and tendons are strong enough to handle stress during extensive activities.
- Do cross-training by alternating high-impact activities such as running and hill-climbing with low-impact exercises such as swimming and cycling.
- Avoid high heel shoes, which may make you prone to injury. Wear good quality supportive shoes while exercising and performing sports activities.
What Causes Achilles tendinopathy?
The primary cause of Achilles tendinopathy is overuse. When one places stress on the Achilles tendon, the fibrous structure develops microscopic tears. These tears can lead to degeneration when the tendon is not given enough time to heal and repair itself.
Runners and athletes who play sports with a lot of jumping, such as basketball and volleyball, are prone to Achilles tendinopathy.
A rapid increase in the intensity or amount of exercise activity, such as making sudden changes in a running or exercise program without giving time for the body to adapt, can also lead to Achilles tendinopathy.
Foot problems could also cause Achilles tendinopathy. Individuals who have a collapsed foot arch or flat-foot are prone to Achilles tendinopathy. The flat arch constantly pulls and strains the Achilles tendon resulting in mechanical stress which leads to microtears.
Individuals who are overweight and obese are also at risk for developing Achilles tendinopathy since excessive weight places more significant strain on the foot and the Achilles tendon
What Is the Difference Between Achilles Tendonitis and Achilles Tendinopathy?
Achilles tendinopathy is a broad term used for chronic tendon issues or disorders.
Achilles tendonitis is defined as the inflammation of the Achilles tendon. It is an acute injury, which means that its occurrence is usually severe with sudden onset. The inflammation associated with tendonitis is due to acute overloading of the tendon, trauma, or Achilles muscle and tendon fatigue.
Achilles tendinosis is the degeneration of the collagen fibers (fibers that make up the tendon) because of chronic overuse. Repeated microtears without giving the tendon adequate rest to repair itself result in impaired healing of the tendon.
During impaired healing, the collagen fibers become disarrayed, chaotic and unable to properly link the torn tissues, rather than forming uniform cables to link torn fibers. This inability to connect the torn tissues creates scar tissue that is weak and has poor flexibility.
Since Achilles tendinosis is a chronic injury, it is highly plausible that its cause is due to multiple factors such as poor healing, overuse, muscle tightness and poor blood circulation in the tendon.
Dr Aarti is an MBBS (Bachelor of Medicine and Surgery) from Baroda Medical College (The Maharaja Sayajirao University, Baroda). Dr. Aarti has also completed her Masters of Medical Science and Technology from the prestigious Indian Institute of Technology, Kharagpur.