Achilles Tendinopathy

Achilles tendinopathy can cause several symptoms, including:

• Increasing pain, usually at the back of your leg or heel.
• Stiffness in the Achilles tendon, particularly on rising in the morning. This will often ease after a few minutes of walking but may last longer.
• Swelling at the back of your ankle.
• Tenderness when you touch the tendon.
• A grating noise or creaking feeling (crepitus) when you move your ankle.

Achilles tendinopathy can affect your day-to-day life. It may mean you need to take time off work, especially if you have an active job. You may not be able to do a lot of activity, including sports, until your tendon gets better.

The exact cause of Achilles tendinopathy is still not completely understood, but it commonly results from overuse injury.

Achilles tendinopathy was previously known as Achilles tendonitis because it was originally thought to be the result of inflammation within the tendon (“tendo” = tendon, “itis” = inflamed). However, the underlying process is no longer thought to be inflammatory in nature and tendinopathy is probably a more suitable term as it reflects a more generalised tendon injury.

We know that tendinopathy occurs when a tendon is unable to adapt to the strain being placed upon it. This leads to repeated small amounts of damage within the tendon fibres and results in the tendon trying to heal itself in response to this damage.

Whilst this problem can affect both athletes and non-athletes, it is more common in people who take part in sports that mainly involve running; such as football, tennis, volleyball, badminton, and middle- or long-distance running. It affects people of all ages and both men and women.

Risk Factors

• Age: Achilles tendinopathy is most common from the age of 30yrs onwards.
• Gender: It is more common in men.
• Weight: If you have are overweight then you are more likely to develop Achilles tendinopathy.
• Diabetes, High blood pressure, High cholesterol, or Thyroid problems: all increase your risk of developing Achilles tendinopathy.
• Family history of tendon problems.
• Previous injury of your Achilles tendon or muscles around it in the past.
• Antibiotics: taking antibiotics belonging to the quinolone group can increase your risk of developing Achilles tendonitis whilst you are taking them.
• Footwear: wearing the wrong sort of shoes or ones that don’t fit properly — especially if they push on the back of your heel.
• Foot Anatomy: having a high-arched or low-arched foot — this can put more strain on your Achilles tendon.

Sports and other activities can put a lot of stress on your Achilles tendon. You may also increase your risk of damage if you:

• Use badly designed equipment, including wearing the wrong
• Footwear.
• Suddenly increase how much exercise you do.
• Training on hard, slippery or slanting surfaces.
• Exercise in extreme weather conditions, especially the cold.

Achilles tendinopathy can usually be diagnosed from the typical symptoms described above.

Occasionally, your GP may suggest that you have an ultrasound scan to see if there are any significant tears in your Achilles tendon if the symptoms persist despite conservative management or there is clinical concern.

If your symptoms are very bad, or have lasted for more than six weeks, you may be referred to an orthopaedic surgeon who specialises in foot and ankle surgery.

If you have an underlying condition, such as arthritis, diabetes or high cholesterol levels, you may also be referred to a specialist doctor.

There are several things you can do to help prevent Achilles tendinopathy:

• If you have underlying health problems that put you more at risk, make sure they’re being treated properly.
• Lose weight if you’re overweight to reduce the strain on your Achilles tendon.
• Make sure your shoes fit properly. They should have a lace-up fastening that keeps your heel in place. There should be enough room at the top so your toes can move around freely.
• Whether you’re working or exercising, make sure you use the right equipment and techniques.
• Limit repetitive motions that overuse your tendon.
• Whatever exercise you do, build up slowly. Gradually increase the intensity and the length of time you spend being active.
• Warm up your muscles before you exercise and cool them down after you’ve finished.

Follow these steps for 2 to 3 days to help manage pain and to support the tendon:

• Rest: try to avoid moving the tendon for 2 to 3 days.
• Ice: put an ice pack (or try a bag of frozen peas wrapped in a tea towel) on the tendon for up to 20 minutes every 2 to 3 hours.
• Support: wrap an elastic bandage around the area, use a tube bandage, or use a soft brace. You can buy these from pharmacies. It should be snug, not tight. It’s important to take a bandage or brace off before going to bed.
• Heel Lifts: these can be bought over the counter or online and have good evidence of benefit. Raising the heel takes the pressure off the tendon as it doesn’t have to stretch as much to reach the floor.
• Painkillers such as paracetamol or ibuprofen may help to relieve pain. Ibuprofen is from a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs). However, you should not use ibuprofen or other NSAIDs for more than 7-14 days if you have Achilles tendinopathy. This is because they may possibly reduce the ability of the tendon to heal in the long term. They may also cause symptoms of Achilles tendinopathy to be masked, or covered up, which again may delay healing. Your pharmacist can recommend the best painkiller for you. They may also recommend a nonsteroidal anti-inflammatory (NSAID) cream or gel you rub on your skin.

When you can move the injured area without pain stopping you, try to keep moving it so the joint does not become stiff.

To help prevent further injury or pain, try to avoid:

• heavy lifting, strong gripping or twisting actions that make the symptoms worse
• playing sports, until the tendon has recovered

If your symptoms aren’t any better after a week or two, you should consider booking an appointment with a physiotherapist. You can either do this privately or via self-referral to an NHS physiotherapist. If you can’t self-refer in your area, ask your GP to refer you. A podiatrist may also be able to help you by advising on footwear (see below).

Physiotherapy can help to strengthen and stretch your Achilles tendon. You’ll probably be recommended to do the exercises every day for at least three months to get the best out of them.

Exercises

The following exercises will help to stretch and strengthen your Achilles tendon and have been proven to be helpful. You should aim to do these every day. Such exercises may help with pain control and stiffness.

• Stand about 40 cm away from a wall and put both hands on the wall at shoulder height, feet slightly apart, with one foot in front of the other. Bend your front knee but keep your back knee straight and lean in towards the wall to stretch. You should feel your calf muscle tighten. Keep this position for several seconds, then relax. Do this about 10 times and then switch to the other leg. Now repeat the same exercise for both legs but, this time, bring your back foot forward slightly so that your back knee is also slightly bent. Lean against the wall as before, keep the position, relax and then repeat 10 times before switching to the other leg. Repeat this routine twice a day.
• Stand on both feet. Use your unaffected leg to raise up on to tiptoes. Transfer your weight across to your affected leg and lower yourself down. Repeat and aim for three sets of 15 repetitions twice each day. The standing on tiptoe exercise should be performed with your knees straight and with your knees bent.
• Stand on the bottom step of some stairs (facing upstairs) with your legs slightly apart and with your heels just off the end of the step. Hold the stair rail for support. Raise up on tiptoes, then, standing on the affected leg, lower your heel, keeping your knee straight. Put your good leg down before lifting your heel. Repeat and aim for three sets of 15 repetitions twice each day. Repeat but this time keeping the knee of the affected leg slightly bent. Try to do these exercises twice a day. These exercises are sometimes called Alfredson’s exercises after the person who first showed that they work.
• Keep a towel (or a long piece of elastic) by the side of your bed. First thing in the morning, before you get out of bed, loop the towel around the ball of one of your feet. Then pull the towel towards you, keeping your knee straight. Hold the pull for about 30 seconds. This exercise will pull your toes and the upper part of your foot towards you. Repeat this exercise three times for each foot.
• Sit on a chair with your knees bent at right angles and your feet and heels flat on the floor. Lift your foot upwards, keeping your heel on the floor. Hold the position for a few seconds and then relax. Repeat about 10 times. Try to do this exercise five to six times a day.

You can find further Achilles tendon exercises and video demonstrations on the Tyneside Integrated Musculoskeletal Service patient information site here.

A podiatrist specialises in conditions that affect the feet and can analyse the way you walk. They can also advise you about wearing the right footwear to suit your feet, posture and activities. Wearing orthotics (special inserts) in each shoe may help to treat and prevent Achilles tendinopathy. These may also help if there’s a problem with the shape of your foot or the way your foot works. If you have a low foot arch, this increases the stress on your Achilles tendon. You can buy orthotics from pharmacies or other retailers, or they can be custom-made for you by a podiatrist.

In most cases Achilles tendonitis will improve over several weeks with conservative home management although it may take several months to fully settle.

You should therefore consult your GP if:

• your symptoms are not improving over time
• you’re in a lot of pain
• you think you have ruptured (torn) a tendon*
• your symptoms came on after starting antibiotic medication

Sudden pain in your heel or calf can mean that you have torn the tendon. This is called an Achilles tendon rupture. Your tendon becomes swollen, bruised, and sore, and you may even hear it snap. If this happens, seek urgent medical advice.

Achilles tendinopathy is a self-limiting condition and will therefore usually settle over time without the need for specialist intervention. However, in severe or chronic cases where the usual conservative measures (see above) have failed to help, your GP may refer you to an Orthopaedic specialist to consider other treatments:

Extracorporeal shockwave therapy.

A machine passes shockwaves through your skin to the damaged part of your tendon. You may need several sessions. This will only be used if your consultant thinks it is appropriate and is only available in some areas. It is usually performed in hospital through the department of radiology.

Surgery for Achilles tendinopathy

It is very unusual for Achilles tendinopathy to require surgery, particularly because of the potential for complications.

• Achilles Tendinopathy, Treatment & Information – Patient.info
• Achilles Tendinopathy: Advice & management, information for patients – Oxford University Hospital NHS Foundation Trust
• Achilles Tendinopathy – Tyneside NHS Integrated Musculoskeletal Service

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