Achilles Tendinopathyl

By Dr. Chad M. Pens

Since the time of Homer’s Iliad, Achilles has been the name associated with the tendon that connects the calf musculature to the heel. According to Greek mythology, Achilles was only vulnerable at his heel. The Achilles tendon is the largest tendon in the human body and can withstand forces of 1,000 pounds or more; however, it is also the most frequently ruptured tendon in the body. Chronic pain associated with the Achilles tendon is very common among physically active individuals, particularly those involved in activities that include running and jumping. There are an estimated 34 million runners in the United States, and 2 out of every 3 will sustain an overuse injury that will prevent them from running. Achilles tendon injuries are the most common overuse injury suffered by the leg, accounting for between 5-18% of all running injuries.

 

The cause of chronic Achilles tendon pain is multifactorial. Overuse, age-related changes, structural abnormalities, insufficient muscle flexibility, mechanical overload, muscle weakness, and biomechanical faults are potential contributing factors. Tendonitis, as it is most commonly referred, is an overuse injury wherein the tendinous tissue becomes overwhelmed by repetitive forces that exceeds the body’s ability to repair the damage. Current research shows that there is an absence of inflammatory cells and chemicals, therefore the more accurate terminology today is to say tendinopathy, instead of tendonitis, indicating there are pathological changes within the tendon itself. Achilles tendinopathy most commonly affects recreational male runners between the ages of 35 - 45 and is considered to be secondary to overuse.

The most common causes of Achilles tendon injuries include inadequate muscle flexibility or length, excessive pronation, and training errors such as sudden increases in duration, frequency, intensity and type of exercise. Alignment issues at the hip, knee, ankle and foot as well as weaknesses in the hip can lead to increased stress on the Achilles tendon.

The symptoms of Achilles tendinopathy follow the familiar pattern that other tendon injuries do. First, the tendon will demonstrate mild diffuse or localized pain after exercise only. This is followed by stiffness in the tendon associated with the first few steps in the morning and often subsides as the morning progresses. Next, the tendon is “tight” at the start of physical activity, but eventually warms up and goes away with exercise. The more severe the tendon injury, the more the tendon pain persists with exercises resulting in a sense of weakness in the leg that may necessitate stopping due to pain. Occasionally there is perceived thickening of the tendon itself. The location of the tendon pain is either at the tendon insertion on the heel (calcaneous) or approximately 1.5 inches above the heel.

Treatment depends on the degree of injury to the tendon and the severity of the pain. The plan of care will ultimately depend on the specific findings of the physical therapist’s evaluation in order to establish a treatment plan specific to the injured individual. Initial rest from the aggravating activity is recommended along with ice to control for pain. Exercise modification is necessary to allow for the injured tendon to be rested. A flexibility or stretching program to address inflexibilities in the calf muscles is very common. Footwear changes or recommendations are often made. Orthotics can be fabricated to correct for excessive pronation of the foot. Your physician may prescribe NSAIDs 9non-steroidal anti-inflammatory drugs) to help control for pain and irritation. One must be very careful about continuing the exercises in question when taking these medications even in lower doses. Since the pain is reduced by the medications, continuing to run and jump can cause further structural damage to the tendon. Specific strengthening exercises to load and strengthen the muscle and tendon itself are necessary to facilitate tissue repair. Ultimately this will allow the injured tendon to tolerate the high stresses as mentioned earlier and allow the individual to return to running and jumping again. When it comes time to return to sporting activities again, your therapist will establish a gradual return to sport plan to follow.

You may not be able to prevent Achilles tendinopathy, but here are steps you can take to reduce your risk of injury:

• Make sure you have good footwear for whatever your exercise of choice may be. It is important to have adequate cushion under you feet given that the forces at heel strike when walking are 2 times your body weight and when running are in excess of 5-7 times your body weight.
• Changing your footwear after 500 miles of wear is important whether you walk or run for exercise.
• If you have flat feet, make sure you have good arch supports or corrective orthotics, if they have been prescribed for you.
• Avoid common training errors like doing too much too soon. Increasing intensity (sprinting), adding hill training, training frequency, or increasing mileage too fast can lead to breakdown. When attempting to increase mileage, do so gradually making sure not to increase mileage by more than 10% per week.
• Flexibility of your calf muscles is key. Be sure to stretch after a light warm up and again after your exercise program, and remember to cool down appropriately.

Achilles tendon pain can be very debilitating and can become a chronic condition. If you have been suffering from Achilles pain, do what is best for you and your body and seek professional medical assistance today. Do not try to run through the pain or just rest and hope for it to go away. See your physical therapist today to get you back on the road to pain free exercise.