The Achilles tendon, located at the back of the ankle, is the thickest and strongest tendon in the body. The tendon is an extension of the calf muscles (gastrocnemius and soleus) and it attaches to the heel (calcaneus). When the calf muscles contract the foot is pushed in a downward direction. This allows for push off in walking, running, jumping and standing on the toes. Each Achilles tendon is subject to a person’s entire body weight with each step and during a sprint or push off this can be significantly increased. A common disorder of the Achilles tendon is tendinosis. This describes a condition in which the tendons normal structure is compromised and some degenerative changes are generally present. Pain, swelling and restricted activity occur as a result of these changes.
Causes of Injury
Achilles tendinosis is usually caused by overuse or overloading of the calf muscles. There are a number of factors which could increase a person’s risk of developing this condition by placing excessive force on the Achilles. These include:
- A recent or sudden increase in intensity, frequency and duration of activity, particularly those involving running and jumping
- Change of training surface or running on hard or uneven surfaces, including hills
- Inadequate or reduced rest periods between activity
- Inappropriate, or change of, footwear
- Poor biomechanics of the foot (ie. High or low arches)
- Tightness or weakness in the calf muscles
- Ankle stiffness
Signs and Symptoms
Achilles tendinosis can be either acute (occurring over a period of a few days, following an increase in training) or chronic (gradual onset over a prolonged period). If an acute episode goes untreated it may develop into chronic Achilles tendinosis, which is much more difficult to treat. The most common signs and symptoms include:
- Pain at the back of the ankle, just above the heel bone where the Achilles tendon inserts
- Pain and stiffness in the morning or following a period of rest
- Pain with exercise, particularly with sprinting, which may or may not reduce once warmed up. In chronic cases the pain is more likely to persist
- Stiffness of the tendon and discomfort with calf muscle stretches
- Tenderness on palpation and swelling or thickening of the tendon
- Impaired strength and movement of the affected leg
Immediate Treatment/ Management
Initially treatment is aimed at managing pain and reducing any further damage to the tendon. Seeking treatment or advice early is extremely important and will generally consist of:
- Education and advice regarding the condition and discussion of likely contributing factors and how these can be modified
- Relative rest from aggravating activities
- Ice after activity
- Elevation of the leg to assist in reducing swelling
- Heel raises or wearing a shoe with a heel to reduce stretch on the tendon
- Physiotherapy- ultrasound, massage, dry needling, taping, orthotics and a customised rehabilitation program consisting of stretching and strengthening
- Advice to consult a pharmacist or doctor regarding pain relief or anti-inflammatory medication when required.
Return to Sport/Activity
Achilles tendinosis, if managed promptly and properly, should resolve after 4-6 weeks. If, however, the injury is left and treatment is not sought early further tendon damage or a tendon tear may result and recovery can take months.
Once pain is controlled, a gradual return to activity will be commenced as appropriate. Heel raises and taping may be used to reduce loading on the tendon initially.
Most people will find relief with non-surgical treatment, however if all conservative treatment options have been exhausted and the individual has not progressed after 4-6 months, surgery may be considered. Surgical options include removal of the damaged portion of the tendon, lengthening of the tendon or moving the tendon attachment. Each of these will result in a lengthy rehabilitation process.