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No.8 Achilles Tendinosis

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In the second of our series on the ailments distance runners can suffer, former national cross country champion and physiotherapist Robbie O'Donnell looks at achilles tendinosis.


What Is Achilles Tendinopathy?

The Achilles Tendon is the rope-like structure found behind the ankle. It connects the calf muscle to the heel of the foot. Its purpose is to transmit the forces generated by the calf into the foot to allow pushing off the toes (such as when hopping or running). 

Historically Achilles Tendinopathy was thought to be inflammation of the tendon. Although this may be true in some instances, a more recent understanding of Achilles Tendinopathy is that these Achilles injuries are due to excessive load being placed onto the Achilles Tendon which actually results in physical changes being made to the tendon structure itself in response to the load.

Tendon injuries can be quite complicated but the easiest way to dumb it down is to say that tendon injuries are all about load management. Overload a tendon and you will have problems but at the same time under loading them is an issue as well. You need to become the “Load Master”. 

Achilles Tendinopathy injuries are generally classified into 3 stages:

Reactive Tendinopathy: This generally involves the tendon responding to a sudden and large increase in loading. For runners this often relates to an increase in distance, increase in how often you’re running or a change in the type of training (such as introducing increased speed or hills).

In this stage the cells react to the load being placed on the tendon and they revert from being passive parts of the tendon to active parts and release chemicals that cause pain. Treatment at this point in time is all about calming the active cells down. It should be the easiest stage of tendon injury to treat but it relies on responding to the pain and resting, icing etc.

This phase of injury is usually a short term adaptive change to the overload and is generally reversible.

Tendon Dysrepair: This phase of injury generally follows Reactive Tendinopathy if the Achilles Tendon continues to be excessively loaded. In overall presentation this phase of injury is similar to the previous phase however the structure of the Achilles tendon starts to break down. Think of it like the fibres of a rope starting to fray from too much stress and strain being placed on the rope.

Degenerative Tendinopathy: This is the final stage of Achilles Tendinopathy. It tends to be more common in the older athlete. This phase of injury is generally in response to the Achilles Tendon being chronically overloaded. By this stage of Achilles Tendinopathy there are numerous changes that have occurred in the tendon which result in its physical structure being broken down and making the tendon less effective at dealing with load. In this stage the tendon often feels thickened as well as lumpy in certain areas.

Although the above stages have been described as separate phases of Achilles injury, our current understanding of Achilles Tendinopathy is that it presents as a continuum (a sliding scale of injury). This means that an Achilles Tendinopathy injury has the ability to present as certain phase but can shift between the above phases as the injury improves or worsens.


Signs and Symptoms

Although the symptoms of Achilles Tendinopathy will differ from person to person and depending on which phase of injury they are in, some of the more common signs associated will an Achilles injury include:

·       A burning pain through the Achilles tendon early in exercise which becomes less severe during exercise (as you have warmed up) but then worsens after the exercise (once you have cooled down).

·       Achilles pain and/or stiffness potentially being worse first thing in the morning.

·       Tenderness in the Achilles tendon and/or a thicker and stiffer feel to the Achilles tendon.

How Does It Happen?

As outlined earlier, Achilles Tendinopathy tends to be developed as a result of overloading the Achilles Tendon due to excessive training either in a short term time frame (acute) or over a longer time frame (chronic).

Other factors that may also contribute to overloading the Achilles Tendon may also include:

·         Pronating feet (flat feet) or uneven leg length.

·         Running uphill or on hard surfaces.

·         Running downhill

·         Running on a slanted surfaces or uneven terrain

·         Gluteal weakness and pelvic instability.

·         Reduced muscle strength and flexibility

·         Running with inappropriate footwear, including proper shoes that have worn out.

How Do I Treat Achilles Tendinopathy?

Remembering that the 3 phases of an Achilles Tendinopathy tend to be a sliding scale of injury, the management of these injuries is usually aimed at treating one end of the scale or the other (meaning that there are only 2 phases of injury management for Achilles Tendinopathy).

Achilles Tendinopathy injuries are either treated as:

·       Reactive / Early Dysrepair

·       Degenerative / Late Dysrepair

Proper management of an Achilles Tendinopathy depends on correctly identifying which phase of injury you are in so please seek treatment with a sports physiotherapist. 

Managing Achilles Tendinopathy in the Reactive / Early Dysrepair phase:

The key focus for treating tendinopathy in the Reactive / Early Dysrepair phase is load management. Load management isn’t as simple as just resting the injured tendon (such as when using crutches) as this can sometimes result in a loss of strength and make return to activity difficult.

Load management is exactly as stated, managing the amount of load placed onto the tendon so that there is enough load to stimulate strengthening and healing but not too much load that may potentially aggravate the tendon. Finding this balance of load is often difficult as a number of things can place load onto a tendon (such as running, walking and even stretching!).

Another thing that can make finding the correct balance of load for a tendon more complex is that tendons don’t always feel sore during activity. In some instances, tendons may pull up sore a couple of hours up to a couple of days following activity.

Treatment is all about very small systematic changes to load - you need to find the appropriate load for the stage of tendinopathy and you wait for the tendon to tell you it is OK.

A good strength/endurance program underpins the management of all tendinopathy treatment!

Avoid calf/achilles stretching. Although this may contradict what you may have been told in the past. Our recent understanding of tendon injuries is that in an acute stage of Reactive Tendinopathy, tendons do not respond well to stretching. As the tendon begins to settle from the acute stage of a Reactive Tendinopathy, stretching exercises may be gradually introduced  and progressed based on your response to treatment (similar to the load management principle). Once again, your physiotherapist can assist in guiding you as to when progressing load or exercises may be appropriate.

In conclusion the common key factors for appropriate management of an Achilles Tendinopathy will include a focus on load management, gradually progressing your intensity/duration of training and an appropriate level of strength exercises.

Appropriate and early examination of the injury can assist in determining which phase of tendinopathy you are in and, as such, can help with customising your rehabilitation to ensure a better standard of recovery. The earlier you seek treatment when you develop achilles soreness the quicker you are likely to respond. A chronically overloaded tendon that becomes degenerative can be very slow to heal.

Article written by Rob O’Donnell, Physiotherapist at Southern Suburbs Physiotherapy Centre and former Australian Distance running representative. Southern Suburbs Physiotherapy has clinics in 3 loactions:  705 Centre Road East Bentleigh, 100 Lower Dandenong Road Parkdale and 99 Bay Street Brighton and there are physio’s with special interests in treating runners at all locations. For more details go to www.sspc.com.au