Achilles Tendon

Clinical Features

  • Often gradual onset but may be sudden
  • Pain with exercise
  • Pain and stiffness worse in the morning
  • Local pain in the Achilles tendon
  • Tendon may be tender to touch
  • Thickening or swelling may be evident

Achilles tendinopathy and tendonitis are conditions causing pain and weakness in the lower calf and heel region. They are common in sporting individuals, with runners up to 30 times more at risk of developing Achilles tendon issues compared to sedentary individuals. The Achilles tendon is comprised of two calf muscle tendons; gastrocnemius and soleus, which attach onto the calcaneus (or heel) of the foot.

Achilles tendonitis is an acute condition involving inflammation of the tendon itself or the soft tissue immediately adjacent to it. 'Tendinopathy' is characterised by thinning and degenerative micro-tearing of the tendon seen. Inflammation may be present in the early stages of the problem, but is almost always absent in the long term, so the backyard advice of 'take some anti-inflammatory pills and hope it will go away' doesn't often work. Long term, the tendon may display abnormal blood vessel formation and collagen fibre disarray with negligible signs of tissue repair. The result is pain and decreased tensile strength in the calf muscle and tendon, heightening the risk of more serious tears or even tendon rupture.

Achilles pain is often caused by overuse or when a sudden unaccustomed load exceeds the tissue tolerance. It may come on when training loads are rapidly increased or recovery time between activity is reduced, triggering mechanical failure of the tissue. Equally, many structures in the human body deteriorate with a lack of use, and the Achilles is no different. It will decondition, becoming weaker over time if there is little demand to keep it strong. Many sedentary individuals make the mistake of commencing a difficult training regime in preparation for a one-off event or seasonal sport. The office worker who decides to do a 20km ‘fun run’ with little training is a prime example. The sudden overload of training places great stress on a tendon that is accustomed to a much lower level of activity and injury results.

Factors which may lead to Achilles tendinopathy

  • Increase in training load
  • Changing running surface
  • Decreased calf muscle strength
  • Tight gastrocnemius/soleus
  • Decreased movement in the ankle, especially dorsiflexion
  • Poor footwear choice or a recent change in footwear
  • Excessive pronation of the mid foot (flat feet)
  • Increasing age leading to reduced flexibility and healing potential

Other Common Causes of Pain in the Achilles Region

  • Bursitis: inflammation of two bursae in this region include the retro-calcaneal bursa and the Achilles bursa.
  • Posterior Impingement Syndrome: Impingement of the soft tissues at the rear of the ankle can occur when the talus (a bone in the ankle) butts into the adjacent aspect of the tibia. This is common in ballet dancers, cricketers and footballers who regularly push the extremes of ankle movement.
  • ‘Sever’s Disease’ is an overuse injury causing pain at the Achilles insertion site at the heel. It is nearly always seen in younger adolescents around 9-11 years of age, with boys having a much higher incidence of the problem than girls.

How can we help?

  • Activity Modification: We can advise you on how to reduce aggravating activities to allow other treatment modalities to be effective and allow healing. This may involve reducing training or completely stopping training for a period with gradual return to sport/activity.
  • Exercise: Research shows an eccentric loading and stretching program prescribed by your Physiotherapist can be highly effective at reducing pain in patients with Achilles tendinopathy. This is a graduated program which will increase from low repetitions and low loads to fast paced, high repetitions with increasing loads and difficulty.
  • Biomechanical Assessment: Correction of foot posture and lower limb biomechanics will often affect pain and function of the Achilles tendon when teamed with other interventions.
  • Manual Therapy: Effectively reduces stiffness in the ankle and foot to help reduce pain and improve range of movement.
  • Taping and Orthotics: These have a role in providing support to the arches of the foot and assist biomechanics in the lower limbs to reduce the stress placed on the Achilles tendon.
  • Electrotherapy: Ultrasound, low level laser therapy and electrical stimulation may be employed by your physiotherapist to help aid the healing process and for pain relief.
  • Anti-inflammatory Medication: Anti-inflammatory medication may provide some relief initially, but as Achilles tendinopathy is not predominantly an inflammatory condition it may have only minor effects in the long term.