Achilles Tendinopathy: Causes, Symptoms, and Best Treatments

What is the best home treatment for Achilles tendinopathy?

Achilles tendonitis can be treated at home using relatively simple methods, and self-care is important to prevent recurring episodes.

At-home treatment methods include:

Pain relief & modalities

• Rest: Avoid activities that hurt your tendon and allow recovery.
• Ice: Apply ice on your back of your heel to reduce pain and swelling.
• Pain Relief: Taking nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen for pain relief. Please speak to GP or pharmacy first if you have heart or gastric problems.
• Shoe wear: Make sure your shoes give you good support, with heel cushioning and firm arch support.

Modification in daily activities

Achilles Tendinopathy exercise

• Exercise: including isometric, eccentric training targeting your calf muscles.
• Stretching: Stretch your calf and Achilles tendon every day, especially before and after exercise.

• Low-Impact Activities: Swimming or cycling can reduce stress on your tendon whilst exercising.
• Avoid High Impact Activities: Running uphill can put too much stress on the tendon.
• Activity Level: Slowly build up your activity level to avoid overloading your tendon too much.
• Cross-Train: If your pain allows, mix high-impact activities (like running) with low-impact activities (like swimming) to avoid stressing your tendon too much.

Do consider altnerative treatment as acupuncture or shockwave therapy with tendon-loading appear superior to a wait-and-see approach at 3 months.

What is the best way to cure my Achilles tendinopathy?

Achilles tendinopathy, commonly referred to as Achilles tendonitis, is best addressed through a combination of approaches aimed at reducing strain on the tendon, gradually increasing its capacity to withstand load, and promoting healing.

Understanding Achilles Tendinopathy

• Achilles tendinopathy is a degenerative condition caused by overuse and cumulative microtrauma. It is characterized by pain, swelling, and impaired function, especially during walking and exercise.

Initial Management and Activity Modification

• Early management may include relative rest, activity modification, and patient education. It is crucial to identify an optimal level of loading that keeps symptoms tolerable during, immediately after, and the day following activity.
• Avoid activities that place excessive stress on the Achilles tendon, such as hill running.

Exercise and Loading Protocols

• Isometric Exercises: These can be incorporated as a warm-up or as an independent stimulus, involving holding a contraction with little to no movement. Examples include double and single leg heel raises, and seated heel raises.

• Eccentric loading protocols: Such as the Alfredson protocol, are commonly used for midportion tendinopathy. This involves slowly lowering the heel below the edge of a step to load the tendon eccentrically.
• Heavy slow resistance training: Another approach, involving slow heel raises performed on a seated calf raise or leg press machine.

Later Stage Exercises

• Energy storage and release exercises: These include jumping, landing, plyometrics, and exercises that prioritize a faster rate of loading.
• Return to sport: This involves a gradual return to the preferred sport or activity. This is achieved by fitting in runs, practices, sporting events, and other activities into a weekly calendar based on the individual's schedule, symptoms, and function.

How did you recover from your Achilles tendon injury?

For Achilles tendinopathy, several exercise options can aid in healing and restoring function. These exercises should be performed within tolerable pain levels, and it's important to monitor symptoms during and after exercise. The goal is to progressively load the Achilles tendon to increase its capacity and function.

Isometric Exercises (Stage 0)

• These exercises involve holding a muscle contraction without movement and can be used as a warm-up or an independent stimulus.
• Examples: Double leg heel raises; Single leg heel raises; Seated heel raises.
• Hold for 45 seconds at 4/10 effort with 2 minutes rest between sets, for 3-5 sets.

Heavy Slow Resistance Training (Stage 1)

• These exercises are a foundation for Achilles tendinopathy programs, emphasizing slow and controlled movements.
• Examples: Single or Double leg heel raises on flat ground, Single leg heel raises on a step with or without weight.
• Aim for a minimum of 1-2 exercises, 2-3 days per week, with slow and controlled repetitions.
• Other exercises: Split squats, single leg deadlifts, step downs, and hip thrusts.

Energy Storage and Release (Stage 2)

• These exercises incorporate jumping, landing, and plyometrics to prioritize a faster rate of loading.
• Hopping Progression: Start by hopping in place on two legs, then progress to hopping forward and backward, and finally side to side. Work through the same progression on a single leg.
• Jumping Progression: Start with a sub-maximal vertical jump on two legs before progressing to a maximal vertical jump on two legs. Then, work on sub-maximal and maximal jumps on one leg, and practice jumping forward, side to side, and diagonally.
• Perform these exercises 2-3 times per week with an emphasis on execution, not cardio.

Return to Sport (Stage 3)

• This stage involves gradually returning to a preferred sport or activity.

Why, when after running, do my left ankle/Achilles feel stiff?

Following a run, stiffness in the left ankle/Achilles tendon can arise from several factors related to Achilles tendinopathy.

Potential reasons for ankle/Achilles stiffness after running:

• Inadequate Warm-Up: Failing to warm up adequately before running can leave the Achilles tendon less prepared for the activity's demands, resulting in stiffness and pain.
• Overuse and Microtrauma: Achilles tendinopathy is often the result of overuse and cumulative microtrauma to the tendon. Running, especially with increased intensity or duration, can strain the Achilles tendon.
• Training errors: A rapid increase in impact exercise volume can contribute to Achilles tendinopathy.
• Reduced Flexibility: Tight calf muscles and decreased ankle movement (particularly dorsiflexion) may lead to increased stiffness.
• Age: As you age, it takes longer to recover, and the structure of the Achilles tendon weakens, making it more susceptible to injury.
• Localized Tendon Thickening: Patients with Achilles tendinopathy often experience localized tendon thickening.
• Morning Stiffness: Experiencing morning pain or stiffness during the first steps of the day or at the beginning of an exercise session is a common symptom of Achilles tendinopathy.
• Improper Footwear: Worn-out or unsupportive shoes can fail to provide adequate cushioning and arch support, increasing tension in the Achilles tendon.

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How can Achilles tendinopathy cause knee pain?

Achilles tendinopathy can lead to compensatory changes in biomechanics. These changes can indirectly contribute to knee pain.

Details on how Achilles tendonitis may cause knee pain:

• Altered Gait: Pain and stiffness in the Achilles tendon can cause an individual to alter their walking or running pattern (gait) to minimize stress on the affected tendon. This altered gait can place additional stress on other joints, including the knee.
• Kinetic Chain Imbalance: Achilles tendinopathy can disrupt the normal function of the kinetic chain, the interconnected group of body segments and joints that work together to produce movement. When the Achilles tendon is not functioning properly, it can affect the alignment and movement patterns of the entire lower limb, potentially leading to increased stress and pain in the knee.
• Muscle Weakness and Compensation: Achilles tendinopathy can lead to weakness in the calf muscles, which are important for stabilizing the ankle and controlling knee movement. To compensate for this weakness, other muscles around the knee may have to work harder, leading to overuse and pain.
• Hyperpronation: Achilles tendinopathy is often associated with either pes cavus or pes planus with hyperpronation.

Seek a physiotherapist or podiatrist to address any biomechanical abnormalities in the kinetic chain.

Does wearing heels shorten your Achilles tendon?

Regularly wearing high heels, which can shorten the calf muscle, might impact the Achilles tendon over time. Tight calf muscles are known to place more stress on the Achilles tendon.

Heel lifts or more supportive shoes can be trailed with the intention of temporarily reducing Achilles tendon load early on when symptoms are high.

Why does my Achilles tendon sometimes 'click'?

Potential causes of a clicking Achilles tendon:

• Tendon abnormalities: Disruption in the normal tendon structure due to tendinopathy could cause the tendon to move or rub in an unusual way, leading to a clicking sensation.
• Inflammation or Bursitis: Inflammation of the retrocalcaneal or superficial calcaneal bursa could contribute to the sensation.
• Adhesions: The presence of adhesions between the tendon and surrounding tissues might cause a clicking feeling as the tendon moves.

Consult a GP or physiotherapist for a thorough evaluation.

Signs of an Achilles Rupture or Tear?

Several signs and symptoms associated with an Achilles tendon rupture or tear:

• A popping sound: You might hear a pop that seems to come from the back of your heel or calf.
• Sudden, sharp pain: A sudden and sharp pain in the back of your leg or heel.
• Feeling of being kicked: People describe the feeling as if they were kicked in the back of the leg.
• Giving way sensation: A feeling of popping or giving way in their heel.
• Swelling and bruising: The injury typically presents with swelling and bruising.
• Palpable gap: There may be a palpable gap, most frequently 2 to 6 cm above the heel bone.
• Impaired movement: Difficulty flexing the affected foot.
• Positive Thompson Test: Inability of the ankle to plantar flex when the calf muscles are squeezed while lying on the stomach.

It is important to seek immediate medical attention if you experience these symptoms, as a ruptured Achilles tendon typically requires prompt diagnosis and treatment.

What causes tear to your Achilles tendon?

Here are some factors and activities that are commonly associated with Achilles tendon ruptures:

• Sudden forceful contraction: An Achilles tendon rupture most commonly occurs from a sudden and forceful contraction of the calf muscles while the ankle is dorsiflexed, such as during sport-specific movements like forward acceleration, cutting, and jumping.
• Overuse and Strain: Achilles tendinopathy and ruptures can be caused by repetitive or intense strain on the tendon.
• Loading imbalance: They most commonly occur in runners who have suddenly increased the intensity or duration of their running, walking, or jumping.
• Activities: Middle-aged people who play sports, such as tennis or basketball, but only on the weekends without specific training.
• Tight calf muscles: Starting an exercise or sport with tight calf muscles can place more stress on the tendon.
• Exercising on an uneven surface: Running or training on unstable or rough terrain increases the risk.
• Starting a new sport: Engaging in a sport that the body is not accustomed to can put excessive strain on the tendon.
• Medical conditions: Conditions such as psoriasis, high blood pressure, and diabetes can contribute to Achilles tendon weakness.
• Certain medications: Fluoroquinolone is an antibiotics used to treat bacterial infections, have been linked to increased risk of tendon rupture.

References

• Johns Hopkins Medicine - Achilles Tendon Injuries
• Mayo Clinic - Achilles Tendinitis
• NHS - Cancer Symptoms
• von Rickenbach K. J., Borgstrom H., Tenforde A., Borg-Stein J., McInnis K. C. Massachusetts General Brigham Sports Medicine Rehabilitation Protocol for Achilles Rupture Repair.
• Wang Y., Zhou H., Nie Z., Cui S. Prevalence of Achilles tendinopathy in physical exercise: A systematic review and meta-analysis. Sports Medicine and Health Science, 4 (2022) 152–159.
  Available at: Sports Medicine and Health Science Journal.