Your Achilles Heel

The Achilles tendon is the thickest and strongest tendon in the human body. That being said, this doesn't mean you can’t injure it.

I hear different terminology used all the time, so what is tendinitis, tendinosis or tendinopathy?

Tendinopathy:

This is a broad term encompassing painful conditions occurring in and around tendons, which includes tendinitis and tendinosis.

Tendinitis:

This basically means inflammation of a tendon

Tendinosis:

This means degeneration of tendon (meaning cumulative damage).

So what does this mean to me?

For a long time tendinitis was the term used and it was considered that injured tendons were simply inflamed. Then the thinking shifted to the thought that there was little or no inflammation present in these conditions (Andres & Murrell 2008). However as is with research, the thinking is changing again: There may be an inflammatory response associated with chronic tendinopathy, even though recent opinions had decided it to be non-inflammatory (Rees 2013).

So both types can occur!

This is important as the way that you treat each one has to be very different.

So why if the tendon is so strong does it get injured?

It’s a case of overload, underload or over stretch. A great example of the load that can go through the Achilles tendon is below:

Running produces six to eight times the body weight through the Achilles tendon (Pierre-Jerome 2010).

Bet you didn't expect that did you!

Achilles tendinopathy causes are biomechanical faults, systemic diseases, smoking, age, activity level & obesity (Van Sterkenburg 2011).

Tendinopathy at the mid-portion of the tendon, is due to decreased vascularity at this point in the Achilles (Riley 2008).

Individuals with an A2 allele of the COL5A1 BstUI RFLP gene are less likely of developing chronic Achilles tendinopathy (Mokone et al 2006).

Taking fluoroquinolones (antibiotics) increases the risk of Achilles tendinopathy (van der Linden et al 2002).

This being said though, basically tendinopathy occurs from cumulative overloading or overstretching or from lack of loading or lack of flexibility.

So what specifically causes these effects?

Recovery time:

If you don’t allow enough recovery between loading activities then the tendon hasn’t got enough time to repair, and training again on it too soon will build cumulative damage. A long healing time is required for a tendon to heal due to poor vascularisation (blood flow) (Nowak & Handyford 2000). Some people believe just to recover the microtrauma from a run takes at least 24 hours on average to repair. So if you do more than the average distance or heal slower than average person then you will need 48 hours.

Fatigue:

When the muscle is fatigued the contraction strength is not as strong or fast, leading to more load or stretch being passed to the tendon. Exercise can disturb proprioception through fatigue, this has implications for musculoskeletal injuries (Proske & Gandevia 2012). Obviously when you fatigue your movement alters, which will change the way that your tendon is loaded. For example, when running, if your gluteus medius tires then the pelvis will drop on the opposite side, the hip will internally rotate on your weight bearing leg, causing overpronation in the foot. This alignment in the foot will change the angle of load through the Achilles from an ideal vertical direction to a lateral one. The reason that this is significant is down to the structure of the tendon (The fibres line up vertically and not laterally, so it is very strong in the vertical plane but very weak in the lateral one).

This gluteus example is shown in the evidence also:

Gluteus Medius & Maximus had a delay in onset & a shorter duration of activity in achilles tendinopathy sufferers (Smith et al 2013).

Another specific reason is lack of flexibility:

If the calf muscles and the Achilles are too short for the activity at hand then it is easier to potentially tear and if you don’t warm the tissue up before activity then the tissue is not as pliable making it tighter and more likely to damage.

Interestingly excessive flexibility is another factor:

Some people who are hypermobile (double jointed) or people who have overlengthened their tendon are more likely to have problems as the tensile strength of the tendon is reduced, making it easier to overload.

Muscle and tendon weakness:

If the muscle isn’t strong enough and hasn’t been trained to take the loads of the sport (underload cause) then it can overload and tear. Age is also a factor here:

The average age for achilles tendinopathy is 43.4 years & in 34.6% of cases sport was involved (De Jonge 2011).

So why’s this?

Aging & Disuse contribute to a tendon's loss of resilience & strength (Nowak & Handyford 2000). And this is where loading (strength training) is even more important than ever to compensate for the loss of strength.

So what’s the chance of getting Achilles tendinopathy?

Annual incidence of Achilles tendinopathy is 2.01 per 1000 people (De Jonge 2011).

But if you do activities that you haven’t prepared your body for, then you are more likely to get it. This is why Achilles ruptures typically occur in males in their 30s and 40s who play sport intermittently (Khan & Carey Smith 2010). In runners the incidence ranges from 9.1% to 10.9% (Lopes et al 2012).

How long does it generally last for?

De Jonge (2011) found the mean duration of symptoms in Achilles tendinopathy in the general population was 11.3 weeks (range 1 to 52 weeks). However if you don’t rectify the cause of your symptoms then it will either persist or come back again in the future.

What are the symptoms of Achilles tendinopathy?

Achilles tendinopathy is most commonly painful in this area:

However you can also get insertional tendinopathy, which is here:

It is typically worse in the morning, may be constant or intermittent & aggravated either during or after weight-bearing exercise (Maffulli 2010).

Neurovascular (nerves & blood vessel) ingrowths into the tendon (neovascularisation) are thought to play a role in Achilles tendon pain (Alfredson 2007).

Symptoms and onset can help you to work out if it tendinosis or tendinitis:

Tendinosis:

Tends to be in the older age group and usually comes on for no reason (no overuse). There is usually a significant thickening to the tendon and it is likely to not be the first episode of problems with the Achilles. The symptoms tend to be non-inflammatory, which typically means no pain at rest and no heat.

Tendinitis:

Tends to be younger age groups but not always, people who are very active are at risk. It is usually painful with activity and at rest, as it is inflamed. It is often warm to touch. Usually it is the first episode of any problems with the Achilles. The tendon might be swollen but not thickened with any scar tissue.

Now I’m going to throw a spanner in the works:

You can have both!

You can have a chronic tendinosis with an acute flare up of tendinitis from overuse.

What are the best treatments for Achilles tendinopathy?

Right, this depends on whether you have tendinosis or tendinitis.

Obviously either way you need to establish why you have it and if possible change these issues.

Are you Overloading? Underloading? Overstretching?

Correct these causes and the problem has the best chance to recover. That being said there is plenty of research out there showing the best ways of treating it.

If you have Tendinitis then the priority is to settle the inflammation down and use that inflammation to stimulate healing.

Use P.O.L.I.C.E. with an acute episode of tendinitis in the first 48 - 72 hours:

P: Protect the injury from further harm: This can be stopping the activity, using crutches, strapping it up, etc.

O.L: Optimal loading: This means load it but don’t overload it! This was put in place of rest because people were being too literal with rest and actually doing nothing, which is bad! So the key here is to move it, walk on it, etc. The key thing to remember is that as long as after doing the activity it is no worse for doing it, you are fine but if it is worse afterwards, then you have overloaded it.

I: Ice: This is to minimise the amount of swelling that gets to the injury site. You should wrap the ice in a damp tea towel and apply for 20 minutes. The cooling effect should last for roughly 2 hours so you should re-apply it every 2 hours.

C: Compression: Now most people think that ice is the most important aspect but believe it or not it is actually compression. Compression helps control oedema formation & reduces swelling by promoting re-absorption (Knight 1995). Compression can take the form of tubi-grip or strapping and the aim is to create a back pressure that minimises the amount of swelling to the area. This is vital, as the more swelling you have, the more painful the injury will feel and the stiffer the area will become. It will inhibit muscle activity leading to muscle atrophy and it decreases proprioception. The other thing is that the more swelling there is, the longer it will take for your body to get rid of it.

E: Elevation: Basically keep the injury up as much as you can (in between your optimal loading etc.)

What about using anti-inflammatories?

Certainly not for tendinosis and in tendinitis probably not either (jury’s out). See what the evidence says:

Ibuprofen inhibits tendon cell proliferation, therefore has a negative effect on tendon healing (Tsai et al 2004).

The Control group who didn’t take nonsteroidal anti-inflammatory drugs (NSAIDS) demonstrated progressively increasing collagen organization during the course of the study, whereas the NSAIDS group did not. This basically means NSAIDS where worse than doing nothing. (Cohen et al 2006).

The reason is that inflammation is needed to heal so we should have it and without it we can’t actually heal.

Ultrasound:

Ultrasound works best for: Ligament, Tendon, Fascia, Joint capsules & Scar tissue as they absorb it best (Sparrow et al 2005). Ultrasound doesn't have an anti inflammatory effect (Hashish 1988). Which is good! We need inflammation to heal & U/S promotes it! So Ultrasound is good for both tendinitis and tendinosis.

Eccentric loading:

An eccentric muscle contraction is the tensioning/ contraction of a muscle as it is being lengthened.

Eccentric exercises have long been considered an excellent way of treating Achilles tendinopathy.

They work on the basis of the fact that loading of tendon creates an upregulation of insulin-like growth factor (IGF-I) & this stimulates healing (Khan & Scott 2009).

This is especially good for tendinosis but I'd advise to settle the inflammation down first in tendinitis before starting this.

The evidence says the following:

Painful eccentric calf-muscle training showed good clinical results in chronic mid-portion Achilles tendinosis (Jonsson 2009).

Eccentric exercises are superior to wait and see for Achilles tendinopathy (Magnussen et al 2009).

Eccentric exercises are superior to traditional concentric exercises for Achilles tendinopathy (Magnussen et al 2009).

However more recently there is debate as to the need to have the loading done just eccentrically:

There is little clinical evidence for isolating the eccentric component, in Achilles tendinopathy exercise (Malliaras et al 2013).

But….

Yu et al (2013) recently stated eccentric strengthening was more effective than concentric strengthening in Achilles tendinopathy.

So overall clear as mud!!!

My view is go up and down (concentric and eccentric). Both work and it’s easier to do than pure eccentrics.

However if you want to follow the eccentric protocol it is below:

Alfredson protocol was superior to Stanish model to reduce pain & improve function in Achilles tendinopathy (Stasinopoulos & Manias 2013).

Alfredson protocol:

It involves two different exercise: straight-leg and bent-leg heel drops. Start on your tiptoes, gradually lower your heel below the forefoot, then use the other leg (or your arms on a railing) to raise yourself back to the starting position. Do three sets of 15 reps of each exercise, twice a day (yes, that's 180 reps per day) for 12 weeks. When you feel no discomfort or next-day soreness from the program, add some weight.

The Stanish model is once-daily, 6-week eccentric loading programme.

Shockwave therapy:

Eccentric exercises are equal to shock wave therapy for Achilles tendinopathy (Magnussen et al 2009). This is only for tendinosis.

Night splints:

Eccentric exercises are superior to night splints for Achilles tendinopathy (Magnussen et al 2009). Night splints can be for either tendinitis or tendinosis but only if tolerated.

Soft tissue mobilisation:

Deep transverse frictions: Excellent anecdotal evidence that fits the current understanding of tendinopathy but evidence struggles to support its use. (Joseph et al 2012). This is mostly for use in tendinosis

Injections:

Autologous blood:

Injected locally to promote repair activity through the administration of growth factors directly to the site of injury (Coombes 2010).

However, there is no good quality evidence for autologous blood injections for chronic tendinopathy when compared to usual care (Rabago et al 2009).

Platelet-rich plasma:

Injected locally to promote repair activity through the administration of concentrated growth factors directly to the injury site (Coombes 2010).

However, there is insufficient evidence to support the use of Platelet Rich Therapies for musculoskeletal soft tissue injuries (Moraes et al 2013).

Aprotinin:

Injected locally to inhibit collagenase which would otherwise break down collagen and has been found to be increased in tendinopathy (Coombes 2010).

Polysulphated glycosaminoglycan:

Injected locally to prevent destruction and facilitate repair through inhibiting metalloproteinase enzyme activity (Coombes 2010).

Botulinum toxin:

Injected locally to decrease tensile stress through the tendon and inhibit substance P, which is increased in tendinopathy (Coombes 2010).

Sodium hyaluronate:

Injected locally to absorb mechanical stress and provide a protective buffer for tissues (Coombes 2010).

Corticosteroid:

Injected locally to down regulate (acting to decrease) inflammation in the affected tendon (Coombes 2010). Now with this injection you would definitely not want to do this with a tendinosis and there is reasoning that maybe it could be detrimental to the tendon in the long term whether it is tendinosis or tendinitis. This piece of research may not be on the Achilles but Tennis elbow is also a tendinopathy:

Corticosteroid injection versus placebo injection resulted in worse clinical outcomes after 1 year with Tennis elbow (Coombes et al 2013).

Food for thought.

High volume saline:

A saline solution is injected along the surface of Achilles tendon, producing a mechanical effect on the new vascular ingrowth (Coombes 2010).

Polidocanol:

Targeted disruption of new vasculature by administration of a scelerosant to precipitate blood vessel fibrosis (Coombes 2010).

Prolotherapy:

Hypertonic glucose injected locally to initiate repair activity by causing local tissue trauma (Coombes 2010).

What about rupturing the Achilles?

Rupture of the Achilles tendon is common and said to be increasing (Khan & Carey Smith 2010).

98% of Achilles ruptures occur in pathological tendon (Cook & Purdam 2009).

Achilles rupture: Surgical compared with non-surgical treatment had a lower risk of re-rupture (Khan & Carey Smith 2010).

Obviously everybody is different and ideally should be assessed and screened to highlight their individual issues that increase their risk of injury along with the exact cause of the Achilles problem.

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