Formally known as Achilles Tendonitis the new and preferred term for pain in the Achilles region is ‘Tendinopathy’. This essentially means Painful Tendon. Helpful diagnosis!
Now, there are two types of tendon pain: Mid portion Tendinopathy and Insertional Tendinopathy. Now don’t get too worried about diagnosis as that’s our job to identify and diagnose it appropriately.
The mid portion one is the most common to folk and while there are risk factors it seems absolutely anyone could get this condition.
When a tendon becomes painful it appears to ‘react’ to the load or exercise it has been exposed to. This loading causes pain. The tendon essentially becomes intolerant to the exercise and activates nerves to tell your brain. The result is pain!
Tendons are composed of tenocytes and are therefore structurally different from other tissues in the body. Initially, there is some inflammation but it appears this is not the main driving force behind the condition. Because of pain, the calf muscle (in the case of the Achilles) is not able to deliver as much force or contraction. The tendon is loaded to a lesser extent and over time becomes ‘deconditioned’. The tenocyte matrix is less organised and is again less tolerant to loading. There may be the presence of different cells like proteoglycans which are big sponges and can give the tendon its inflamed appearance. There is also a suggestion of scar tissue build up but again this is to a lesser extent and perhaps a too simple a model of how the tendon heals itself.
There does not to be an association between tendon pain in the Achilles and the tendon snapping. If there is a tendon rupture then this appears to be an acute event without preceding pain.
- Pain in the middle of the tendon
- Pain on running
- Pain may get better or worse with activity
- Pain in the morning for the first 5 or 100 steps
- Pain on descending the stairs.
- Pain on hopping
Mid Portion vs Insertional:
The pain in Mid portion is in the middle of the tendon rather than at the base of the tendon where it attaches to the calcaneus (Heel Bone). Well, should be anyway! The key difference is that compression is the key factor in insertional. So the tendon does not like to be compressed. You will probably like walking up hill less, walking down stairs where the foot is in dorsiflexion (toes and foot pulled up). Tight fitting shoes are also an issue so the running shoes might be a tell-tail sign of a problem. However, her it is definitely advisable to get seen by one of our sports physiotherapists at Core Body Clinic. Heel pain can also be associated with Bursitis and Planter Heel pain. Diagnosis is key and a good sports physiotherapist will help you manage the problem before it gets out of hand.
What you will not have:
With Achilles diagnosis you will not experience burning pain and Pins and needles
You also will not suffer pain shooting up the leg and into the back
At Core Body Clinic our physiotherapists will look at the whole of you. Check your balance, knee alignment during function, foot posture and position. We will also look at your footwear to ensure you have the correct fitting trainers and shoes. We may look at walking and see how your foot functions and if possible, running. This will tell us what your form is like and how we might modify it to suit your pain so that you could operate at a low load level (keeping you running)
We will also check your hamstring strength and length, hip flexor length and also the ranges of movement in your spine.
We will look at calf strength and ankle flexibility and probably give the tendon a poke and prod. While this helps to show us where the issue is it does not tell us
We know that activity is good for tendons. They love it! But in the early stages gentle massage, rest, ultrasound (big placebo but can be therapeutic), taping, R.I.C.E and Anti-inflammatories (NSAIDS) can all help. But none of these will sort your tendon out.
Once we have confirmed diagnosis we will set about prescribing a bespoke plan of action to get you back to your normal functional level.
Isometric exercises are thought to be helpful. This is basically contracting the calf muscle, like a heel raise and holding the position for 30-60 seconds. This directly affects the central nervous system, reduces sensitivity and therefore pain. It needs to be done properly and requires appropriate diagnosis by one of our physiotherapists.
Graduated exercises are the main stay once pain begins to settle. These are carefully constructed and prescribed in consistency with your pain. Over doing the exercises too quickly will land you back to square one! They need to be gradual and increase in load so that getting you back to climbing the stairs or Everest is a smooth pathway of recovery
Massage and Ultrasound can be helpful but we know tendons need LOAD to rebuild themselves so unfortunately while we can’t rub it better, direct therapy can help in the short term.
Taping and orthotics could be of consideration. It is up to your physiotherapist to assess your feet. Biomechanics may or may not contribute to the development of Achilles tendinopathy but once you are suffering having the correct fitting shoes can be of major benefit.
Return to Running
At Core Body Clinic the focus of our Sports Physiotherapists is to work with you to get you back running. We will NEVER say don’t run. If you are a keen runner then we will aim to get you running again at the earliest possible convenience.
We may even advocate running from day one!
We can manage your pain and symptoms with effective strategies like appropriate footwear, taping, load management (how much running and how much exercise you should do) and direct therapies (Massage, ultrasound).
Graduated running is KEY! Start small. Walk for 5 minutes, run for 5 minutes, walk, run, walk, run – get the picture? The tendon essentially stores kinetic energy and if in a state of reaction it will become more tender and painful over the time of the run. Key is to stop before it becomes too sensitised.
Avoid hills to begin with (Hard to do in Reading and Tilehurst!) and have no expectations. You may need a week or two off. Aqua jogging is a great alternative early on and changing activity to cycling can be a great way to keep your cardio fitness up.
See a Physio!