Cracking the Code: Achilles Tendinopathy Unveiled

As you can see in the image above the Achilles tendon is the structure that connects your calf muscles (Gastrocnemius and Soleus) to your heel bone. It is the largest tendon in your body and it is also the most commonly injured tendon.

What is an Achilles tendinopathy?

An Achilles tendinopathy actually refers to multiple changes that occur within the tendon or surrounding structures.

Most of our body is in a constant state of building (during recovery) and breaking down tissue (during exercise).

Depending how much stress or load we give these tissues will depend on how much is broken down and how much recovery is required to restore it back to full health.

Simply put, if we begin to load the tendon too much and too frequently, the amount of tissue being broken down will surpass the amount that is being built.

Structural changes within the tendon will occu and the tendon will then become less efficient at dealing with stress/load. This creates a snowballing effect of pain and reduced function.

Stages of Tendinopathy

There are 3 stages of tendinopathy that are noted in the literature:

Reactive Tendinopathy: This occurs as a response to a sudden increase in load through the tendon (Otherwise known as acute overload). It will result in a short term irritation or pain felt within or around the tendon.
Tendon disrepair: This stage typically follows after a reactive tendinopathy. When a person continually overloads the tendon or pushes though the reactive/painful stage it will result in disrepair and disorder in the structure of the tendon.
Degenerative tendinopathy: This is the stage where we start to see cell death within the tendon. These patients may have a history of repeated bouts of tendon pain and is more common in older athletes. This type of tendon breakdown can be extensive enough to see tears within the tendon on ultrasound or in severe case lead to a rupture of the Achilles tendon.

Symptoms of a Tendinopathy

Runners will typically not have a mechanism of injury or an event for an Achilles tendinopathy to occur.

They will often simply report a gradual increase pain with training.

Most of the time a tendinopathy will follow a typical pattern of symptoms.

First thing in the morning a runner will find that the first few steps out of bed are quite painful and/or stiff. They will point to the middle part of the Achilles tendon.
They will often feel tight upward into the calf.

As we continue to keep moving these symptoms will commonly reduce and in some cases completely resolve.

Then on cooling down or at night following the daily run, most runners will find that the ache returns or increases.

Another pattern of symptoms can typically be found during training also.

Some runners may find that at the start of the run the Achilles can be quite tender and then as they warm into their run the pain subsides only to return after their run.

Others will find no pain at the start of the run and then a gradual onset of symptoms as they continue through their run.

All of these symptoms give us very important information into how we are going to treat and manage the runner with an Achilles tendinopathy.

Treatment for Achilles Tendinitis in runners

Now this is where things can get tricky for an Achilles tendinopathy and where many other clinics get it all wrong and the patient doesn’t get better!

A good result comes down to how we manage the load and prescribe the right type of exercises depending on the type of tendinopathy.

In most cases an Achilles tendinopathy will not get better on its own.

This is because tendons have what is called a happy loading window.

You see, tendon’s need load to heal.

If the load is too much for the tendon the tendon will continue to get ‘pissed off’ and pain will increase.

On the other hand if the tendon is under loaded, it will not receive enough load to maintain the healing and regeneration (building) process of the tendon.

When managing a reactive tendinopathy load management is extremely important. As soon as you begin to feel symptoms in your Achilles tendon it is time to reduce your load.

Anti-inflammatory medication has also been shown to help reduce the symptoms and allow you to begin a loading program (Consultation with your GP will determine your ability to take anti-inflammatory medication).

The most effective loading program for a reactive achilles tendinopathy is isometric calf raises. It eases pain and keeps the muscles around it strong while pain/reactivity settles.

Come up onto your toes and hold for time, depending on how far along your tendinopathy is will determine how long you should hold the isometric contraction for and how many repititions you should complete.

A Physiotherapist is in the best position to be able to guide you along in this process and progression of your exercises as the tendon begins to heal.

The length of time a reactive Achilles tendinopathy takes to heal will also depend on how far along the tendinopathy is and your current symptoms.

This could take as little as 2 weeks when picked up early, or up to 6 weeks in more irritable cases where the runner has pushed the tendon too hard.

Now, many runners don’t want to stop running and often push through the reactive phase into the disrepair or degenerative stages.

When this occurs, the treatment time extends.

Expect anywhere up to 20 weeks or more for more severe cases when the tendon itself has lost capacity and load tolerance, muscle atrophy has occurred and others regions above and below in the kinetic chain have weakened.

Here is another important tendon tip for runners!

Once your symptoms have resided your rehabilitation is not over.

This is where finding the original cause of your symptoms comes in.

The problem with an Achilles tendinopathy in runners is that often the tendon cops all the work when areas above and below are, or have, become over time weaker.

This can be calf, ankle and foot muscle strength, even up through the quad, hip and trunk/pelvis/core strength and control.

If these areas are not strong enough, remember running loads are 6.5x body weight when out pounding the pavement, the tendinopathy can easily return when you return to your normal training load.

Other causative factors can be running technique. Don’t forget a detailed assessment of your technique can highlight this or also highlight muscle imbalances or inefficiencies in your running gait.

Exercises for rehabilitation of achilles tendinopathy.

Management of a tendon in disrepair is slightly different to a reactive tendinopathy.

Some of the same principles apply in regards to load management but the exercise selection can be different. Once symptoms have begun to settle it is important to load the tendon in a more eccentric manner.

Eccentric exercises are important to restore the elastic or stored kinetic energy with a tendon to efficiently propel us forward during running!

Exercises for Achilles tendoninopathy.

The same principles also apply to a degenerative tendinopathy once your symptoms have settled.

However, given the length of time and structural changes within the tendon. The length of time to build resilience and capacity to tolerate, absorb and propel the load of our body mass forward with running is much, much longer.

You will also need a structured strengthening program for the whole body and kinetic chain to build a system that is strong and robust enough to run well again.

In closing, management of a tendinopathy can be quite tricky and requires specific progression and loading to relieve symptoms and successful return the runner to high volumes.

Every person’s symptoms will be different and there is no one size fits all for exercise selection. This is why so many runners struggle to self manage the injury themselves especially while attempting to continue training.

It is important to seek advice from us to assist in guiding you to a return to normal training load and resolution of your symptoms.

If you are a runner and suffering an Achilles tendinopathy book in with us at Fighting Fit Physiotherapy for an initial assessment.

We have the skills, the technology to assess, and the facility to prescribe all your strength & conditioning, and even assess your running technique in order to ensure you make a successful return to long runs pain-free. Looking for other services? We offer also offer metabolic testing & exercise physiotherapy in Gold Coast.

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Attention runners! Achilles Tendinopathy: sometimes known as the silent menace. But it doesn't have to be, and let me tell you why!

What is an Achilles tendinopathy?

Stages of Tendinopathy

Symptoms of a Tendinopathy

Treatment for Achilles Tendinitis in runners

Here is another important tendon tip for runners!

Exercises for rehabilitation of achilles tendinopathy.

Management of a tendon in disrepair is slightly different to a reactive tendinopathy.

Exercises for Achilles tendoninopathy.

The same principles also apply to a degenerative tendinopathy once your symptoms have settled.

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