COGENT EVIDENCE
Folarin Babatunde PT PhD MScSEM MScPT BScPT
November 2024
The Achilles tendon is the strongest and biggest tendon in the human body, and it can be affected by both degenerative and traumatic processes. The Achilles tendon is the most frequently involved tendon, accounting for 20% of all tendon injuries.
Anatomy and Function
The Achilles tendon gets its name from Achilles — a hero in ancient Greek mythology who was not vulnerable to any injuries except for weak one spot on the back of his heel. Achilles tendon is the tendon at the back of your leg right above your ankle. It connects the muscles in the calf to your heel bone called the calcaneus. This explains why 'Calcaneal tendon' is the medical name for the Achilles tendon. Tendons are cords of strong, flexible tissue that connect bones to muscles throughout the body. When you contract (squeeze) muscles, the tendons act like levers attached to bones and make them move. Your Achilles tendon lets you move your heel and foot. When your calf muscles contract, your Achilles tendon lifts your heel allowing you to walk, run, hop, jump, tip toe and use the stairs.
Who gets Achilles tendinopathy?
Achilles Tendinopathy (AT) is very common among runners (6% to 10% at any one time) and people who participate in running sports. However, it can also occur in less active individuals. The lifetime prevalence is 52% for middle- and long-distance runners, 36% for short-distance runners, 24% for general athletes and 6% in the general population. Both men and women are affected equally by AT with the peak age for incidence being 40 to 59 years. Midportion AT is more common than insertional AT and about one in three people experience symptoms in both heels.
What Causes Achilles Tendinopathy?
AT is an overuse injury and generally occurs from activities that load the tendon such as walking, running and jumping and involves a rapid stretch-shorten cycle of the muscle-tendon unit and repetitive high Achilles tendon force and strain. For example, the Achilles tendon is impacted by a force 5-7% times the body weight per stride and up to 6% strain. Moreover, tendons adapt slowly to stress and strain compared to muscles. Extrinsic factors (outside the body) account for the changes observed in AT are due to prolonged tendon compression, excessive loading, repetitive loading, fatigue loading and improper loading. Intrinsic factors moderate the risk profile and are more common among less active people who develop tendinopathy.
Extrinsic Factors
A rapid increase in weekly running mileage
Introduction of hill running
Higher intensity track sessions
Running up a hill
Running backwards
Changing direction as is common soccer, basketball, and football
Training in cold weather
Intrinsic factors
Diabetes mellitus is associated with tendinopathy altering cellular metabolism
Dyslipidemia leads to disorganization of collagen fibrils
Inflammatory arthropathies (rheumatoid, psoriatic arthritis) can cause direct tendon damage
Genetic factors may play a major role in tendon strength and capacity for recovery after injury
Prior lower limb tendinopathy or fracture
Use of fluroquinolone antibiotics
Moderate alcohol use
Foot alteration such as pes cavus, forefoot varus, ankle lateral instability.
Limited lower extremity flexibility
Decreased isokinetic plantar flexor strength
Physical activity levels
Age
Body mass index (BMI)
What Are the Typical Symptoms of Achilles Tendinopathy?
Swelling that is present all the time and gets worse throughout the day or with activity
Pain and stiffness along the tendon especially in the morning
Pain along the tendon or back of the heel that worsens with activity
Severe pain the day after exercising
Tendon thickening
Formation of bone spurs at the heel (insertional)
Heel pain when wearing shoes
How Is Achilles Tendinopathy Diagnosed?
The AT is diagnosed in physiotherapy based on a detailed patient history and physical evaluation. Diagnosis accuracy requires acknowledging that activities that provoke Achilles tendon pain will most likely involve stretch-shorten cycle loads such as walking, running, jumping and related sports.
Pinching the midportion of the tendon with two fingers (2-6 cm above the calcaneus).
Pointing to a specific area at the back of the calcaneus when asked about their pain.
Reporting a change in loading activity that coincides with the earliest experience of pain.
Progressive increase in the severity of pain and impact on function.
Report of minor symptoms (pain or stiffness) upon weight-bearing after prolonged rest or sleep (‘morning stiffness’ or ‘arising pain’)
Pain once walking or running starts that improves after a few minutes (‘warm-up’ phenomenon).
Persistent symptoms for several hours or even days following bouts of activity and eventually throughout active periods and ultimately limit activity as the condition progresses.
The most commonly identified objective clinical tests for AT is tendon palpation including pain on palpation, localized tendon thickening or swelling, tendon pain during loading activities (single leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. Physiotherapists use the VISA-A questionnaire outcome measure to monitor AT.
Do I Need Imaging For Achilles Tendinopathy?
Imaging is not regarded as a reference standard because Achilles tendon imaging pathology is not uncommon in people without any symptoms. For instance, about 1 in 2 people without pain show abnormalities in their Achilles Tendon structure including thickening with significant variation relatively explained by age, physical activity and BMI. Therefore, the widespread presence of persons with AT but absent symptoms shows that the diagnosis of AT based on imaging alone could be incorrect and lead to the needless use of healthcare resources.
However, further investigations including imaging become necessary when patients show poor- or non-response to the initial recommended management approaches and to confirm another structural source of heel pain.
What Other Conditions Can Lead To Pain At The Back of The Heel?
Other common musculoskeletal disorders of the soft tissues associated with posterior heel pain includes the following diagnosis:
Retrocalcaneal bursitis
Kager's fat pad inflammation
Achilles tendon rupture
Achilles paratenonitis
Posterior impingement (Os Trigonum syndrome)
Calcaneal stress fracture
Flexor Hallucis Longus tendinopathy
Plantar fasciitis
Nerve entrapment or neuroma
Heel pad syndrome
Haglund deformity
Sever's disease
Insertional calcific tendinosis
Lumbar (S1) radiculopathy
What Options Do I Have to Treat My Pain?
There are many ways to treat pain related to AT. Management of AT can be grouped into conservative and surgical approaches depending on how acute or chronic the AT symptoms are. When a complete rupture of the AT is diagnosed, surgical intervention is often recommended. Â
Conservative Therapy
Conservation therapy is first-line management of Achilles tendinitis and includes the following physiotherapy delivered interventions:
Modifying or reducing levels of activity provoking symptoms
Use of adaptive footwear
Use of manual therapy
Eccentric stretching exercises
Extracorporeal Shockwave Therapy
Tendon loading exercises
Biologics
Surgery
Surgical procedures and approaches vary and are optional for 10 to 30% of patients who fail conservative therapy after 6 months.
Open debridement
Topaz or Tenax
Resection of superior calcaneus and bursa for Haglund deformity
Removal and re-attachment of the AT
Gastrocnemius muscle recession
Tendon transferÂ
How Can Physiotherapy Help?
The first line of care for anyone with Achilles Tendinopathy is conservative and physiotherapists play a crucial role and focused on physical intervention and patient education.
Eccentric stretching exercises is an integral part of physiotherapy and can achieve a 40% reduction in pain with prevention of progression to chronic tendinopathy.
Extracorporeal shock wave therapy (ESWT) has been shown to reduce pain by 60% and achieve 80% in patient satisfaction, functionality and quality of life.
Traditional needle acupuncture may be beneficial for some individuals.
Education focused on sport modification, eccentric exercise therapy, proper footwear, warm-up and flexibility training and gradual progression of activities.
POST OPERATIVE MANAGEMENT PHYSIOTHERAPY
After surgery for Achilles tendinopathy, patients would go through a period of immobilization ranging from 3 to 8 weeks which typically involves using a cast, walking boot, or posterior splint in traditional protocols. The duration of immobilization ranges from 3 to 8 weeks. Current evidence shows that a Physiotherapy led accelerated weight-bearing postoperative rehabilitation protocols may be also improve function in patients.
FOR MORE INFORMATION
Book an appointment with one of our physiotherapists at Cogent Physical Rehabilitation Center for an assessment and discussion on how physiotherapy can help you find relief from sciatica.
Bibliography
Malliaras P. Physiotherapy management of Achilles tendinopath. J Physio, 2022;68:221-237.
Medina Pabón MA, Naqvi U. Achilles Tendinopathy. [Updated 2023 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
Scott, A, et al. Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology Brit J Sports Med, 2020;54:260-262
Silbernagel K.G and Crossley K.M. AÂ proposed return-to-sport program for patients with midportion Achilles tendinopathy: rationale and implementation JÂ Orthop Sports Phys Ther, 2015;45:876-886.
Vo TP, Ho GWK, Andrea J. Achilles Tendinopathy, A Brief Review and Update of Current Literature. Curr Sports Med Rep. 2021;20(9):453-461.
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