Depending on which article you read, the incidence of Achilles tendon pathology amongst endurance athletes is between 10% and 28%1. This makes it an extremely common injury which generates significant confusion amongst the injured athlete. There are multiple treatment modalities for Achilles tendonitis, some simple (eg stretching) and some non-so simple (eg injecting your own blood directly into the tendon). The athlete is often advised of different treatment modalities by different medical practitioners. In addition, because Achilles tendonitis is such a common injury, many athletes have friends or colleagues with a similar injury who have undergone different treatments with varying degrees of success. This article will attempt to clarify what Achilles tendonitis involves and how it is treated, and hopefully explain some of the common misconceptions associated with management of this chronic injury.

There are a several terms that describe Achilles tendonitis. These can be interchangeable amongst health professionals and can generate some confusion for the athlete when determining what injury they actually have. A group of foot and ankle surgeons from Finland have described a syndrome of pain and swelling around the Achilles tendon, in association with impaired performance, as Achilles tendinopathy2. This can include, but is not limited to:

  • Peritendonitis  – acute inflammation within the substance of the tendon, or the soft tissue surrounding it.
  • Tendinosis – tendon degeneration (which may or may not be reversible) secondary to chronic inflammation
  • Insertional tendonitis – acute inflammation where the Achilles tendon inserts into the calcaneum (heel bone)
  • Retrocalcaneal bursitis – inflammation of a soft tissue pad near the calcaneum (heel bone) where the tendon rubs over the bone

Why are runners and triathletes so susceptible to Achilles tendonitis? Like any medical problem, there are factors that athletes can control, such as intensity and volume of training, and factors that the  athletes are unable to control, such as leg length discrepancy and malalignment of the ankle. These are often the most frustrating factors for athletes because body biomechanics can be very difficult to adjust.

Hyperpronation and a cavus foot are both associated with Achilles tendon problems. Hyperpronation occurs when the foot hits the ground and rolls inwards, stretching the tendon causing small ‘micro-tears’ within the substance of the tendon. This causes the tendon to become inflamed and later presents as Achilles tedinopathy (see below).

 

HyperpronationHyperpronation

 

A cavus foot occurs in patients with an arch that is too high. This puts pressure on the outside of the foot and disrupts the shock-absorbing mechanism of the padded sole of the foot. This predisposes the athlete to insertional tendonitis and chronic foot pain (see below).

Cavus FootCavus Foot

 

Leg length discrepancy as a cause of Achilles tendinopathy is controversial. Orthopaedic teaching dictates that a leg length discrepancy of 2cm in a normal distribution of individuals (anyone within 95% of the population for height) will not cause any functional limitations3. However, endurance athletes subject their bodies to significant stress and a subtle leg length discrepancy may be associated with Achilles problems in this group of people.

The next time you watch a long distance running event or triathlon, look at the feet of the athletes. You will see lots of feet that are rolling inwards or outwards, or patients start to limp by the end of the race. I suspect a large proportion of these athletes would have some degree of Achilles tendonitis, treated or untreated.

There is also some evidence that there is a genetic predisposition to tendon injury. This includes inherited defects in collagen or matrix proteins that make up the body and substance of the tendon7. These patients often have chronic tendinopathy in multiple tendons and do not usually tolerate high intensity physical activity.

Age is, unfortunately, associated with an increased incidence of Achilles tendinopathy4. Commonly, a middle-aged athlete who decided to participate in an ironman or marathon presents with heel or Achilles pain. This condition is more common in men, but with the increasing popularity of triathlon and distance running amongst women, is becoming increasingly common in females. A careful history usually reveals an intensive exercise program without any time for adaptation. Suddenly stressing an aging tendon causes microtears and the resulting inflammation can predispose the athlete to tendon degeneration and chronic tendonitis. It can be very difficult to restore the tendon to its original quality after chronic micro-tears.

By the time an athlete presents to an orthopaedic surgeon, the athlete is sore, cranky and desperate for any intervention that will get them back to sport. The answer to any orthopaedic problem is to always consider non-operative management as first line therapy. Patients need to be counselled that Achilles tendinopathy is a long term injury that requires extensive rehabilitation. Non-operative treatment options include:

  • Adjustment of activity levels – athletes commonly believe they are invincible. A sensible training program with gradual increase in volume and intensity is the best prevention of chronic Achilles injury. The first sign of irritation or swelling should be taken seriously, rather than ‘pushing through it’. This can be frustrating for a motivated athlete but often the alternative is years of pain and potentially avoidance of any running-based activity.
  • Stretching and strengthening exercises – a good musculoskeletal physiotherapist is vital in the non-operative management of Achilles tendonitis. A tight calf muscle will result in undue stress on the Achilles tendon, so logic states that stretching the calf muscle will reduce the load on the Achilles tendon. A landmark paper suggested that eccentric exercises (stretching the tendon whilst gently loading the fibres) reduced the pain associated with Achilles tendonitis by up to 60%6. Athletes do need to take some responsibility for their injuries and a dedicated stretching program is vital to avoid surgery in the future. This can take time, up to half an hour a day, but the time invested in restoring the muscle imbalance will influence the long term outcome of this condition.
  • Foot orthoses – these can help correct the underlying biomechanical cause of the tendon irritation. For example, an athlete who overpronates may benefit from an arch support in their shoe. Patients with a subtle leg length discrepancy may improve with a raised shoe or heel support. A good podiatrist, physiotherapist or sports medicine doctor should be able to detect any adjustable biomechanical  issues with the leg or foot.
  • Anti-inflammatory medication – paracetamol (panadol), ibupfroen (neurofen) and voltaren (diclofenac) all have anti-inflammatory properties. These medications have some role in settling the acute phase of the injury but are not a long term solution and do not replace the above non-operative treatment modalities. Side effects include gastrointestinal upset, bleeding, skin reactions and drug interactions. They may offer some benefit in the short term, but the long term management of tendonitis still needs to be addressed.

Many athletes ask about the role of steroid injections into the Achilles tendon or area of inflammation. Personally, I do not advocate the use of steroid injection due to multiple published cases of spontaneous rupture of the Achilles tendon following steroid injection. There is no evidence to suggest that it is of any benefit1 and a ruptured Achilles tendon is significantly worse for the athlete than chronic tendonitis. Many patients request a steroid injection because a fellow athlete had an excellent recovery from such intervention but personally I would recommend other treatment modalities.

Autologous blood transfusion, where a small amount of blood taken from the athlete is injected directly into the Achilles tendon, was developed because it was thought that the growth factors present in blood may help stimulate the tendon to heal. However, this is still experimental and although studies on animals and in the laboratory show some success, extrapolation to humans has not been proven8.

Once all non-operative treatments have been exhausted, some athletes are in so much pain that they are unable to walk, let alone compete. Surgery is an absolute last attempt at preserving the integrity of the Achilles tendon and can only be regarded as a ‘last ditch’ effort. By the time a patient requires surgery, the tendon is degenerate, filled with scar and mucous tissue and is sometimes completely unsalvageable. In this instance, the tendon can only be debrided back to healthy tissue, if there is any left, and adhesions to the surrounding structures removed. If the tendon has ruptured completely, a tendon transfer can be done to restore the function of the tendon. However, once a tendon transfer has been performed it is unlikely that the athlete will ever get back to competing at the pre-operative level.

Sometimes, unfortunately, a combination of biomechanical, genetic and training factors have rendered the athlete completely incapable of competing in their chosen sport. In this instance, the only recommendation would be to modify or change the activity that is causing the injury. Some people just don’t have the genetic make up to tolerate high intensity, high volume exercise. A change of sport for a few years might let the tendon settle enough to attempt a gradual re-introduction to the initial mechanism of injury. I have seen athletes switch to mountain biking, swimming and rowing to avoid the complications of chronic Achilles tendonitis and excel in their new sports.

However, Achilles tendonitis is not all doom and gloom! Early detection and adjustment can prevent a lifetime of hobbling over the finishing line*. At the first sign of a ‘niggle’, seek assessment by a physiotherapist or sports medicine doctor for accurate diagnosis, imaging and commencement of a supervised rehabilitation program.

*The author told her boyfriend to ‘toughen up princess’ when he complained of heel pain during a long run and three years later he is still bringing this up at training after developing chronic Achilles tendonitis.

 

References

  1. M. Paavola, P. Kannus, T.A.H. Järvinen et al.. Achilles tendinopathy. J Bone Joint Surg, 84-A (11) (2002), pp. 2062–2076
  2. Tero A.H. Jrvinen, MD, PhDa. Achilles Tendon Disorders: Etiology and Epidemiology. Ankle Clin N Am
  3. Murphy, GA. Surgical treatment of non-insertional Achilles tendonitis. Foot and ankle clinics of North America, 14(4) 2009.
  4. Michael S. Hennessy, BSc, FRCSEd (Tr&Orth),  Andrew P. Molloy, FRCS (Tr&Orth),  Simon W. Sturdee, FRCS (Tr&Orth). Noninsertional Achilles Tendinopathy. Foot and Ankle Clinics of North America. Volume 12, Issue 4, December 2007, Pages 617–64
  5. Jason E. Lake, MD, Susan N. Ishikawa, MD. Achilles Tendon: Conservative Treatment of Achilles Tendinopathy: Emerging Techniques. Foot and Ankle Clinics of North America. Volume 14, Issue 4, December 2009, Pages 663–674
  6. Schepsis AA, Jones H, Haas AL: Achilles tendon disorders in athletes. Am JSports Med 2002;30:287-305.
  7. Raleigh, SM; Van der Merwe, L; Ribbans,WJ; et al.: Variants within he MMP3 gene are associated with Achilles tendinopathy: Possible interaction with the COL5A1 gene. Br J Sports Med, 2008.
  8. Nicola Maffulli, MD, MS, PhD, FRCS(Orth), Umile Giuseppe Longo, MD, and Vincenzo Denaro, MD. Novel Approaches for the Management of Tendinopathy. The Journal of Bone and Joint Surgery, 92-A, 15 2010.

 

About The Author

Stef Hanson. Chief.

Chief and founder of WITSUP Serious about what I do, but don't take myself too seriously

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