Achilles Tendinopathy
1. Introduction
This condition commonly presents with pain in the Achilles and/or heel region. For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed it was a condition that mainly involved inflammation, leading to treatments such as steroid injections and strong anti-inflammatory medication. However, our understanding of tendon-related pain has improved and we now know that tendons are less likely to inflame in response to overload (6).
Our understanding of the best way to manage tendon problems is continually developing and we work hard to try and provide the most up to date evidence based information on this page.
Frequently Asked Questions
- Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon that joins your heel bone to your calf muscles.
- Achilles tendinopathy is a moderately common condition, particularly in the sporting population.
- In the general population, it is not very common, with less than 0.5% getting the condition.
- It is estimated to affect more than 150,000 people in the UK every year (1).
- No.
- With the correct advice and rehabilitation approach, tendinopathies generally recover well without surgery.
- They are not linked to other serious pathology.
- Middle-aged, middle-distance and long-distance runners (3) are most likely to develop an Achilles tendinopathy.
- Can also affect non-runners but more so in sports such as tennis and gymnastics, and dancers.
- Localised pain along the tendon and/or near the heel.
- Painful to touch or squeeze.
- Painful to weight-bear first thing in the morning.
- Normally worse as you begin your activity (walking/running) but eases as you warm up, up until a certain point.
- Modify your activity.
- Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
- Advice from a qualified physiotherapist will be helpful in most cases.
- Most people recover within 3 months (4).
- Some patients may require prolonged rehabilitation and symptoms can persist over a year (5).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
Symptoms are localised to the Achilles tendon and surrounding areas. This presents commonly as increased soreness with increased load/activity, either during or after activity. Normally this is on walking and/or running, but can also present more noticeably whilst using steps or going up/downhills. Pain tends to be worse in the morning but improves (< 30 mins) as it warms up (7).
Tendon pain is ‘dose–dependent’, which means the pain will be aggravated based on the amount of load and the volume it is subjected to (8). Essentially, if you load the tendon excessively by exposing it to higher tensile forces, or by performing repetitive movements in a relatively short period of time, the tendon cannot adapt quickly enough and may begin to become irritable, leading to pain and ultimately the risk of developing a tendinopathy. Gradually progressing and managing how much you load the tendon is the best way to avoid developing tendinopathies.
3. Causes
The Achilles tendon is very strong and withstands up to twice our body weight when walking, which increases up to six times when running (6). It is essentially a spring-like mechanism and thus stores and releases energy very quickly as we walk or run. Repetition of this spring-like activity over a single exercise session, or with insufficient rest to enable repair and remodelling between sessions, can induce pathology and a change in the tendon’s mechanical properties, which is a risk factor for developing symptoms (9). Despite this, it is rare that damage is caused and the tendon is very good at healing itself.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing achilles tendinopathy. It does not mean everyone with these risk factors will develop symptoms.
- Prior lower limb tendinopathy or fracture – stiffness can increase the risk of the condition.
- Moderate alcohol use – this can affect tendon nutrition.
- Diabetes mellitus and/or altered cholesterol levels.
- Training during cold weather – if not properly warmed up.
- Decreased calf muscle strength – increases the load on the tendon.
- Altered walking pattern with decreased foot propulsion – increases the load on the tendon.
- The greater rolling motion of the foot as it is planted when walking and/or running – increases the load on the tendon.
- An increase in weight – increases the load on the tendon.
- A change in footwear – increases load on the tendon.
5. Prevalence
- Achilles tendinopathy is a moderately common condition, particularly in the sporting population.
- In the general population, it is less common, with less than 0.5% getting the condition. It is estimated to affect more than 150,000 people in the UK every year (1).
- Achilles tendinopathy is one of the most frequently observed ankle and foot overuse injuries.
- It may affect 9% of recreational runners and cause up to 5% of professional athletes to end their careers.
6. Assessment & Diagnosis
A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your physiotherapist will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your Achilles tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
If walking or running is your main activity that brings on symptoms, try to modify rather than stop completely. See some of the guidelines below.
8. Rehabilitation
Research is very clear that modifying the load that goes through the tendon is the key element that stimulates recovery (6). Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing Achilles tendinopathy. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Achilles Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining a range of movement within the ankle, appropriate loading of the tendon and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. This should not exceed any more than 6/10 on your perceived pain scale when exercising and pain should clear in 24 hours following completion of the exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
Progress onto this programme once the above no longer becomes challenging. More focus is given to progressive loading of the tendon and lower limb strengthening. This should not exceed any more than 6/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging, progressive loading of the affected tendon complex. This should not exceed any more than 6/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting and sprinting exercises (11).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
- Podiatry referral to address gross biomechanical alignment issues may be helpful in the short term.
- Heel inserts for your footwear may help relieve symptoms if occurring nearer the heel (12). Your therapist will guide you on this.
- Steroid injections are not a recommended treatment for the Achilles tendon as it can affect the integrity of the tissue and has been shown to lead to long-term problems (13).
- Surgery –this should be the last option if all other treatment attempts have been exhausted (2).
References
- Kearney, R., Parsons, N. and Costa, M. (2013). Achilles tendinopathy management: a pilot randomised controlled trial comparing platelet-rich plasma injection with an eccentric loading programme. Bone and Joint Research 2, 227-232.
- Uquillas, C.A., Guss, M.S., Ryan, D.J., et al. (2015). Everything Achilles: knowledge update and current concepts in management: AAOS exhibit selection. Journal of Bone and Joint Surgery. American Volume 97, 1187-1195.
- Ackermann, P.W., Phisitkul, P. and Pearce, C.J. (2018). Achilles tendinopathy – pathophysiology: state of the art. Journal of ISAKOS: Joint Disorders and Orthopaedic Sports Medicine 3, 304-314.
- Asplund, C. and Best, T. (2013). Achilles tendon disorders. BMJ 346.
- Morton, S., Newth, A. and Majeed, A. (2016). Pain at the back of the heel. BMJ.
- Silbernagel, K.G., Hanlon, S. and Sprague, A. (2020). Current clinical concepts: conservative management of Achilles tendinopathy. Journal of Athletic Training 55, 438-447.
- Martin, R.L., Chimenti, R., Cuddeford, T., et al. (2018). Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018. Journal of Orthopaedic and Sports Physical Therapy 48.
- M. Cassel H. Baur A. Hirschmüller A. Carlsohn K. Fröhlich F. Mayer (2014). Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes https://doi.org/10.1111/sms.12318.
- Cook, J. L. & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43, 409-416.
- van der Vlist AC et al .(2019). Clinical risk factors for Achilles tendinopathy: a systematic review Br J Sports Med.
- Malliaras P, Barton CJ, Reeves ND, Langberg H. (2013). Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 267-86.
- Maffulli, N., Saxena, A., Wagner, E. and Torre, G. (2019). Achilles insertional tendinopathy: state of the art. Journal of ISAKOS: Joint Disorders and Orthopaedic Sports Medicine 4, 48-57.
- Coombes, B., Bisset, L. and Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 376, 1751-1767.
Other Conditions in
Ankles, Feet
Tibialis Posterior Tendinopathy
A condition involving injury to the tendon found around the bone at the inner side of the ankle leading to pain and weakness.
Lateral Ankle Sprain
Pain and loss of function following an injury to the ligaments on the outside of the ankle.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankle Fractures
When a bone, or bones, that make up the ankle joint are stressed beyond their capability resulting in a fracture.