Achilles Tendon Pain
The strongest tendon in the body conjoins the gastrocnemius and soleus muscles to the heel bone (calcaneous). The average length is about 15 cm and does not have a true synovial sheath covering and protecting it but rather a single cell layer of fatty areolar tissue called a paratenon. Blood supply is evident in three locations, being most vascular proximally where it attached to the muscles and least in the mid section of the tendon.
- Achilles Tendinitis / Bursitis
This is an inflammatory condition of the attachment of the achilles tendon / bursa to the heel bone called the calcaneous.
- Achilles Tendinopathy
This is a non-inflammatory condition of the mid-section of the Achilles tendon. This area has increased tenderness on palpation versus the non-affected side. It is characterized by degenerative changes of the tendon (tendinosis). This is the more prevalent of the two types of Achilles tendon pain.
Achilles tendon disorders are reported in a wide variety of sports. Seen amongst a variety of athletics it is more symptomatic during training as opposed to during competition. It accounts for up to 9% in recreational & competitive runners. People who are less active are not immune to this either. Although there is an increased prevalence of Achilles injuries as age increases, the mean age for Achilles disorders is reported to be between 30-50 years of age.
Risk Factors for Achilles Tendinopathy
- Abnormal dorsiflexion range of motion (Specifically decreased dorsiflexion with the knee extended)
- Tendon structure as identified with diagnostic ultrasound imaging
- Abnormal range of motion in the hind-foot (subtalar joint)
- Decreased plantar flexion strength
- Increased foot pronation (flat feet)
- Possible Medical conditions: obesity, hypertension, hyperlipidemia, diabetes
- Extrinsic factors: (training errors, environmental factors, faulty equipment)
Diagnosis / Classification
- Localized pain / stiffness in Achilles tendon
- Intermittent pain related to activity or exercise
- Stiffness upon weight bearing after prolonged immobilization (such as sleeping)
- Stiffness & pain at the commencement of exercise training session that lessens as exercise continues. – As condition worsens a progression of pain may be felt at the end of the exercise session ro pain throughout the duration of activity occurs
- Decrease plantar flexion endurance
- Arc sign: area of palpated swelling moves with dorsiflexion & plantar flexion
- “Royal London Hospital Test”: positive when tenderness at 3 cm proximal to calcaneous with ankle in slight plantar flexion, that decreases as ankle is dorsiflexed
Other Possible Diagnoses
- Acute Achilles tendon rupture
- Partial tear of Achilles tendon
- Retrocalcaneal bursitis
- Posterior ankle impingment
- Irritation or neuroma of sural nerve
- Os trigonum syndrome
- Accessory soleus muscle
- Achilles tendon ossification
- Systemic Inflammatory disease
- Insertional Achilles tendinopathy
Is Additional Imaging Useful?
Likely that both ultrasound and MRI imaging will play an important role in verifying tendon structure to augment clinical decision-making.
Prognosis / Outcome
- Long-term prognosis for patients with acute-to-subchronic Achilles tendinopathy favourable with non-operative treatment. (Follow-up studies show 71% to 100% are able to return to prior level of activity
- Significant decreases in pain and improvement in function reported following 6 to 12 weeks of intervention
- If conservative therapy is unsuccessful, surgery recommended to remove fibrotic adhesions / degenerative nodules to restore vascularity – (Paavola et al found 29% of those with acute to subacute Achilles tendinopathy required surgical intervention with favourable outcome)
Treatment / Intervention
- Eccentric Loading – specifically designed strengthening program
- Foot Orthoses
- Hands-on Manual Therapy to restore ankle joint mobility and soft tissue release techniques
- Addressing other joint imbalances higher up: hip / SI joint & spine
- Electric modalities
- Heel lifts
For more information about achilles tendon pain please contact InSync Physio.
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