A Patient's Guide to Achilles Tendinopathy

A tendon attaches muscle to bone. Your Achilles tendon is the biggest and strongest tendon in the body. It is found at the back of the lower leg, just above the heel bone. It attaches your calf muscles (gastrocnemius andsoleus) to the heel bone (calcaneus) and helps you go up onto tiptoes.

Tendinopathy is a term used to describe pain, swelling or impaired function of a tendon. Achilles tendinopathy means that the Achilles tendon is affected.

There are two main types of Achilles tendinopathy:

Non-insertional: also called mid-portion which occurs between 2cm and 6cm
above the insertion of the tendon on the heel bone.

Insertional: involves the lower portion of the tendon, where it attaches to the
heel bone.

The cause of Achilles tendinopathy is still not completely understood, but can occur when a tendon is unable to adapt to the strain being placed upon it.This leads to repeated small amounts of damage within the tendon fibres resulting in the tendon trying to heal itself.

Achilles tendinopathy can affect anyone. Non-insertional Achilles tendinopathyis more common in active people, including those doing sports involving repetitive actions such as running or jumping. Insertional Achilles tendinopathy is more common in older people and those who are less athletic or overweight.

People with very high or low arches in their feet can be prone to Achilles tendinopathy because this puts strain on the tendon.

There are some other risk factors that can be associated with Achilles tendinopathy. These include:

• Changes in activity (increased or decreased activities, on different surfaces)
• Footwear
• Being overweight
• Inflammatory conditions
• Hormonal changes
• Some conditions such as diabetes, or having high cholesterol
• Some medications such as statins, corticosteroids, fluoroquinolone, antibiotics

The most common symptoms that people complain of are:

Pain: Pain is typically ‘aching’ around the heel which is then made worse byactivity or pressure to the area. Some people can ‘exercise’ through the painwhich means that the pain settles during exercise but increases after.

Morning stiffness: Many patients note stiffness at the back of the ankle when they first get up in the morning. This usually eases after a few minutesof walking, but sometimes may last longer. Stiffness can also occur afterprolonged sitting.

Tenderness over the Achilles tendon:The tendon is often very tender to touch or when gently squeezed. There may be a painful lump which can rub against the back of shoes, boots or sandals.

Clinical examination is usually sufficient to make the diagnosis althoughthis can be confirmed with imaging modalities.

If imaging is required, it may be an ultrasound scan or an MRI scan dependingupon the clinical indication.

• Identify and manage any underlying risk factors or causes.
• Rest and Elevation. These may include a certain amount of time until the
• inflammation has settled.
• Physiotherapy. This may include advice and education, also exercises for strengthening, balance, stability and stretches.
• Orthotics. If altered biomechanics such as high arch or low arch foot are
• present, then an orthotic such as an insole may be appropriate.
• Shockwave therapy. A handheld probe which emits energy waves can be
• used to stimulate a healing response.
• Surgery. When symptoms persist after exhausting conservative therapy, then surgery may be discussed.

Most people with Achilles tendinopathy improve with conservative treatment although this can take several months or more.

You should feel a gentle stretch with exercises 1-6 but they should not be painful. Avoid exercises 3-5 if you have an insertional Achilles tendinopathy.

With the other exercises 7-11, you may have an increase in your pain when you start an exercise or as you progress. As long as this does not go higher than what you perceive to be as 4/10 on a scale where 0 is no pain and 10 is the worst pain you can imagine, this is normal and acceptable, and should settle. If your pain does not settle decrease the number of repetitions and thefrequency, or stop.

If you have any concerns regarding these exercises, please contact the footand ankle unit, or your physiotherapist for advice.

Please note that this is advisory information only and your experiences maydiffer from those described. Do not attempt any of these exercises withoutbeing advised by a member of the foot and ankle clinical team or a fullyqualified physiotherapist. We cannot be held liable for the outcome of you undertaking any of the exercises shown here, independently of direct supervision from the RNOH.

We cannot be held liable for the outcome of you undertaking any of theexercises shown here, independently of direct supervision from the RNOH.

If you have orthotics (insoles), wear these with your shoes or make sure that your foot is in a good position.

Please note that this is advisory information only and your experiences maydiffer from those described. Do not attempt any of these exercises without being advised by a member of the foot and ankle clinical team or a fully qualified physiotherapist.

Hold position for 30 seconds then relax and repeat 3 times.Do this in exercises 1 to 6.

These exercises can also be seen in videos on the RNOH website.Visit: www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides
(Scroll to an select the “Therapies” tab, and then select “Foot & Ankle –stretches video”)

Isometric exercises are characterised by holding a static position, engaging the muscles without noticeable movement.

There are two types of muscle contraction: concentric and eccentric.
Concentric muscle action is where a muscle shortens – for example lifting a weight in your hand by bending your elbow shortens the biceps muscle.
Eccentric muscle action is the opposite and the muscle lengthens whilst being activated - for example lowering a heavy weight in your hand slowly by straightening your elbow. At the ankle, rising up on tiptoes is concentric since the calf muscle shortens, but lowering yourself down slowly from tiptoes leads
to the calf muscle lengthening which is eccentric.

The exercises, along with the number of repetitions, time for the hold and number of sets you are given will depend on the presentation of your Achilles tendinopathy, and how sensitive or irritable it is. A suggested guide has been mentioned.

For exercises 7 to 11, lift your heel off the floor to either halfway or to the maximum range as advised. Over time these exercises (8 to 11) can be made more challenging by adding weight, such as by wearing a back pack with weight. The exercises can also be carried out with your knees bent, but take advise from your physiotherapist.

These exercises can also be seen in videos on the RNOH website.Visit: www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides
(Scroll to an select the “Therapies” tab, and then select “Foot & Ankle –loading video”)

Q. Will I be able to return to sports?

A. If you respond to treatment, then there is no reason why you cannot return to sporting activity.

Returning to sport is guided by symptoms and the type of sport youlike to do. We advise a gradual return to your sport to avoid reaggravating your problem. You will probably have become deconditioned whilst the tendon has been irritable, which is why maintaining your cardiovascular fitness through other activities (such as swimming and cycling) is important.

Q. Can I still run during my rehabilitation phase?

A.This is dependent upon what phase of recovery you are in. Once youare on the final phase of recovery, you may be able to return to running providing you have little discomfort when doing so. Alternative forms of exercise such as swimming or cycling may be considered to maintain your cardiovascular fitness.

Q. Will I always have to do my exercise programme?

A. Not normally although if symptoms recur, it is advisable to restart your exercise programme.

Q. What happens if I do not respond to the exercise programme?

A. If this is the case for you, your clinician or physiotherapist will see whether there are any alternative treatments to offer.

Q. Is surgery better than exercise programme?

A. Surgery is a final resort when all other treatments have beenunsuccessful. It is not considered a first line treatment since it carries risks greater than exercise programmes and has not been proven to
be more successful.