Achilles tendinopathy – your guide to rehabilitation

We all need our feet to get us places, and we can do so by running, walking or – for the adventurous ones – jumping. The Achilles tendon is a major contributor facilitating these movements. It is also the longest and strongest tendon of the human body, with a length of around 15 cm in adults, and it can take loads of 12-times your body weight. The tendon originates from both our calf muscles (gastrocnemius and soleus) and inserts at the backside of our heel (posterior calcaneus). The tendon facilitates plantarflexion of your foot, which is needed when pushing your toes to the ground or when using the gas pedal of a car. Essentially, a tendon is a strong bundle of collagen-rich, fibrous connective tissue linking bones and muscles (Kirkendall and Garrett 1997).

What is the difference between tendinopathy and tendinitis?

First, let’s get some confusion with terminology out of the way. Even in medical research, tendinopathy and tendinitis have often wrongly been used interchangeably for the same condition. Tendinopathy is defined as a failed healing response of a tendon, resulting in structural changes with a thickened and weakened tendon. On the other hand, tendinitis refers to an inflammation of the tendon itself (Trojian and Amoako 2015).

What is Achilles tendinopathy? And how does it occur? 

Achilles tendinopathy is characterised as an overload injury of the tendon in the presence of pain. This injury affects around 2-3 per 1000 persons. In clinical practice, tendinopathies resulting from mechanical overload are often seen. In this case, the Achilles tendon is exposed to an unusual load where changes have happened too quickly, or the intensity was too high for too long. 

Let’s imagine two scenarios that could potentially put you at a higher risk of developing Achilles tendinopathy: you suddenly decide to go running 3-4x/week without having run before or not for a very long time. Or, you choose to hike for multiple weeks in a row with a heavy backpack. In both cases, you expose your Achilles tendon to a greater risk of developing tendinopathy because there is not enough time for the tendon to heal itself after such high levels of repetitive activity and load in a relatively short time. 

A normal tendon healing process involves three overlapping phases: a normal inflammatory phase (24 – 48 hrs), followed by a repair (6 – 12 weeks) and a remodelling phase. If this process is disturbed, the tendon thickens in an attempt to protect itself. Still, the new tendon structure is weaker, has fewer blood vessels and becomes painful and stiffer, resulting in tendinopathy (Sharma and Maffulli 2005). 

Characteristic signs of Achilles tendinopathy are pain and local tenderness in the area of the tendon itself, more pain in the morning when waking up, increased pain with loads, such as hopping or calf raises, muscle weakness when plantarflexing the foot and limited range of motion when lifting your toes towards your knees (dorsiflexion). It is, however, essential to understand that tendon pathologies and pain are critical features for tendinopathies, but pathological tendons can also be present without provoking pain (Cardoso et al. 2019). 

There are several risk factors for developing tendinopathy. Non-modifiable risk factors are older age, male sex, menopause and underlying auto-immune diseases. Modifiable risk factors include Diabetes Type II, adiposity and higher cholesterol levels. Additionally, increased rolling on the lateral side of your foot during running or walking and weakness in your plantar flexion can increase your risk for Achilles tendinopathy (Malliaras and O’Neill 2017). Lastly, athletes who undergo a sudden increase in training loads or are deconditioned are at a higher risk of tendinopathies (Cardoso et al. 2019). 

How long can it take to recover from Achilles tendinopathy? And what will my recovery be?

Recovering from Achilles tendinopathy can be a testing process, with recovery periods ranging from 3 to 12 months (Lagas et al. 2019). For a successful recovery without chronic complaints, you will need patience and a positive mindset to ensure adequate healing and minimise the risk of re-injury. Several treatment options for tendinopathy have been tested and reviewed in the last years. The most significant results were observed with exercise-based training programs with slow and heavy movements (van der Vlist et al. 2021). Performing these exercises might result in temporary discomfort but will improve during rehabilitation. Although complete rest sounds tempting and will give immediate pain relief, evidence shows that this strategy will decrease the tendon’s loading capacity and muscle power. Consequently, rest is not advised as a rehabilitation plan (Cardoso et al. 2019). Following a stretching program as a recovery plan has also not shown any significant effects (Peters et al. 2015).

The latest Dutch multidisciplinary guideline on Achilles Tendinopathy advises starting with isotonic exercises, e.g. squats or calf raises, and continuing with isometric exercises, e.g. wall holds, standing on all toes. The training adaptations and modifications should be adjusted depending on pain levels (de Vos et al. 2021) 

 At Movement Based Therapy, we follow the latest evidence-based research to create an optimal and effective training plan tailored to your lifestyle. Rehabilitating from Achilles Tendinopathy can be testing for one’s patience, so no precious time should be lost with treatments that have not proved to be effective. Our approach will focus on actively mobilising and strengthening the soft tissue around the calves with as many movement possibilities as possible. We believe that movement will always be the better solution to injuries, so we will not spend our physiotherapy session sitting around!

Questions about our approach? Don’t hesitate to contact us and we will be happy to answer all of your questions!

References 

1. Lagas IF, Tol JL, Weir A, et al. One in four patients with midportion Achilles Tendinopathy has persisting symptoms after 10 years: a prospective cohort study. AmJ Sports Med 2019.
2. Malliaras P, O’Neill S. Potential risk factors leading to tendinopathy. Apunts Med Esport 2017;52(194):43e82.
3. Kirkendall DT, Garrett WE. Function and biomechanics of tendons. Scand J Med Sci Sports. 1997; 7(2):62–6.
4. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005; 87 (1): 187–202.
5. Trojian T, Amoako A. Tendinopathy not tendonitis. ACSM’s Health & Fitness Journal: November/December 2015;19(6):37-42.
6. de Vos R-J, van der Vlist AC, Zwerver J, et al. Br J Sports Med 2021;55:1125–1134.
7. van der Vlist AC, Winters M, Weir A, Ardern CL, Welton NJ, Caldwell DM, Verhaar JAN, de Vos RJ. Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Br J Sports Med. 2021 Mar;55(5):249-256.