This was a question from my husband. His Achilles pain has been bothering him off and on for years. I asked him where it hurt and he pointed to an area just above his heel. He had Achilles tendinopathy, which is more commonly known as Achilles tendinitis. He was wondering if Achilles tendinitis stretching would help with his pain. Lucky for him, he married an orthopedic physical therapist. Read on to learn more about Achilles tendinopathy. Let’s start with anatomy!
Wait a minute. Isn’t Achilles tendonitis?
Tendinopathy is a term used to encompass any issue with the tendon. This includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. Let’s review the difference.
A tendon is the connective tissue that attaches the muscle to the bone. Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is an inflammatory condition that has a recovery period of 1-6 weeks .
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overuse with no time for the tendon to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early stage tendinosis can heal within 6 to 10 weeks but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis but the term tendonitis is often used to encompass both.
In theory my husband could have Achilles tendonitis or tendinosis. However, he has had pain on and off for years and does very little to treat it. Because of this, I am pretty confident that he had Achilles tendinosis. Unfortunately, that means that his recovery would be longer and more difficult.
What is Achilles tendinopathy?
The Achilles tendon is the largest and strongest tendon in the body. It attaches the calf muscles to the bottom of the heel. The calf muscles are located on the back of the lower leg. These are the gastrocnemius and the soleus muscles.
These muscles plantar flex the foot which means that they point the foot down. They are very important in pushing the foot off of the ground. Push off is used during walking, running, and jumping. The Achilles tendon transmits the force from the calf muscles and also helps control the ankle position when the foot touches the ground. The tendon becomes irritated from overuse and chronic excessive force on it.
Pain can occur at any area along the tendon but is most common at two different points:
- Midportion Achilles tendinopathy – Tenderness is located just above the heel. This is the most common type of Achilles tendinopathy.
- Insertional Achilles tendinopathy – Tenderness is located where the tendon inserts on the heel bone.
What are the symptoms of Achilles tendinopathy?
There are several symptoms associated with Achilles tendinopathy. These include:
- Tenderness with manual pressure in the heel or above the heel
- General pain and stiffness with walking but is worst with the first several steps of the day
- Tightness in the calf
- Swelling in the back of the ankle can occur during the acute (beginning) phase
- Increased pain at the beginning and after activity
Who gets Achilles tendinopathy?
Anyone can get Achilles tendinopathy. It can occur in athletes and non-athletes. About one quarter of all athletes develop the condition. It affects around half of all runners. However, you do not need to be an athlete to have Achilles tendinopathy. It affects less active people as well.
What are the risk factors for Achilles tendinopathy?
There are many risk factors for developing this condition. They can be divided into 2 categories – intrinsic and extrinsic.
- Intrinsic
- Overpronation of the foot
- Flat feet
- High arches
- Obesity
- Diabetes
- Gout
- Hypertension
- Tight calf muscles
- Muscle weakness
- Older age
- More common in men
- Extrinsic
- Poor technique with training or exercise
- Progressing mileage and intensity of training too quickly
- Improper shoe wear
- Training on hard or sloped surfaces
Could I rupture my tendon?
Achilles tendinopathy is a risk factor for Achilles tendon rupture. This is a full or partial tear of the tendon. It usually occurs while playing sports and is more common in 30-40 year old men. The “weekend warrior” is susceptible to an Achilles tendon rupture. This is the person who does not exercise or stretch regularly but plays a high intensity sport, like basketball, on the weekends.
What should I do?
- Physical therapy – This would be my first stop. Physical therapy can help decrease the pain and swelling with techniques including manual therapy and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. Your PT will also assess your shoe wear, training schedule, and technique to help prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if a tear is suspected or the injury is not responding to physical therapy. Your orthopedist can order imagining to determine the extent of the tendon injury.
What can I do at home?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat achilles tendinopathy. Basically stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. Swimming and biking would be good alternative activities that do not put much stress through the ankle and foot.
- Ice – Ice can help decrease the pain and swelling at the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity. Ice immediately after activity.
- Compression socks – Wearing compression socks while performing your activity can help decrease swelling and pain by improving circulation.
- Stretching – Stretching the calf muscles can help improve the motion at the ankle. This includes stretching the gastrocnemius and the soleus. See the video below.
- Strengthening – It is important to strengthen the calf muscles along with the muscles of the knee, and hip. All of these muscles work together to stabilize the ankle while running, cutting, and jumping. Adding resistance bands and loop resistance bands can decrease the difficulty. See the videos below.
- Shoe wear and orthotics – Having flat feet is a risk factor for Achilles tendinopathy because it puts an increase pull on the tendon. Changing shoe wear or using orthotics to place the foot in a neutral position will help decrease the stress on the tendon. An overpronation shoe might help or you might need orthotics. Most running stores will evaluate your foot type and suggest appropriate shoe wear and/or orthotics. Your PT can also evaluate your foot and help determine appropriate shoe wear.
In review
- Achilles tendinopathy is an overuse injury of the gastrocnemius and soleus tendon.
- The tendon is sustaining micro trauma and is not resting enough to heal.
- It is characterized by pain in the back of the heel.
- This pain is the worst in the morning.
- Improves with rest.
- It occurs when there is chronic excessive force on the tendon.
- It affects people who are very active or play sports but can also occur to those that are sedentary.
- About 50% of all runners will have Achilles tendinopathy at some point.
- There are many risk factors for Achilles tendinopathy.
- Failure to treat can lead to rupture in a small percentage of people.
- Physical therapy can treat this condition and help prevent reoccurrence.
- An orthopedist might be needed if a tear is suspected.
- There are several things you can do at home.
- Relative rest
- Ice
- Stretching
- Strengthening
- Shoe wear
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Achilles_Tendinopathy
https://www.ncbi.nlm.nih.gov/books/NBK538149/
https://www.choosept.com/guide/physical-therapy-guide-achilles-tendon-injuries-tendinopathy