Achilles tendinopathy

Achilles tendon issues can be categorised into insertional and mid-portion problems (see image below).

Insertional Achilles pain (green circle) relates to the lower part of the tendon, where the tendon attaches onto the heel bone (known as the calcaneum). This can also involve a structure called the retrocalcaneal bursa.

• Mid portion Achilles pain (blue circle) involves the middle portion of the tendon only.
  

Location of pain of mid portion Achilles pain (blue circle) &  insertional Achilles pain (green circle).

Repetitive or unaccustomed activity of the Achilles can cause the tendon to become irritated and inflamed. This causes the tendon to swell and become painful. Tendon inflammation is termed tendinitis. The hallmark sign of this is extreme tenderness when you touch or squeeze the tendon.

If the tendon does not have enough time to recover and is subjected to further activity, the healing process can become compromised, resulting in a thickened, weakened and painful tendon. This repetitive process of acute inflammation and poor tendon healing results in tendinopathy (Almekinders et al, 2007).

What are the symptoms of mid-Achilles tendon issues?

The most common symptom of a mid-Achilles tendinopathy is pain. Pain is usually felt at the beginning and at the end of exercise, be it a walk or run, with a reduction of symptoms whilst completing the exercise itself. Many patients report being able to ‘exercise through’ their pain but report a return of symptoms after completing their walk or run.

As a mid-portion Achilles tendinopathy develops this reduction of pain during exercise rescinds resulting in a continuously painful tendon. If this is allowed to continue the pain experienced with a mid-portion Achilles tendinopathy can spill over into everyday life. Activities such as walking or ascending and descending stairs or often described as painful in severe cases.

Many people describe a swollen, thickened tendon which is painful to touch. The most common location being 2-3 inches above the calcaneus (heel bone) (Almekinders et al, 2007).

How is a mid-portion Achilles tendinopathy treated?

Most people respond very well to conservative management of a mid-portion Achilles tendinopathy. This commonly involves a specific set of home exercises designed to strengthen your Achilles and calf muscles. Approximately, 50-60% of clients will improve with a specific, tailored exercise programme.

Exercise prescription should be prescribed and supervised by a physiotherapist.

If you are a runner here are a few tips which might help;

• Reduce the activities which irritate or increase your pain. For example, if you get pain running, consider reducing your training load by 50% for 2 weeks.
• How old are you will trainers? If you wear trainers over 6 months old or you have run over 500 miles in them, it may be time for a new pair.
• Applying a small bag of frozen peas in a tea towel over your Achilles for 10 minutes will help reduce your pain. Be careful not to cause an ice burn.
• Eccentric heel raise exercises can help strengthen your Achilles tendon and calf muscle. Here is an exercise that can help – try this exercise 3 sets x 15 reps everyday for 4 weeks. If this exercise does not help after a month or makes the pain worse then we would suggest you are assessed by one of our expert clinicians.
• Try applying a topical anti-inflammatory gel such as Voltarol however, speak to your pharmacist first.

What if physiotherapy has not helped your Achilles pain?

In some cases, conservative management may not resolve your pain. If this is the case there are two main treatment options.

Extracorporeal Shockwave Therapy (ESWT)

Shockwave therapy is an effective treatment modality and is supported by a large body of research. Approximately, 70% of Achilles issues will improve with shockwave therapy (Korakakis et al, 2017). It is an effective and safe treatment for Achilles tendinopathy.

Shockwave therapy produces a small dose of controlled microtrauma to the Achilles tendon by means of powerful pulses of soundwaves. This stimulates the body’s natural healing process, allowing the tendon to repair. Local nerve endings surrounding the painful tendon become desensitised by these pulses, resulting in further pain reduction.

Recent evidence suggests positive results with the application of 3-5 shockwave sessions running concurrently with a progressive loading exercise program for the treatment of all lower limb tendinopathies.

All clinicians at Complete are trained to deliver shockwave. If you would like more information concerning shockwave therapy, please contact us.

Ultrasound guided injections

There are a few injection techniques available for treating mid-portion Achilles tendinopathy. These are reserved for cases that are not improving with exercise based physiotherapy.

All these injections are designed to be carried out alongside your rehabilitation exercises. Injections are not stand-alone treatments.

Furthermore, we do not recommend injections to be carried out into the tendon itself. The injections we use target the structures surrounding the tendon, which have been shown to be the source of the pain in mid-portion Achilles tendon problems.

1. High volume/’stripping’ technique

This is a novel injection technique which we have been using for many years at Complete. It accounts for approximately 80% of the injections we carry out for mid portion Achilles issues.

It involves injecting a large volume of saline (sterile water) mixed with local anaesthetic, with or without steroid, to ‘strip’ the surrounding fat and vessels (known as neovascularisation) away from the Achilles. This procedure must be carried out with ultrasound guidance and can be an affective remedy.

When a tendon becomes tendinopathic the internal structure of the tendon is altered. The tendon becomes thickened and a process called neovascularisation occurs. Neovascularisation is the growth of new blood vessels in response to an injury to the tendon. These new vessels bring with them small nerves, which have been shown to be one of the causes of the pain in Achilles tendon problems.

High volume ultrasound-guided injection is designed to disrupt the neovascularisation and reduce the pain to allow you to accelerate your recovery  (Barker-Davies et al, 2017).

Current research shows that ultrasound guided high-volume injection for Achilles tendinopathy can significantly reduce pain and increase function when accompanied by a progressive exercise loading program (Walkley et al, 2019 and Maffulli et al, 2012).

The decision to inject steroid or not is dependent on many factors and will be discussed at your appointment once a scan has been carried out. Steroid, also known as corticosteroid, is a strong anti-inflammatory and is excellent at reducing pain in the short term. However, this has to be carefully considered as there are reports of tendon rupture following corticosteroid injection around load-bearing tendons (the Achilles tendon is a primary load-bearing tendon).

A systematic review of randomised control trials completed in a study conducted by Coombes et al (2010) concluded that only one case of tendon rupture was observed in the 991 participants.

2. Plantaris related pain

If you have pain on the inside of the Achilles tendon and an ultrasound scan reveals that your Achilles pain is related to the plantaris tendon, the plantaris tendon can ‘rub’ on the Achilles tendon causing pain.

We would then plan to carry out a high volume injection technique described above but it would be slightly modified to target Plantaris. The injection technique aims to separate the plantaris tendon away from the Achilles.

Complete Physio has a team of highly experienced physiotherapists who are fully qualified musculoskeletal sonographers, independent prescribers and injection therapist clinicians, fully qualified physiotherapists and musculoskeletal sonographers. Complete are able to offer a same day service for all guided injections. There is no need for a GP referral.

For further information please contact us on 0207 4823875 or email injections@complete-physio.co.uk.