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Achilles tendonitis or Achilles tendinopathy is an overuse injury causing pain, inflammation and or degeneration of the achilles tendon at the back of the ankle.
If not caught early this can be a difficult injury to cure but with the right treatment and particularly eccentric strengthening exercises a full recovery can usually be achieved.
Symptoms consist of pain and stiffness at the back of the ankle which may have come on gradually over time and often be worse first thing in the morning. Achilles tendonitis can be either acute or chronic.
Acute tendonitis is usually more painful and of recent onset. Chronic injuries will have come on gradually and over weeks or mayfollow an acute injury. Chronic injuries do not not necessarily prevent activity but can niggle away affecting performance.
Symptoms of acute Achilles tendonitis will be a gradual onset of pain at the back of the ankle, just above the heel bone which may develop over a period of days. The Achilles tendon may be painful and stiff at the start of exercise and first thing in the morning.
As the tendon warms up the pain will go often for it to return later in the day or towards the end of a prolonged training session. The tendon will be very tender on palpation or pressing in on the achilles tendon or squeezing it from the sides.
Chronic injuries may follow on from acute Achilles tendonitis if it goes untreated or is not allowed sufficient rest. Chronic achilles tendinosis is a difficult condition to treat, particularly in older athletes who appear to suffer more often.
There will be a gradual onset of Achilles tendon pain over a period of weeks, or even months. The pain will come on during exercise and is constant throughout the training session. Pain will be felt in the tendon when walking especially up hill or up stairs because the achilles has to stretch further than normal.
The VISA achilles tendon pain questionnaire has been designed to measure progress during rehabilitation. The athlete simply answers a number of questions and their score can give an estimate of how bad the injury is.
Download the VISA questionnaire....
Treatment for acute injuries includes rest and application of ice or cold therapy to reduce pain and inflammation. More chronic injuries may respond better to heat treatment with a strict 12 week heel drop exercise program which has been shown to be effective.
For an acute injury applying ice for 10 minutes every hour or so reducing frequency as required for the first 2 to 3 days can help reduce pain and inflammation. Rest is important so try to stay off your feet as much as possible. Wearing a heal lift (in both shoes) can help reduce the strain on the tendon by shortening the calf muscle very slightly, although this should only be done as a short term measure. Gentle calf stretching exercises can help stretch the muscles and aid recovery.
Longer term chronic Achilles tendon injuries may respond better to application of heat, again applied for 10 minutes every couple of hours as required. Applying gentle self massage to the achilles tendon may also be beneficial. If achilles tendonitis has been a persistant problem then the Hakan Alfredson's heel drop protocol exercises have been shown to be effective in up to 90% of patients. They involve performing a heel drop exercises 180 times every day for 12 weeks during which time pain may actually get worse before it gets better.
A Doctor may prescribe anti-inflammatory medication such as ibuprofen which might help with acute achilles inflammation and pain but has not been proven to be beneficial long term and may even inhibit healing. Taping the Achilles tendon can provide protection and support while the injury is healing, especially if the athlete needs to be on their feet, although the tape will need to be re-applied regularly.
Application of electrotherapy such as ultrasound can also help reduce pain and inflammation and providing a micro massage effect to the tissues. Sports massage can help mobilize the tissues of the tendon and relax the calf muscles.
A full rehabilitation program consisting of calf muscle stretching and eccentric heel drop exercises can be recommended with advise on a gradual return to activity and full training.
A professional therapist can identify possible causes such as biomechanical problems with the foot which may be contributing to the chance of injury.
A combination of treatment approaches and patience will work best. Occasionally a steroid injection may be given however injecting directly into the tendon is not recommended.
The Hakan Alfredson's heel drop protocol exercises have been shown to be effective in up to 90% of patients suffering with achilles tendon pain and involve the patient dropping the heel to horizontal in a slow and controlled manner.
The athlete performs an eccentric heel drop exercise on a step going up with both legs and slowly lowering the heel to the horizontal position. Eccentric exercises are those where the muscles (in this case the calf muscles) get longer as they contract. Exercises are performed twice a day to a total of 180 repetitions and continued for 12 weeks. Pain may often get worse over the 12 weeks before it starts to get better.
See more on achilles tendon heel drop exercises....
The achilles tendon is the large tendon at the back of the ankle. It connects the big calf muscles at the back of the lower leg (gastrocnemius and soleus muscles) to the foot and inserts at the back of the heel or calcaneus bone.
It provides the power in the push off phase of walking and running where huge forces are transmitted through the achilles tendon.
Causes & prevention
Achilles tendonitis is usually an overuse injury caused by doing too much too soon. Poor footwear, soft training surfaces, tight muscles and foot biomechanics can all increase the likelihood of injury. The term Achilles tendinopathy is probably a better term to describe the range of conditions that can cause Achilles tendon pain.
Strictly speaking tendonitis suggests an inflammatory condition of the tendon but in reality few injuries are actually down to pure inflammation. The main finding, particularly in older athletes is usually degeneration. Other very similar conditions may actually be due to inflammation or degeneration of the tendon sheath which surrounds the tendon rather than the achilles tendon itself (called Tenosynovitis).
If the athlete over pronates when running then this can cause the foot to flatten which in turn causes the lower leg to rotate inwards which twists the achilles tendon increase the stresses on it making it more susceptible for over use. A podiatrist can perform gait analysis to identify any biomechanical issues and correct them with orthotic inserts which are worn inside shoes, or for less sever cases advising on correct footwear for your running style.
Make sure you have the right running shoes for your foot type and the sport. Many specialist running shops will do gait analysis and have experience of advising the correct shoes. A worn out shoe or one that does not provide enough support can increase the strain on the achilles tendon.
Avoiding overuse and modifying training methods is important to prevent the injury from returning. For example running on soft surfaces, especially sand is not good for the achilles tendon as it allows the heel to sink causing additional stretch on the tendon. If you are a runner then increase your weekly mileage gradually and by no more than 10% per week.
We have a number of resources to help in the recovery of achilles tendonitis including our 12 week exercise check sheet and our downloadable VISA achilles pain questionnaire which is a great way to monitor how bad your injury is.
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