Achilles Tendinopathy

Achilles tendinopathy is a very common condition in active people, specially in runners and jumpers affecting the quality of life if untreated or ignored. It’s found more in the middle-age and it can affect the sedentary and older people as well.

Achilles tendinopathy can be divided in two types: the insertional with an incidence of a 20-25% and the non insertional with an incidence of 55 to 65%.

Types of Achilles Tendinopathy

Noninsertional achilles tendinopathy is often associate with physical activity, and repetitive overuse injury causing small tears within the tendon. It presents with pain two to six cm above the heel. Worse pain at the beginning of exercising and right after finishing exercising.

Insertional achilles tendinopathy is often associated with older age, obesity, steroid use, and preexisting conditions, such as diabetes, or arthritis. It presents with pain in the posterior heel between the achilles tendon insertion and the calcaneus bone. It is common to find an overgrowth or bone deformity of the calcaneus bone. Worse pain in the morning and the day after exercising.

Sign and Symptoms

• Tenderness or stiffness in the lower leg and the achilles tendon specially in the morning.
• Difficulty walking, running, and jumping.
• Sharp, nagging pain with the first few steps of walking after prolong sitting, or resting.
• Heel pain and tenderness.
• Worse pain with calf stretching, walking uphill, or running uphill.
• Persistent pain for four weeks or more above heel.
• Reduce ankle flexibility.
• Pain with stair climbing.
• Pain subsides with warm-up prior activity.
• Pain with one leg squat.

Causes

Insertional or pain between achilles tendon and the bone is caused by:

Excessive pressure on the tendon due to tight shoes around the achilles tendon insertion. Another cause, is first time or recreational runner, hikers, jumpers, or weightlifters.

Noninsertional or pain two to six centimeters above the heel is cause by:

Repetitive overuse related to sports such as running, jumping, or hiking.

Risk Factors

• Older age, obesity, sedentary lifestyle.
• Steroid use
• Inflammatory arthritis (rheumatoid arthritis, gout, restless leg syndrome).
• History of tendinopathy.
• Antibiotic treatment (Fluoroquinolone has found to increase the risk for Achilles Tendinopathy).
• Foot misalignment (excessive pronation).
• Active hill runner, hikers, jumpers.
• Improper training (including increasing running speed, frequency, intensity too soon).
• Recreational and competitive sports.

Recovery Time

Physical therapy is a very effective choice to prevent surgery including right shoe use, eccentric exercises, gentle stretches, and patient education for at least 3 to 6 months.

Treatment

» Pain Management

Cold packs for 15-20 minutes every hour to decrease pain and inflammation after walking, or after being active.

Hot pack for 15-20 minutes to decrease joint stiffness, and muscle tightness after resting, walking up, or after prolong sitting.

Shoe insert, the best choice is a heel lift to decrease the rate of loading on the Achilles tendon. Gentle stretches taught by a Doctor of Physical Therapy for proper form and safety. Exercise progression for 3 to 6-12 months ( see eccentric-loading exercise progression)

» Antalgic gait

Gait training wearing always the right shoe, avoiding walking barefoot, and walking on uneven surfaces.

» Decrease Range of Motion

Active and Active assistive range of motion exercise to improve ankle flexibility as follow: Move feet up and down several times a day while sitting or resting.
Avoid stretches with straps, instead do active stretches using the contraction of the front muscle of the lower leg to stretch the calf muscles.

Active Lower back, lower leg, and calf stretch

• Rest on the back
• Rest legs against wall
• Bring toes toward you
• Hold this position for 30 seconds, repeat three times a day.

» Reduce Strength

Focus on gluts medius and maximus exercises as follow:

• Bridges.
• Side Clamshell
• Lateral Resistant Band Walk.
• Side Plank
• Bird Dog

10 repetitions, 10 second hold, do these exercises daily.

» Eccentric-loading Exercises Progression:

Week 1-2:

1. Seated heel raises Bring heels up keeping toes on the floor 3 sets of 10-15 of repetitions, 2x/day
2. Standing on the floor two-legged heel raises (when ankle flexibility is regained), with knees straignt, lift both heels up and slowly bring the heels down. 3 sets of 10-15 reps, 2x/day.

Week 2-5:

3. Standing on a small step, or staircase with the heels hanging over the edge of the step. Keep knees straight and hold onto a hand rail for support and balance. Raise the heels up and slowly bring the heels down, moving the heels toward the floor. 3 sets of 10-15 repetitions 2x/day.
4. Do number three with both knee slightly bent for 3 sets of 10-15 repetitions, 2x/day
5. Shifting weight form uninjured to injured leg. Stand up on a small step, or staircase with the heels hanging over the edge of the step. Keep knees straight and hold onto a hand rail for support and balance. Raise the heels up and lift uninjured foot off the step. Slowly bring the injured heel down (keeping the uninjured foot off the step), moving the heel toward the floor. Return the non-injure foot to the step and start over again. 3 sets of 10-15 repetitions 2x/day.
6. Do number five with both knee slightly bent for 3 sets of 10-15 repetitions, 2x/day

Week 3-12:

7. 1. Shifting weight from uninjured to injured leg wearing a back pack.
   2. Stand up on a small step, or staircase with the heels hanging over the edge of the step.
   3. Keep knees straight and hold onto a hand rail for support and balance.
   4. Raise the heels up and lift uninjured foot off the step.
   5. Slowly bring the injured heel down (keeping the other foot off the step), moving the heel toward the floor.
   6. Return the non-injure foot to the step and start over again.
   7. 3 sets of 10-15 repetitions 2x/day.
8. Do number seven with both knee slightly bent for 3 sets of 10-15 repetitions, 2x/day

Education

• Education in avoiding and modify activities that increase pain.
• Proper foot wear.
• Recent research found out that corticosteroid injection are not recommended.

What to Avoid?

• Aggressive ankle stretch.
• Barefoot walking.
• Tight shoes around the Achilles tendon insertion.

If you are dealing with physical and emotional pain, or you want to be more active and you don’t know how to start, call now to find out how Physical Therapy can help you recover faster, move easier, and effortless: 805-203-9940

The information in this blog is for educational and informational purpose only, its content is provided based upon evidence-based medicine, knowledge, and experience as a Doctor of Physical Therapy (DPT).