Achilles tendinopathy

An Achilles tendinopathy can be reliably diagnosed by your doctor or physiotherapist by taking a history of your condition. In some circumstances it may be necessary to conduct a physical examination but this is usually not necessary initially in uncomplicated Achilles tendinopathy.

The main feature on examination is often pain and thickening of the Achilles tendon when palpated.

X-rays and scans are not routinely required.

You may experience some pain and swelling at the back of the heal. This might feel as an area which is thick and lumpy behind your heal. The pain associated with Achilles tendinitis typically begins as a mild ache in the back of the leg or above the heel after running or other sports activity. Episodes of more severe pain may occur after prolonged running, stair climbing or sprinting, including prolonged standing. Often the most severe symptoms will be felt not at the time of these activities but the following morning when the Achilles tendon has developed stiffness overnight.

It is possible for the Achilles tendon to rupture as a sudden event. You may have felt a sudden sharp pain and/or heard a snap at the time of injury. In this case, you would be unable to stand on tiptoe, would walk with a flat foot and will notice severe swelling and bruising in the Achilles region. In this case, you should see your doctor as soon as possible, as early referral onwards usually results in better outcomes.

Causes

• Sports. Achilles tendinopathy is common in middle-aged people who play sports, such as tennis or basketball. The structure of the Achilles tendon weakens with age, which can make it more susceptible to injury, particularly in people who may participate in sports only on the weekends or who have suddenly increased the intensity of their running programs.
• Foot mechanics. A naturally flat arch in your foot can put more strain on the Achilles tendon.
• Obesity. Excessive weight and tight calf muscles can also increase tendon strain.

Achilles tendinopathy can be diagnosed clinically, gently pressing on the affected area determines the location of pain, tenderness or swelling. Further tests such as Ultrasound or MRI may be required if the tendon is suspected to have ruptured.

An Achilles tendinopathy can be managed effectively by adhering to the following advice and exercise routine. It is worth bearing in mind that recovery can take several weeks.

Immediate management

Immediate management is aimed at reducing swelling and alleviating pain to allow rehabilitation to commence as early as possible following injury.

• Apply a cold/ice pack to the painful area for 5-10 minutes every 2-3 hours, as tolerated, taking care to avoid any skin damage.
• You may wish to take painkillers such as paracetamol or use non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen gel or tablets (please read the leaflet or speak to your pharmacist to check that these are safe for you to use).

Ongoing management

Physiotherapy - The key treatment is physiotherapy, which involves stretching exercises of the tendo Achilles. Specific stretching and strengthening exercises to promote healing and strengthening of the Achilles tendon and its supporting structures.

A special type of strengthening called "eccentric" strengthening, involving a slow let down of a weight after raising it, has been found to be especially helpful for persistent Achilles problems.

Heel pad - A shoe insert or wedge that slightly elevates your heel can relieve strain on the tendon and provide a cushion that lessens the amount of force exerted on your Achilles tendon.

Medication - Painkillers as when required is advised.

Modifying aggravating activities. The Achilles tendon may need 4-6 weeks of relative rest initially to settle symptoms while you work on strengthening the calf muscles and Achilles tendon (see below).

Exercises. Regular exercises to strengthen and stretch the calf muscles and Achilles tendon.

If you are at all concerned about whether these exercises are suitable for you or if you experience any pain while doing them, please seek appropriate clinical advice from your GP or Physiotherapist.

Footwear. You should ensure that you use well-fitting, supportive footwear with adequate arch support, both during your everyday activities and, particularly, during exercise. Very flat shoes and high heels can also exacerbate the problem. Orthotic inserts placed inside your shoes can further reduce the load placed on the Achilles tendon.

Shockwave therapy. This may be offered as a treatment option for individuals with persistent pain in spite of undergoing a full course of physiotherapy.

Patients who do not benefit from physiotherapy and other measures may be offered surgery. This involves stripping part of your tendon and allowing it to heal again.

Surgery is carried out as a daycase under anaesthesia. You will walk with some surgical shoes for 2 weeks and you will be invited to attend a follow-up appointment.

There are some risks associated with surgery, however these are small. There is a small risk of wound infection, developing clots in your leg or lung, swelling of your foot and ankle for up to to 3 months or more, over sensitivity of scar, injury to any of major nerves or blood vessels around the area of surgery, temporary or permanent numbness around the area of surgery.

In very rare occasions you may have chronic pain as a result of surgery (CRPS), loss of limb and anaesthetic risk. However, these risks are very rare. Please discuss this further with your surgeon.

You should get back to most of your normal activities, including driving at 2-4 weeks. It is normal to have some discomfort and swelling for up to 3 months.