Achilles tendinopathy (or Achilles tendinitis) is a repetitive strain (overuse) injury , which leads to pain on the Achilles tendon about 2-6 cm above the insertion on the calcaneus (bone of the ankle). Despite many practitioners still use the term “tendinitis”(implying that the fundamental problem is inflammatory), many studies have shown that histologically there is non-inflammatory intratendinous collagen degeneration. It is very common in running and jumping sports, but it is also seen in elderly and sedentary people. The Achilles tendon is the thickest and strongest tendon in the body. It serves to attach three muscles (gastrocnemius, soleus and plantaris) to the calcaneus bone.
- Inadequate warm-up or stretching.
- Overuse (jumping, running, etc).
- Inappropriate shoes or hard surfaces (reduced shock absorption).
- Gastrocnemius-soleus dysfunction.
- Body weight.
- Direct trauma.
- Flatfoot/overpronation/underpronation/pes cavus.
- Leg Length Discrepancy.
- Poor technique.
- Poor flexibility.
- Rapid changes in:
- running surface (from grass to road)
- distance or speed
- surface inclination (running uphill)
- History. Onset, duration and aggravating factors should be documented. Achilles tendinopathy usually presents with pain 2-6 cm above its insertion, often worse at the beginning of a training session and after exercise. However patient may complain pain during exercise/stretching/daily activities (walking, stair climbing) and morning stiffness.
- Physical examination. Patient should be examined standing and prone. Patients with Achilles tendinopathy may or may not have visible swelling (however in chronic conditions a visible “soft lump” enlargement may be seen). In addition patients may have:
- Increased pain along medial/lateral margins of tendon.
- Pain with passive dorsiflexion or stretching.
- Increased pain with side squeeze test.
- “Painful arc sign” helps to distinguish between tendon and paratenon lesions.The “painful arc” sign helps to distinguish between tendon and paratenon lesions. In paratendinopathy, the area of maximum thickening and tenderness remains fixed in relation to the malleoli from full dorsiflexion to plantar flexion, whereas lesions within the tendon move with ankle motion.
- Special Test. Thompson test to exclude Achilles tendon rupture.
- Ultrasound scan may be used to confirm the diagnosis.
1. Rest and ice
2. Ultrasound to tendon
3. Soft tissue calf muscles/myofascial release/trigger points
4. Osseous mobilization/manipulation of foot/pelvis/spine
5. Heel lift bilaterally, it helps to reduce the stress on the Achilles tendon.
7. Gentle stretching (decrease adhesions).
8. Acupuncture/Dry needling.
9. Wear well padded and supportive shoes
1. Ice after exercise.
2. Continue osseous mobilization/manipulation of foot/pelvis/spine.
3. Warm up/down and stretching.
4. Train in higher heel shoe or with small heel lift.
5. Until pain subside avoid running uphill, downhill or jumping.
6. Eccentric exercise.
7. Muscle energy techniques.
8. Continue massage, ultrasound, dry needling or acupuncture.
9. Correct muscle weakness, training errors, biomechanical abnormalities, poor equipment, muscle tightness.
- Chronicity (prematurely return to training, improper shoes, bad habits).
- Achilles tendon rupture
Treatment should be continued for 4-6 weeks, usually pain decrease in 10-14days, stiffness may last persist longer.
Avoid overtraining and progress slowly in new activity.
Do not sprint of do hill running if you are not used to it. Wear shoes that are suited to your foot type, avoiding wearing worn out shoes or high heels or running in low heeled shoes.
Warm-up and stretch especially gastrocnemius and soleus. Isolated eccentric strength training has been shown to be effective for treating Achilles tendinopathy.
Use an Achilles tendon support. Progress slowly in new activity, avoiding overtraining. Partial rupture are found after steroid injections.
Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
"Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome