In this blog we look to explain the process of Achilles tendinopathy.
We will talk about common risk factors, proven treatments, new treatment ideas, and what doesn’t work.
Achilles tendinopathy is one of the most common ankle overuse injuries and is more likely to be found in active individuals who participate in running and jumping sports.
Achilles tendinopathy can be a frustrating condition because of the potential for pain to become persistent and significantly limit athletic participation and daily function.
Don’t worry though there are actionable steps that you can take to to improve this condition.
But first let’s learn a little more about the problem itself.
Your tendon is not inflamed!:
First it is important to point out that we are using the term “tendinopathy” rather than “tendinitis.”
The term tendinitis had been used for decades but it turns out this is actually a bit of a misnomer. The term tendinitis implies that there is an inflammatory condition occurring.
Recent studies however have found that tendon changes occur as a result of failed healing where inflammation and inflammatory cells are not found.
The tendon itself, like most tendons, has a relatively low blood supply. In the Achilles the area of the tendon that is least vascularized is approximately 2 to 6 cm above its insertion into the heel. This explains why this is the most likely area of the tendon to be injured.
Achilles tendinopathy is actually a stalled healing process:
This section is going to be a bit technical, but bare with me because it is important.
In normal tendon healing an injured tendon must go through the four phases of healing.
The first phase, the inflammatory phase, typically lasts two to three days and is important in laying the ground work for healing to occur.
After two to three days if everything goes according to plan the second phase of healing starts to occur. This second phase is called the proliferative phase. This is where new fibrous like tissue is laid down in the area of injury. This typically occurs for 6 weeks until healing starts to enter its next phase: the remodeling phase.
The third phase of healing is the remodeling phase. This is here new tissue starts to align itself in a direction that best absorbs the load through the tendon. This typically lasts another 4 weeks.
Finally, if all goes well, after approximately 10 weeks from the moment of injury the tendon will enter the final phase of healing, the maturation phase.
In this final phase the new fibrous tissue gradually changes to scar tissue over the course of about a year.
That means that if everything goes right it takes an injured tendon about a year to fully heal!!!
So if everything goes right it takes a full year for an injured tendon to heal. Now, that doesn’t mean that you will be out of commission for that full year. You may have healed up sufficiently enough that you can go back to your sport without any pain or limitation.
Its important to know though that the one year mark is still the length of time it will take for the tendon to go through its full healing process.
Tendinopathy is stalled healing:
A tendinopathy occurs when you don’t make it through all four stages of healing.
In fact you end up getting stuck in the second phase, the proliferative phase, of healing.
Being stuck in the proliferative phase leaves a tendon with too many cells responsible for breaking down the tendon. So you get caught in a position where there is too much breakdown vs. buildup.
The tendon can then become weaker and painful. This doesn’t sound like something anyone wants.
Prevention is always the best medicine:
The first question one might want to ask after reading all of the above is: how can someone avoid getting Achilles tendinopathy?
This may be best answered by looking at a list of risk factors associated with Achilles tendinopathy.
Risk Factors:
The first grouping of risk factors are intrinsic factors associated with this disorder. Intrinsic factors include a flat foot, a foot with too much arch, limited mobility of the subtalar joint (heel), and a leg length discrepancy.
Systemic inflammatory conditions such as rheumatoid arthritis, hypertension, diabetes, obesity, hypertension, and certain medications can all increase the risk of developing Achilles tendinopathy as well.
Extrinsic factors include excessive loading of the tendon through sport, training errors that include abrupt changes in frequency or intensity of training, change in training surface (hills or hard surfaces), poor shock absorption and uneven footwear may all contribute to Achilles tendinopathy.
There are a number of factors on this list that can be modified by training and lifestyle changes. Reducing your overall inflammatory lifestyle through diet could easily reduce the risk of developing Achilles tendinopathy.
Likewise, following a gradual progression of exercise and activity without huge jumps in training can significantly reduce your risk.
The bottom line is there are plenty of risk factors on this list that are within your own control!
Now that we know what Achilles tendinopathy is and how it likely got there lets figure out how to get rid of it.
There are a number of different approaches that one may encounter in the medical community. So, let’s review the effectiveness of those approaches.
What doesn’t work
NSAIDs: There is little scientific basis for the use of non-steroidal anti-inflammatory (NSAIDs) medications. As we know from part 1 of this blog post, Achilles tendinopathy is NOT an inflammatory process. So, medications that work to reduce inflammation would add no value to your ability to heal.
Unless you like unnecessary side effects from medication, stay away from the NSAIDs.
Corticosteriod Injections: Just like NSAIDs cortisone is an anti-inflammatory and has no medical rationale for it’s use on this condition.
If that’s not enough, adverse effects were reported in 82% of corticosteroid trials that included further tendon atrophy, tendon rupture, and decreased tendon strength.
This is a no brainer, cortisone has no business being in your Achilles tendon.
What might work
The jury, aka the scientific community, is still out on these interventions.
Some studies have shown some success but there is still more research that needs to be done before the scientific community puts their seal of approval on these treatments.
Extracoporeal shockwave therapy: This is a treatment technique that uses high energy acoustic waves to deliver a mechanical force to the body’s tissues. The workings of this treatment are poorly understood but there have been recent clinical trials that show good results for those with chronic Achilles tendinopathy.
Unfortunately, there needs to be more high-level evidence and specific treatment parameters identified before this treatment moves up the list.
Platelet-rich Plasma (PRP): PRP is the injection of platelet-rich plasma into a site of tendon injury. PRP stimulates healing through a number of growth factors in the plasma. There is a lot of good evidence out there that PRP can help tendon healing elsewhere in the body. Unfortunately, there is not a lot of evidence specific to the Achilles tendon.
Prolotherapy: Prolotherapy is the injection of hyperosmolar dextrose into the tendon. Clinical trials have demonstrated a reduction in pain, improvement in tendon strength and reduction in the size of intratendinous tears associated with the disorder.
Although early research shows benefits with this procedure there still needs to be more high-level studies performed before this treatment is deemed truly effective.
Low level laser therapy: There is conflicting evidence to suggest low level laser therapy is beneficial to Achilles tendinopathy. There are randomized control trials that demonstrate improvement in tendon healing and elasticity.
However other trials showed no effect on pain compared to controls. There is high level evidence to suggest that low level laser therapy may be an effective treatment but more studies are needed to confirm this.
Ultrasound: In animal studies ulatrsound has been shown to stimulate tissue growth and tendon healing. In the acute phases of tendon injury, it has been shown to reduce pain, swelling, and improve patient function.
However there has not been a lot of new evidence to continue to demonstrate its efficacy and for this reason it stays in the “what might work” section of this post.
What does work
Eccentric Exercise: Eccentric exercise remains the gold standard for treating Achilles tendinopathy. There is good high-level evidence for the benefits of eccentric exercise in the management of Achilles tendinopathy.
The mechanism behind the benefits of eccentric exercise are not well understood. Theoretically eccentric exercise produces rapid strengthening of the calf muscle, stiffening of the tendon, and lengthening of the tendon.
Studies have shown some adverse effects if proper form or insufficient rest between bouts of exercise occur so it is important that a physical therapist prescribe the correct dosage of exercise. Most research recommends a course of 6 to 12 weeks of eccentric exercise.
Deep friction massage and tendon mobilization: Studies have demonstrated that deep friction massage combined with stretching can increase tendon healing, improve elasticity of the tendon, and reduce strain through the muscle-tendon unit.
In Conclusion
Achilles tendinopathy is an overuse injury. Over the course of time too much stress was being put through the Achilles. Because of this an injury occurred and that injury is stalled in the second phase of healing.
All the most effective treatments work to progress the tendon through all four phases of healing.
There are easy actionable steps that you can take today to get your Achilles on the path to recovery.
With the right treatment approach and a gradual, progressive return to your activity there is no reason why you can not be rid of your Achilles pain in the future
References:
Li H & Hua Y. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Research International. 2016(6). https://dx.doi.org/10.1155/2016/6492597.
Chaudhry, F. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. Eur J Orthop Surg Traumatol. 2017(27). 441-448.