Achilles Tendinopathy

So I'm going to take you back to ancient times, where Gods ruled the lands, and the Greeks invented the Achilles heel! This weeks post is going to focus on Achilles Tendinopathy.

Other common rock climbing foot issues will come in a later post.

Achilles tendon anatomy

Movements of the Achilles

Function

The Achilles tendon supports 6-15 times your body weight and provides spring like action.

Tendonitis/tendinosis/tendinopathy, what is the difference?

Tendonitis – inflammation

Tendinosis – chronic tendinopathy

Tendinopathy – a disorder of the tendons – an umbrella, catch-all term

Obviously, depending on -osis/-itis depends on the management strategies (to counter the inflammatory process or not).

The common consensus is that these conditions are a tendinosis rather than a tendonitis.

Enthesopathies

The entheses is where the tendon attaches to the bone, and an achilles tendinopathy that occurs within the first 2cm of the tendon attachment to the calcaneus is an enthesopathy.

Differential

• Rule out complete tendon rupture using the calf squeeze test. See above picture.
• Posterior ankle impingement
• Os trigonum syndrome
• retrocalcaneal bursitis
• Posterior Tibial Tendon Dysfunction
• Haglund's deformity

However, to discuss what all of these things are would take a whole blog post unto itself, so I'm just going to leave it there!

Symptoms

• Pain in the heel/around the tendon
• ?swelling - if a tendinitis
• ?heat - if a tendinitis
• Painful to touch or on movement
• Early morning stiffness
• Difficulty standing on your tip-toes (/single leg stress/repetitive/hop)

Causes

Tendinopathy:

• Repetitive strain on tendon
• overuse
• inappropriate footwear
• poor technique
• high-arched foot
• increase intensity in training regime
• lots of jumping
• tight calves
• excessive inversion or eversion

Achilles tendinopathy is more a problem for runners or walkers, but can affect climbers, especially as many climbers are mutli-sports persons.

Enthesopathies: compression of calcaneus from repeated platarflexion e.g. aggressive climbing shoes and/or dynoing etc. as climbing shoes with an aggressive heel, such as 5:10's, could cause this repeated compression on the calcaneus. (obviously, other aggressive climbing shoe are available!)

Treatment

If you suffer from the "5:10 syndrome" as mentioned above, you could try this method of editing your climbing shoes by Llanberis Resoles

NSAIDs....?

I mark this with a question mark, because it depends on your school of thought – whether it is a chronic overuse, or an inflammatory response. If you find it is swollen, then NSAID's may well help, but there is a school of thought that they may inhibit healing if used inappropriately.

There is also the dangers of overuse of NSAID's, as listed in Risks of Ibuprofen post

Acute management (see Management of Acute Injuries post) – again, may not be necessary if the tendinopathy is not an inflammatory process. e.g. if you use RSI of the wrist as an example.

GTN (Glyceryl trinitrate)

This is the same as the spray commonly used for angina, but is utilised topically – i.e. localised patch of GTN. However, the reasoning behind why it works is unclear, and commonly patients exhibit headaches and/or a rash as side effects.

Steroid

A corticosteriod injection may help, but has been shown to only have a short term pain-relieving effects, and not much else. Also, these injections may increase the risk of tendon rupture by weakening the tendon.

Surgical

A surgical intervention is rarely required for Achilles tendinopathy, and would always be a last resort. A very last resort!

There are other such treatments such as extracorporeal shockwave therapy and sclerosing injections, but they are rarely used.

The best bet is for physiotherapy, and using specific protocols, outlined below:

Physiotherapy

Mobilisations of the Achilles tendon

Ultrasound – useful if the tendinopathy is a tendonitis, as ultrasound can be used to reduce the inflammation.

Protocols/Exercises

Eccentric – Alfredson et al 1998

Two types of Eccentric Exercises will be used: (Refer to Photo A, B, and C)

• The calf muscle is to be eccentrically loaded with the knee straight.
• To maximize the activation of the soleus muscle, also performed with the knee bent.
• Perform each exercise 3x with 15 repetitions.
• Use your hand on the wall as a guide for balance
• Begin with weight bearing load, progression to backpack weight when patient can perform the
• exercise routine without pain or discomfort (Photo D). Advanced progression under therapist’s guidance may include resistance from weight training equipment such as a Smith machine or a squat machine.

Eccentric-concentric – Silbernagel et al 2007

Timeframe

These exercises need to be performed regularly, and for a time period of at least 3-6 months if not much longer!

Why do these work?

Effectiveness of eccentric exercises has been proved, however, there are differing theories on why it works.

Some say it affects type 1 collagen and production and, in absence of repeated aggravation, may increase tendon volume over longer term. As such, this increase the tendons tensile strength.

The repetitive stretching of the tendon with a lengthening of the muscle-tendon unit may have an impact of the capacity of the unit to effectively absorb load.

Another theory is that it changes the mechanism of pain-producing nerves by an alteration of neovascularisation (which is an increase of blood flow to an injured area, and along with this, an increase in nerve fibres, meaning increased pain), as the repetitive nature may damage these nerves and vessels.

Exercising during rehab

Due to the length of rehab being several months rehab, many patients ask “Do I have to stop exercising?” Silbernagel et al 2007 found that if the pain in your Achilles tendon does not exceed 5/10 on visual analogue pain scale (VAS) (during or after sport), then it is ok to carry on with your sport, whilst continuing with the exercise protocol.

Risk of rupture?

80% of ruptures completely asymptomatic

97% associated with underlying pathology

As always, if in doubt, always seek advice from a professional!

References

Alfredson H, Cook J 2007 A treatment algorithm for managing Achilles tendinopathy: new treatment options Br J Sports Med. 41(4): 211–216.

Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J 2007 Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study. American Journal of Sports Medicine 35(6): 897-906

Alfredson H, Pietilä T, Jonsson P, Lorentzon R 1998 Heavy-Load Eccentric Calf Muscle Training For Chronic Achilles Tendinosis American Journal of Sports Medicine 26(3): 360-366