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Achilles Tendinopathy

Achilles Tendinopathy

Achilles tendinopathy is a common overuse injury that affects the Achilles tendon, the thick rope-like structure that connects the calf muscles to the heel bone. The tendon undergoes microscopic wear, becomes thickened and swollen, inflamed and painful.

Who is at risk for Achilles tendinopathy?

Achilles tendinopathy is most common in middle-aged and older adults who participate in activities that involve repetitive stress on the Achilles tendon, such as running, jumping, or endurance sports. It can also occur in younger athletes, especially those who are training for endurance events such as a marathon.

What are the main symptoms of Achilles tendinopathy?

 

The main symptoms of Achilles tendinopathy are:

  • Pain in the Achilles tendon, especially when bending or straightening the ankle
  • Stiffness or tightness in the Achilles tendon, particularly after periods of rest, i.e. first thing in the morning or after sitting for long periods and then walking
  • Difficulty walking on stairs or uneven surfaces
  • A sensation of "grating" or "crunching" in the tendon
  • Pain tends to be localised to either the bottom end of the Achilles where it attaches to the heel bone (insertional tendinopathy) or more commonly the middle part of the tendon, 2-3cm above the attachment (mid-portion tendinopathy).

How is Achilles tendinopathy diagnosed?

A doctor diagnoses Achilles tendinopathy based on a medical history, performing a physical examination, and ordering imaging tests. The physical examination will focus on assessing for pain, tenderness, and swelling in the Achilles tendon.

Imaging tests that may be ordered include:

  • Ultrasound:

    An ultrasound can demonstrate thickening and focal structural change within the Achilles tendon. The doctor will also look for an increase in blood flow (vascularity) within the tendon which is not normally observed in a healthy tendon.
  • MRI:

    An MRI can show more detailed images of the Achilles tendon, including any areas of inflammation or damage.

How is Achilles tendinopathy treated?

 

Treatment for Achilles tendinopathy typically involves conservative measures, such as:

  • Rest:

    Avoiding activities that aggravate the symptoms, such as running or jumping.
  • Ice:

    Applying ice packs to the affected area for 10-15 minutes at a time, several times a day.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) and simple analgesia:

    Taking over-the-counter NSAIDs, such as ibuprofen or naproxen, to reduce pain and inflammation.
  • Stretching and strengthening exercises:

    Once the pain starts to settle, stretching and strengthening exercises can help to improve flexibility and strength in the calf muscles. An experienced physiotherapist can offer a graduated tendon loading and strengthening program to normalise the tendon, so that it can tolerate the loads being asked of it with higher level activities such as running.

In some cases, more aggressive treatments may be necessary, such as:

High Volume Injections: 

To reduce inflammation and pain. The doctor will assess the tendon and select a point of maximal blood flow, where the blood vessels from the deep Kager’s fat pad feed into the deep part of the tendon.

At The Joint Injection Clinic, these injections are performed after a thorough consent process, whereby the risk and benefits of the procedure are discussed in detail with your doctor. The experienced medical doctor will then place you in a lying position, face down. The skin is cleaned using a cleaning solution to ensure that the procedure is performed under sterile conditions. Local anaesthetic is injected from the skin to the tendon under ultrasound guidance. After giving the local anaesthetic a few minutes to take effect, the interface between the tendon and the fat pad is injected with local anaesthetic, water or saline for injection and occasionally, a small dose of steroid.

The High Volume Injection itself is normally completed within two to three minutes, after which a plaster is applied and post-injection advice is given. The patient is advised to look out for any signs of infection, specifically to check whether the local area becomes red, hot, tender, swollen or if they develop a fever. If this occurs then the patient is asked to contact the clinic immediately at which time a formal reassessment will occur and if needed oral antibiotics can be prescribed. The patient is also warned that following any injection they may notice a short-term worsening or flare in their symptoms after the local anaesthetic has worn off (4-5 hours). This may last for 3-5 days and the patient is advised to consider icing of the area using an ice pack for 10-15 minutes every hour as required.

Extracorporeal shockwave therapy (ESWT): 

ESWT uses high-energy sound waves to reduce sensitivity within the tendon and promote healing within the tendon.

Surgery: 

Surgery is typically only considered for severe cases of Achilles tendinopathy that do not respond to other treatments.