Achilles tendinopathy: an update

Distinction between two forms

First of all, Achilles tendinopathy can occur in two forms, which differ depending on the localization:

• Insertional tendinopathy
  • Discomfort directly at the transition of the tendon to the calcaneus and up to 2 cm above it

• Midportion endinopathy
  • Discomfort 2-7 cm above the heel bone
  • More common among runners
• Important features for both types
  • Local pain with strain on the Achilles tendon
  • Pressure pain depending on localization
  • In the case of prolonged symptoms: local thickening of the tendon

This distinction is important because it can influence the treatment strategy.

How often does the problem occur?

The figures speak for themselves:

• In the general population, 4-7% are affected at some point in their lives
• For runners, this value rises to 40-53%!

These statistics show: You are not alone with your complaints. Achilles tendon complaints are one of the most common problems in running.

The mechanism: what happens in the tendon

As already known, the main triggers are overloading with a lack of regeneration time.

• Increased compression due to (over)loading, e.g. repeated microtraumas
• Too little adaptation time for the fabric
• A maladaptation of the tendon with:
  • Remodeling of the collagen
  • Changes in the extracellular matrix
  • Altered blood supply
  • Increase in nerve structures in the tendon

Extended risk factors

In addition to the already known factors such as overexertion, obesity, diabetes or high blood pressure, the following aspects can also play a role:

• Kinematic/kinetic restrictions of the lower extremity
• Previous injuries (especially previous Achilles tendon complaints)
• Certain medications
• Genetic factors
• Cold weather
• New footwear (due to compression of the tendon)

Typical symptoms and signs

Achilles tendinopathy is usually manifested by:

• Local pain in the tendon
• Pain on exertion during activities such as calf muscle training or walking
• The “warm-up” phenomenon: pain at the start of exercise with a subsequent decrease during activity
• Morning stiffness/stiffness after long periods of rest
• In case of high irritability: redness, swelling and warming in the affected area

Typically, the pain only occurs during exercise – pain at rest is rather atypical and could indicate other problems.

Rehabilitation: an extended approach

First of all, it is important to determine the state of the current symptoms.

1. Reactive tendinopathy
   • A “fresh” problem
   • Short-term relief and breaks are necessary
   • Long-term goal: Increase resilience
2. Tendon Disrepair (tendon repair)
   • An advanced condition
   • Persistent or recurring problems (over months or years)
   • Healing is still partially possible
   • Focus on training and possibly growth-stimulating therapies (ultrasound, shock wave, ACP injections)
3. Degenerative tendinopathy
   • Little capacity for complete healing
   • Often in older people or former competitive athletes
   • Strategy: “Train the doughnut” – strengthening the healthy tissue around the affected area

The basic therapy

• Progressive loading taking into account individual pain and functional tolerance
• Isometric exercises to start (tension without movement)
• Further: Eccentric exercises or heavy slow resistance training
• Exercise at least 3 times a week
• Accompanying measures:
  • Education (stress is necessary, “waiting and doing nothing” is not successful)
  • Stretching exercises
  • Neuromuscular training (leg+trunk)

The following additional measures can be helpful for short-term pain relief:

• Passive stretching
• Shock wave therapy
• Manual therapy
• Heel wedge
• Injections
• Dry needling
• Tape systems
• Adaptations in everyday life and at work

An exemplary program with time schedules can be found at https://physeli.at/achillestendinopathie/ can be found.

Time frame and forecast

As mentioned in our previous article, healing Achilles tendinopathy requires patience:

• The first improvements should occur within the first 12 weeks
• Complete rehabilitation can take 6-12 months
• Around 85% of athletes return to their sport
• However, 23-37% can suffer from recurring symptoms even after more than 10 years (despite treatment)

The biggest challenge remains to stay on the ball over a long period of time and to carry out the training consistently despite occasional pain.

When to see a doctor?

A medical check-up is advisable for

• Sudden onset of very severe pain
• Persistent pain at rest
• Significant increase in swelling, redness and hyperthermia
• If a differential diagnosis is suspected
• If symptoms worsen despite appropriate therapy

Our support for you

Our top priority is to support you with an individually tailored therapy plan. In addition to physiotherapeutic care, mental support is also an important factor in achieving the desired goals.

We offer:

• A thorough differential diagnosis
• A training plan tailored to you
• Regular checks on your progress
• Supportive therapy measures for pain relief
• Comprehensive advice on stress adjustments in everyday life, work and sport

Do you recognize your own problems here or are you simply curious? Get in touch with us and let’s find your way back to pain-free movement together!

Let’s go!
Your Simon and the Phyeli’s team