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Achilles Tendonitis

By Tom Flynn, PhysiCo

The Achilles tendon is the thick band connecting the calf muscles (gastrocnemius and soleus) to the calcaneum (heel bone).

Achilles tendinitis can be classed as an ‘overuse’ injury, i.e. a result of repeated micro-tears to the tendon and the resultant inflammatory response.

Presentation

Pain and stiffness along the posterior aspect of the ankle. Pain generally occurs whilst running or walking and subsides with rest.

Causes

There are several factors that have been implicated, both intrinsic and extrinsic, in the incidence of Achilles tendinitis.

Poor conditioning

Weakness and/or tightness of the calf muscle group will decrease the musculo-tendinous unit’s ability to respond to stress. In a repetitive activity, such as running, this can easily lead to tissue breakdown.

Repetitive uphill running

A greater amount of upward or dorsi-flexion of the ankle is required for the foot to clear the ground when running uphill. This results in greater stretch and stress on the Achilles tendon.

Repetitive downhill running

When running downhill the Tibia (shin bone) travels faster over the planted foot. This increased speed must be controlled by the eccentric contraction of the calf muscle group. That is, the calf muscles must contract strongly whilst lengthening. This can result in breakdown of the connective tissue component of the muscle, which includes the Achilles tendon.

Poor ankle/foot biomechanics

Excessive pronation of the foot during running has been linked to increased incidence of Achilles tendinitis. Excessive pronation involves increased internal rotation of the tibia. It is believed that this action of the tibia ‘wrings out’ the Achilles tendon causing micro tears. The compromise to the blood flow to the tendon also considerably delays the healing process.

Treatment

At the first sign of pain and/or inflammation in the Achilles tendon, the RICE regime (rest, ice compression, elevation) should be followed. Most importantly, the affected foot/ankle should be rested and ice applied regularly to the site of pain and inflammation on the Achilles tendon. Optimally, ice should be applied for 10 minutes every hour and should never be applied for more than 15 minutes at any one time. If using ice, it should be wrapped in a damp towel to avoid skin damage.

An experienced Physiotherapist should be consulted at this stage, to ensure minimal further damage to the tissues and minimal disruption to the injured runners training. A Physiotherapist will be able to make an accurate differential diagnosis, and treatment tools such as Electrotherapy (including ultrasound) are invaluable in speeding up the healing process.

A regular, gentle calf stretching programme is also essential in the treatment/rehabilitation of the injured runner. In the acute stage, stretching should be gentle (short of sharp pain) and regularly throughout the day. In the latter stages, stretching should become more vigorous, but still short of pain. All stretches should be held statically for a minimum of 30 secs.

Once healing has occurred and signs of tissue damage have cleared, then a muscle strengthening and conditioning programme should be commenced. In some cases this may just involve a recommencement of training at a lower intensity and a slow, graduated increase in training load.

In many cases though, a specific calf strengthening programme will need to be implemented before safe training can be resumed or increased. In the case of the runner with poor ankle/foot biomechanics, the use of an appropriate orthotic device can prove invaluable in treatment and the prevention of recurrent problems. In a study in 1984, Clement and Taunton et al. reported that the majority of results with orthotics were good to excellent and our own clinical experience backs up this finding.

Prevention

Graduated training programme

With any athlete, be they elite or amateur, the temptation to ‘go for that extra yard’ is a hard one to resist. The body will respond to the stress of training by strengthening the necessary musculo-tendinous units necessary to cope with that stress. When more stress is applied to tissues than they are able to cope with, pathological tissue breakdown will start to occur. In order to minimise the chance of injury it is essential that any training programme be progressed gradually with respect to distance and/or speed. This is particularly important when considering hill running. A runner who can cope with a particular mileage on the flat may find that on attempting the same mileage in hilly terrain, when the calf muscles/Achilles tendon is subject to different stress, injury can easily occur.

Stretching

Achilles tendinitis is often linked to poor flexibility of the gastrocnemius/soleus muscle group. Tightness increases the stress on the Achilles tendon and regular, sustained stretching will help decrease this stress.

Improved footwear

Footwear with poor shock absorbency will increase the shock absorbent role that structures such as the Achilles tendon must play whilst running. Running shoes should provide good shock absorbency and stability for the runner’s needs and be replaced regularly.

Correction of poor foot/ankle biomechanics

Slow motion frame-by-frame video analysis of a runner’s biomechanics proves invaluable in this regard. If a fault is detected, appropriate stretching/strengthening programmes and/or the use of an orthotic is often indicated. Correction of intrinsic faults greatly reduces the chance of injury and recurrence.

References

• Clement, DB, Taunton, JE, and Smart, GW: Achilles tendinitis and peritendinitis: Etiology and treatment. Am J Sports Med. 12:179, 1984
  
• Donatelli, RA, (ed.) The Biomechanics of the foot and ankle (1990)

Tom Flynn is from Adelaide, Tom obtained his degree in physiotherapy from the University of South Australia. As a keen sportsman, Tom’s work in Australia involved close links with elite and amateur athletes, including the Australian National Baseball team. A multitude of post graduate courses and seminars including the Olympic Sports Medicine Conference, in combination with continuing ‘hands-on’ experience, have ensured that he remains at the cutting edge of Sports Physiotherapy. Over the last seven years, whilst living in London, he has worked in a variety of settings, often lecturing and training physiotherapists and other health and fitness professionals. Tom joined the PhysiCo team in early 1998.