Achilles Tendinopathy A biomechanical approach to Assessment, Diagnosis, Treatment & Prevention

What is Achilles Tendinopathy? Tendinopathy literally means disease or disorder of tendon Achilles tendinopathy is term used to describe clinical presentation of Achilles tendon pain Symptoms in the Achilles tendon can occur at the insertion or mid-portion Often the symptoms are caused by overloading the tendon through a change in activity or an increase in training Underlying pathology reflects a failed healing response where both inflammatory and degenerative pathologies exist

Anatomy of the Achilles tendon The Achilles tendon is the strongest and largest tendon in the body It attaches the Gastrocnemius and Soleus muscles (Collectively known as the calf) to the Calcaneum (Heel bone) The Achilles tendon (along with Gastrocnemius and soleus muscles allow you to stand on your tip-toes, helps propel you forwards during walking and running and helps propel you upwards during jumping

How common is Achilles Tendinopathy Achilles tendinopathy affects people of all ages and both men and women It’s causes are multifactorial- both intrinsic and extrinsic factors are thought to contribute to symptoms It affects both athletes and non-athletes It is more common in people who run or take part in sports which involve running or jumping

Risk Factors and causes of Achilles Tendinopathy Age- more common in 30+ Gender- more common in males Weight- More at risk if you have an increased BMI Diabetes- If you are diabetic you are more at risk Abnormal biomechanics of foot/ankle/lower limb Tight or Weak muscles- Gastroc/soleus locally Quads/hamstrings/hip flexors/glutes globally Decreased foot & Ankle range of movements- i.e. stiffness Training Error Increased runs per week, increased mileage, introducing speed training, change of footwear or Poor quality footwear, change of running surface, too much hill running

Diagnosis- Subjective Findings Often a change of activity levels or training techniques, with an insidious and gradual increase in symptoms Originally pain may not be disabling, however with continued activity it can begin to affect the person’s ability to train effectively Rest will often ease symptoms, however return to activity will bring on symptoms again Morning pain is a hallmark of Achilles tendinopathy Symptoms are usually localised to tendon

Diagnosis- Objective Findings A tendon rupture should be ruled out- Thompson test Tendon can appear normal, however often there will be subtle or obvious changes in mid-portion or insertion- i.e. thickening Palpation tenderness of Achilles tendon Restriction in ankle ROM- specifically dorsiflexion Possible altered biomechanics of foot/ankle/leg

Biomechanical Assessment Examination of the foot/ankle should take place Barefoot With athletic shoes With/without any orthotics We are looking for any altered biomechanics of the foot/ankle/leg during: Standing Walking Running Single leg heel raise Hopping Malalignments of the Foot/ankle/leg may include Overpronation or underpronation (supination) of the ankle Forefoot varus or valgus Hindfoot varus or valgus Pes planus (flatfoot) or Pes cavus (high arch) Leg length discrepancy

Differential Diagnosis Posterior ankle impingement Medial tendon tendinopathy Bursitis Sural nerve symptoms Referral from Lumbar spine Pain that is non-specific in nature and not clearly related to tendon loading are clues to more complex diagnoses that should include systemic inflammatory diseases.

Typical problem List Tight gastrocnemius/soleus muscles, however other muscles may be tight Weak or deactivated muscles- often decreased glute activity and decreased core stability as well as local weakness in calf Inappropriate footwear- i.e. Over-pronators wearing wrong type of training shoes Old trainers- running shoes should be changed every 300-500 miles Poor training technique

Typical Treatment Plan Advice and Education regarding pain management POLICE (Protection, OPTIMAL LOADING, Ice, Compression, Elevation) Analgesia/NSAIDs Adapting training to decrease stress on Achilles Taping for over-pronation followed by orthotic fitting if indicated Exercise Therapy Stretching and foam rolling of tight muscle groups- likely gastrocnemius/soleus and possibly hamstrings/quads/glutes/hip flexors Strengthening of weak and underactive muscle groups Eccentric strengthening – this is often thought to be the ‘Gold standard’ of exercise therapy for Achilles tendinopathy Core stability Manual Therapy Joint mobilisation- Locally at ankle/foot joints, however Lumbar spine /hip/knee treatment may be indicated Specific soft tissue mobilisation- Locally at Achilles tendon and Gastrocnemius/Soleus muscles, however treatment more globally may be indicated Myofascial release/Trigger pointing PNF

Key points to take away Achilles tendinopathy is common sports injury especially in runners Generally easy to diagnose Thorough assessment should be undertaken to rule out other possible causes of pain It is important to have knowledge and understanding of specific training needs of the individual athlete and how to adjust their training to support their full recovery A comprehensive biomechanical assessment is required to highlight any biomechanical faults or muscle imbalance to ensure a positive outcome Expert manual and exercise therapy skills are essential for a successful outcome in Achilles tendinopathy

References Alfredson H & Cook J (2007). Journal of Sports Medicine. 41: 211-216. Cook JL, Khan KM & Purdham C (2002). Achilles tendinopathy- Masterclass. Manual Therapy 7:3 121-130. Järvinen TAH, Kannus P, Maffulli N & Khan K (2005). Achilles Tendon Disorders: Etiology and Epidemiology. Foot and Ankle Clinics 10:255-266. Kearney R & Costa ML (2010). Insertional Achilles Tendinopathy Management: A Systematic Review. Foot & Ankle International 31:8 689- 694. Magnusson RA, Dunn WR & Thomson AB (2009). Clinical Journal of Sports Medicine. 19:1 54-64. Sussmilch-Leitch SP, Collins NJ, Bialocerkowski AE, Warden SJ & Crossley KM (2012). Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Journal of Foot and Ankle Research 5:15.