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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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 miles
Poor training technique

11. 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

12. 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

13. References
Alfredson H & Cook J (2007). Journal of Sports Medicine. 41:
Cook JL, Khan KM & Purdham C (2002). Achilles tendinopathy- Masterclass. Manual Therapy 7:
Järvinen TAH, Kannus P, Maffulli N & Khan K (2005). Achilles Tendon Disorders: Etiology and Epidemiology. Foot and Ankle Clinics 10:
Kearney R & Costa ML (2010). Insertional Achilles Tendinopathy Management: A Systematic Review. Foot & Ankle International 31:
Magnusson RA, Dunn WR & Thomson AB (2009). Clinical Journal of Sports Medicine. 19:
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.