Today, I will be discussing Achilles tendinopathy which is one of the common problems afflicting
runners of today. It can affect any sportsman but it seems to be especially common in people
who run on hard surfaces. Any change in the intensity type or even the frequency of exercise
can often incite the onset of Achilles tendinopathy. Achilles tendinopathy usually presents as
pain and swelling over the back of the heel usually around 2 to 4 cm away from the heel
bone. This is the common place where people develop pain and swelling and with time this
swelling tends to enlarge in size.
How do we diagnose Achilles tendinopathy? The diagnosis is mainly clinical and people
present with a classical swelling and pain over the back of the heel. Sometimes the pain
can be right at the heel bone, which is called insertional tendinopathy as opposed to the
non-insertional tendinopathy which occurs about 4 cm from the distal insertion of the
Achilles tendon into the bone. Now these two are slightly different entities and the treatment
tends to be fairly similar.
Over the years various terms have been banded around regarding Achilles pathology and that
has led to a lot of confusion. We hear the terms Achilles tendinitis, Achilles tendinosis
and also more commonly these days tendinopathy. Now, it is important to realise that tendinitis
is a term which suggests inflammation in the tendon, now only in certain cases does the
tendon actually get inflamed, more commonly it is a degenerative phenomenon and biopsies
of the tendon have revealed a rather unusual lack of inflammatory cells, so it is a degenerative
process. A consensus of opinion has established a common terminology for Achilles problems
these days and that is tendinopathy which encompasses all degenerative non-inflammatory
painful swollen conditions of the distal Achilles tendon.
Now, why does Achilles tendinopathy happen? Well, it's a combination of biochemical mechanical
and neural factors and various studies have shown that not one individual factor is responsible
for tendinopathy in itself, so it is commonly a combination of all three. A number of different
variables have been implicated and extending from age, sex, male sexes are predominantly
affected, age – usually beyond the age of 30. Even minor modifications and training
footwear, excessive pronation of the forefoot, tightness of the gastroc-soleus complex etc.
have all been implicated in causation of Achilles tendinopathy. So, Achilles tendinopathy is
almost a repetitive stress phenomenon when the reparative potential of the tendon does
not match the degeneration and this results in a chronic disorganisation of the tendon
itself.
Various studies have shown that the matrix is altered, the collagen fibrils become disorganised
and the structure of the tendon itself changes. Very often there are myxoid or lipoid changes
within the tendon suggesting tendinopathy.
So, does Achilles tendinopathy heal on its own? Once the process has started and the
healing process is not matching up to the rate of degeneration, unfortunately, the tendinopathy
tends to progress. Now, most often people find swelling and stiffness especially in
the morning, but after a period of activity, the stiffness resolves and they are able to
get on with things, especially with running. Some people have tried to run through the
pain and yes, they are able to do that, but they pay for it the next day when there is
increased pain and swelling around the tendon, so therefore unfortunately Achilles tendinopathy
needs to be treated. The first option of treatment should be rest and icing the tendon and to
stop the inciting sport for the time being. With physiotherapy and conditioning of the
tendon, gradually restarting the sporting activity is recommended and at any point where
the pain starts to come back, the level of sport should be downgraded again.
If the pain and swelling does not subside with self-treatment, you need to get the help
of a physiotherapist. The mainstay of treatment of Achilles tendinopathy is definitely physiotherapy
and eccentric stretching of the tendon works in about 70% of the cases, so therefore eccentric
stretching done diligently will actually relieve the pain in about two thirds of sufferers.
Now what happens to the rest? Once the first-line management of eccentric stretching has been
exhausted with no significant relief of pain and swelling, we move on to the surgical realms.
Initially, it is non-invasive means by either glyceryl trinitrate patches or shockwave diathermy
which tend to work in both insertional and non-insertional Achilles tendinopathy. Various
minimally invasive procedures are also recommended as following on from a non-invasive means
and these include stripping of the paratenon through small incisions, making incisions
into the tendon itself or tenotomies and excision of the little plantaris tendon which also
contributes to the pain.
Moving on to invasive surgical procedures can be done either through the telescope or
arthroscopic debridement of the tendon and excision of the plantaris muscle which can
be undertaken through small incisions and using a telescope, failing which we move on
to open surgery. At open surgery, what is recommended is excision of the diseased bits
of the tendon and repair of the tendon pack. Sometimes if there is excessive bone at the
back of the heel bone or the calcaneum, this needs to be excised and the tendon needs to
be repaired securely back to it. Following any surgery on the back of the heel, there
is always a chance of wound healing problems and also tendon rupture, so surgery should
not be taken lightly.
Now, this can be extremely variable. Now one thing to remember is there is no overnight
magic cure, this is a chronic degenerative condition and therefore will take time to
resolve, but yes with physiotherapy to start off with and then non-invasive and invasive
means of treatment, most people do tend to get better. It often takes a minimum of 3
to 6 months for you to start running again and unless you are very unfortunate by a year's
time, you should be back doing what you want to do.