What is Achilles tendinopathy? How is it diagnosed and managed?

As physiotherapist who has undergone surgery for my own Achilles tendinopathy, I understand the importance of early diagnosis and management. The biggest mistake people make is ignoring a grumbling Achilles. There are always early warning signs; just because you can keep training, doesn’t mean you should.
Picture of Jimmy Goulis

Jimmy Goulis

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The Achilles tendon is the strongest and largest tendon in the human body. Healthy tendons are made up of tightly packed bundles of collagen fibres that are lined up in straight lines. They act as a spring, storing and releasing energy as we walk, jump, jog or sprint.

The Achilles tendon was named after the Greek hero Achilles. In Greek mythology, Achilles was a warrior whose body was invulnerable to attack, except for one part of his body, his tendon. Many people who have experienced an Achilles injury can relate to this story as their injury often persists and can be resistant to treatment.

Thankfully research has broken new ground in our understanding of tendon injuries and their management. The key to a good outcome is getting an accurate diagnosis from a tendon expert right from the start.

What are the two main types of Achilles injuries?

There are two main types of Achilles injuries – overuse and acute.

01: Overuse injuries commonly called Achilles tendinopathy (sometimes called tendinosis or tendinitis).

02: Sudden forceful injuries that lead to Achilles tendon partial tear or complete rupture.

What exactly is the Achilles tendon?

Before we discuss the two injuries, it is important to understand the basic anatomy of the Achilles region:
 
  • The Achilles tendon joins the calf muscles to the heel bone.
  • The heel bone is also called the calcaneus or calcaneum.
  • We have two calf muscles.
  • The deep calf muscle is called the soleus.
  • The superficial calf muscle is called the gastrocnemius.
  • In simple terms, the two-calf muscles join up to become the Achilles tendon which then attaches to the heel bone.
anatomy of the Achilles
The anatomy of the Achilles (back view)

Why is the Achilles tendon prone to injury?

Tendons essentially join muscles to bones so that they can we can move our joints. As a result of this high stress role, tendons are prone to injury. Muscles tend to absorb forces quite well however tendons take a little longer to adapt. That’s why we need to be careful when we change our activity.

For example, starting a new walking or running program, adding high intensity or even changing our shoes can all affect our Achilles tendon.

I always say to my patients, tendons will often talk to you the next day. So even if you don’t feel pain during an activity, just err on the side of caution because tomorrow might be a different story!

Learn to listen to your tendons. They act a bit like a sulky teenager, surpressing their true feelings until they throw a tantrum!

Common signs and symptoms of Achilles tendinopathy

  • Localised pain at the back of the heel.
  • Morning stiffness that can make you limp in the morning
  • Pain normally improves or ‘warms up’ with activity.
  • Pinching the tendon hurts.
anatomy (side view)
The anatomy of the Achilles (side view)

What are the two zones in the Achilles tendon?

The other important part of the anatomy of the Achilles tendon is that there are two distinct zones to consider in the tendon: midportion and insertional zone. You need to distinguish between these two areas as the treatments are very different.

1. The middle or mid portion of the Achilles tendon

(Also known as midportion Achilles tendinopathy)

This area is about 3 to 4 cm above the heel bone. It’s the part of the tendon you can squeeze between your thumb and index finger. This area is prone to injury due to sudden changes in activity or repeated high load.

For example, a runner who suddenly adds too much high intensity training or a sedentary person who suddenly increases their walking in an effort to lose weight.

The good news is that the middle portion of the tendon generally responds well to physiotherapy. This is generally an isolated tendon injury caused by overuse and no other anatomical structures are generally involved.

2. The insertional zone of the Achilles tendon

(Also known as insertional Achilles tendinopathy)

This is just a fancy way of saying where the Achilles tendon joins into the heel bone. In this region we also have two small fluid filled sacs called bursae.

The role of these bursae is to reduce friction between the tendon and the heel bone. However, bursa can sometimes also become inflamed and a potential source of pain.

So, the combination of Achilles tendon, heel bone and bursa can mean this injury is more difficult to treat. In fact, many of the treatments traditionally used for mid-portion Achilles tendinopathy will make this condition worse.

For example, calf raises over a step are not helpful in the early painful stage and will just compress the Achilles tendon and bursa on the heel bone!

At Pollinate Health we are experts in insertional zone Achilles tendinopathy and know how easy it is to let this injury get out of hand. The longer the symptoms persist, the more stubborn this injury is to treat.

 
side

Achilles tendon rupture

One of the benefits of working in the emergency department is that I see a lot of complete and partial Achilles tendon ruptures.

The typical patient is a 40-year-old male who is playing a team sport like basketball, football or soccer. The story is always very similar:

  • Person attempts to sprint or change direction.
  • They report feeling like someone kicked them in the back of the leg.
  • When they turn around, there is nobody there!

This is one of those injuries that needs immediate attention. In the hands of an experienced physiotherapist or doctor, it is very easy to diagnose. There is usually a palpable gap in the tendon and the calf squeeze test is positive. This means that when a patient is lying down on their stomach with the legs over the edge of the bed, squeezing the calf creates no movement in the ankle. This test is called the Thompson test or the Simmonds test. If this test is positive then there is likely to be a complete rupture of the Achilles tendon.

Thompson
The Thompson Test

If you suspect that you have sustained an Achilles tendon rupture, don’t keep walking on it. Get yourself some crutches and get to the nearest emergency department for optimal initial management.

This usually involves putting the leg in plaster in an ankle pointing down (equinus) position, which puts the ruptured Achilles tendon in the optimal position for healing.

Once this early management is done an ultrasound or Magnetic Resonance Imaging (MRI) is often organised to confirm the diagnosis and location of the tear. Urgent orthopaedic review is crucial to discuss operative versus non-operative management.

Did you know?

Did you know that pointing the ankle downwards (plantar flexed position) brings the ruptured ends of the Achilles tendon closer together to give them the best chance of healing. If this is done early, patients can often avoid the need for surgery altogether. However, this is always a case-by-case decision involving the patient and their orthopaedic surgeon.

ruptured Achilles
The plaster cast specifically for a ruptured Achilles

Pollinate Health – experts in tendon rehabilitation

We are experts in tendon injury diagnosis and management at Pollinate Health.

I have a particular passion for treating tendon injuries having rehabbed my own insertional tendinopathy over many years. I have also developed Achilles tendon rupture rehabilitation protocols in conjunction with orthopaedic surgeons and know what best practice looks like.

It’s important to see health professionals with expertise in tendon management. Reach out today if you have any questions. We are available for telehealth appointments from anywhere in Australia or around most parts of the world.

 

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