This article was kindly written for ARC by Ashbourne Physio Gillian Campbell Ashbourne Physiotherapy Centre
 

ACHILLES ‘TENDINITIS’
(A Myth or Reality?!)

Main race of the season approaching, all training gone to plan,…..well almost, you just need that little bit of extra speed so someone suggests;
‘What about joining us for a bit of sprint training?’
‘What could possibly go wrong?’ …………………..
………Nothing bar that irritating sharp stab in your heel that grabs you as you sprint round the bend onto the last straight of the last sprint. You stop short and do all the right things ice, rest, stretching but still 3-4 weeks later there it is pain just above the heel as soon as you start to jog and stiffness each morning as you try to get down the stairs.

For many years clinicians and athletes alike have learned to dread the diagnosis ‘tendinitis’. This painful injury, common amongst runners and triathletes can mean frustrating lay-offs of many months or even years from racing and training. Over recent years it has become more widely accepted that, in the majority of cases of tendon injury where symptoms have lasted for over 3 – 4 weeks, there is little, if any evidence of inflammation. The accepted terminology now in medical circles is tendinopathy[1] and where further investigations have been performed the predominant problem is one of tendon degeneration or tendinosis[2-5]. This has led to a marked change in attitudes regarding the management of tendinopathy and has caused clinicians to question the previously accepted regimes involving non-steroidal anti-inflammatory drugs (Ibuprofen etc.), steroid injections and electrotherapy such as ultrasound, shortwave and interferential.

Tendons known to be degenerate are more likely to rupture and 97% of ruptured tendons show signs of pre-existing degeneration[6]. In many cases although there may be degenerative change present within the tendon the subject may be unaware of any signs or symptoms of the problem prior to rupture.

Even now we still understand very little about the reasons why some individuals develop tendon injuries and their training partners apparently doing the same training remain unhurt. Suggested causes have been given as:
· Gait faults: (such as pronation or supination i.e. feet rolling in or out)
· Irritation from poorly fitting or worn footwear
· Sudden increase in training load: this can be an increase in distance, speed work or hill training.
Generally speaking it will usually affect athletes involved in sports that require running or jumping[7] although it can be seen in relatively sedentary individuals who take no part in sport at all. Even in these cases, sufferers may report an increase in activity prior to the injury. This may be something as simple as a bit of sightseeing while on holiday.

So what should you do if this strikes you 4 months before ‘the big one’, be it a 10km road race or Ironman Lanzarote?
Ideally consult your sports physiotherapist or consultant to confirm the diagnosis. If you are referred by your GP to the sports consultant they will often examine your tendon using ultrasound imaging which can give a definitive diagnosis as to the extent of your injury. Your GP, however, can order an ultrasound scan directly without needing to go through the hospital sports medicine department or orthopaedic clinic.

Ultrasound Image of Patella Tendon Degeneration

Sometimes it will be suggested that you have a Doppler Scan this is similar to an ultrasound scan but enables the radiologist to visualise any vessels that may have developed in the tissue. Tendon normally appears to have a relatively poorly blood supply but in some cases of tendinosis there may be new blood vessels at the site of the injury. It has been suggested that these may be linked with some of the pain experienced by sufferers[8, 9]

Doppler Ultrasound of Achilles Tendinosis

Recent rehabilitation regimes involving eccentric exercises have shown encouraging results for return to sport[10-14].

Muscles may be worked in 3 different ways:
When the muscle is working against an immobile load so that the joint does not move the work is known as ‘iso-metric’. When the muscle actually moves the joint it is known as ‘iso-kinetic’ and this can be further subdivided into ‘concentric’ where the muscle gets shorter and performs the joint movement and ‘eccentric’ where the muscle lengthens and works to control the joint movement against gravity.

In order to perform eccentric exercises for the treatment of Achilles tendinopathy, the action would be to lower the heel over the edge of a step. It is important to note at this point, as described above, that tendons with degenerative change are more prone to risk of rupture but there is, as yet no reported ruptures associated with the eccentric exercise programme described.

It is also important to remember that there are two different muscles that both join into the achilles tendon, gastrocnemius and soleus. In order to work them both the exercises should be done first with the knee bent and then with it straight. Generally the exercises are to be performed 15 repetitions for each muscle, three times a day.

It is common to experience some discomfort while performing the exercises and this is not a contraindication to continuing the regime. If in doubt discuss any worries with your therapist or doctor. It does, in fact, seem to be a useful part of the recovery to experience some level of pain and some have suggested that this contributes to the rehabilitative process?
As the tendon starts to recover and early morning stiffness and tenderness to palpation start to resolve the exercises should be progressed by adding light weights. This may be in the form or a rucksack on the back with a tin of beans! This may be further progressed by adding more ‘tins’ as able.

In most cases recovery will take 12 weeks for full rehabilitation and return to sport. In practice there is often some variation in this time scale dependant on the original injury, the level of training the individual pursues and many other possible influential factors.

Throughout the recovery period cardiovascular fitness may be maintained by cycling and swimming. If either prove too painful they may be modified by using light gears and spinning on the flat on the bike and using a pull buoy (leg float). In many cases as the rehab progresses you should be able to return to jogging and light running this should obviously be guided by your own therapist.

Eccentric Exercises  
1. Calf raise, both feet (concentric), gastrocnemius.
2. Calf lower, affected leg (eccentric), gastrocnemius.
3. Calf raise, both feet (concentric), soleus.
4. Calf lower, affected leg (eccentric), soleus.
5. Progressions with rucksack and weights.

1. Maffulli, N., K. Khan, and G. Puddu, Overuse tendon conditions: Time to change a confusing terminology. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 1998. 14(8): p. 840 - 843.

2. Jozsa, L. and P. Kannus, Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports, 1997. 7(2): p. 113-8.

3. Jarvinen, M., et al., Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports, 1997. 7: p. 85-95.

4. Tallon, C., N. Maffulli, and S.W.B. Ewen, Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Medicine and Science in Sports and Exercise, 2001. 33(12): p. 1983-1990.

5. Paavola, M., et al., Achilles tendinopathy. J Bone Joint Surg Am, 2002. 84-A(11): p. 2062-76.

6. Kannus, P. and L. Jozsa, Histopathological Changes Preceding Spontaneous Rupture of a Tendon - a Controlled-Study of 891 Patients. Journal of Bone and Joint Surgery-American Volume, 1991. 73A(10): p. 1507-1525.

7. Jarvinen, T.A.H., et al., Achilles tendon injuries. Current Opinion in Rheumatology, 2001. 13(2): p. 150-155.

8. Ohberg, L., R. Lorentzon, and H. Alfredson, Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc, 2001. 9: p. 233-238.

9. Ohberg, L. and H. Alfredson, Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. British Journal of Sports Medicine, 2002. 36: p. 173 - 175.

10. Alfredson, H., et al., Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis. Am J Sports Med, 1998. 26(3): p. 360-366.

11. Mafi, N., R. Lorentzon, and H. Alfredson, Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surgery Sports Traumatology Arthroscopy, 2001. 9(1): p. 42-47.

12. Nieson-Vertommen, S.L., et al., The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clinical Journal of Sport Medicine, 1992. 2: p. 109-113.

13. Ohberg, L., et al., Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up * Commentary. Br J Sports Med, 2004. 38(1): p. 8-11.

14. Silbernagel, K.G., et al., Eccentric overload training for patients with chronic Achilles tendon pain - a randomised controlled study with reliability testing of the evaluation methods. Scandinavian Journal of Medicine & Science in Sports, 2001. 11(4): p. 197-206.