Achilles tendonitis (also known as Achilles tendinopathy or Achilles tendinosis) is an overuse injury causing pain, inflammation and or degeneration of the achilles tendon at the back of the ankle.
If not caught early this can be a difficult injury to cure but with the right treatment and particularly eccentric strengthening exercises a full recovery can usually be achieved.
Providing the power in the push-off phase of the gait cycle, the Achilles tendon can become inflamed when the gastrocnemius is stressed. Although this tendon is strong, its lack of flexibility can easily lead to inflammation, tear or rupture. Achilles tendonitis can be acute or chronic. Signs of an inflamed Achilles tendon include:
- Tendon pain during exercise. Achilles pain gradually comes on with prolonged exercise and typically dissipates with rest.
- Swelling over the Achilles tendon.
- Redness over the skin.
- Sometimes, a creaking can be felt when pressing the fingers into the tendon while moving the foot.
Often more difficult to treat, chronic Achilles tendonitis may follow if the tendon is not treated properly or allowed to fully heal. When this problem becomes chronic, the pain typically disappears after a warm up, yet returns once the person stops training. If the Achilles is repeatedly stressed, the injury worsens until it is impossible to run. In addition to the symptoms of acute Achilles tendonitis, additional signs of a chronic problem include:
- Pain and stiffness in the Achilles tendon in the morning. This pain may be described as diffuse along the tendon rather than specific.
- There may nodules or lumps in the Achilles tendon, particularly 2 cm above the heel.
- Pain in the tendon when walking up a hill or up stairs.
Symptoms consist of pain and stiffness at the back of the ankle which may have come on gradually over time and often be worse first thing in the morning. Achilles tendonitis can be either acute or chronic. Acute tendonitis is usually more painful and of recent onset.
An injury typically occurring from overuse, Achilles tendonitis usually comes on gradually. Ignoring the early warning signs of Achilles pain causes the symptoms to increase until activity is too painful to continue. In general, the more fatigued the calf muscles are, the more stressed the Achilles tendon, and the higher likelihood of tendonitis developing. The most commonly reported causes of Achilles tendonitis include:
- Overuse – Excessive activity before adequate warm-up causes most overuse injuries.
- Running Up Hills – Running up hills causes the Achilles tendon to stretch more than normal on every stride, which fatigues the tendon sooner than normal.
- Overpronation – Overly pronating the foot increases the strain placed on the Achilles tendon. As the foot rolls in and flattens, the lower leg rotates inwards causing a twisting motion. This twist puts an additional strain on the Achilles.
- Tight or Weak – A tightness or weakness in the calf musculature easily leads to fatigue. Once the gastrocnemius fatigues, it tightens and shortens, thus putting additional strain on the Achilles.
What is achilles tendinitis?
The achilles tendon is the large tendon at the back of the ankle. It connects the big calf muscles at the back of the lower leg to the foot and inserts at the back of the heel or calcaneus bone. It provides the power in the push off phase of walking and running where huge forces are transmitted through the achilles tendon. Achilles tendonitis is usually an overuse injury caused by doing too much too soon.
Strictly speaking the term tendonitis suggests an inflammatory condition of the tendon but in reality few injuries are actually down to pure inflammation. The main finding, particularly in older athletes is usually degeneration of the tendon. The term Achilles tendinopathy is probably a better term to describe the range of conditions that can cause Achilles tendon pain.
Although overuse is the primary cause, there are a number of factors which can increase your risk of sustaining the injury including poor footwear, soft training surfaces, tight muscles and foot biomechanics and running uphill.
Achilles Tendonitis Treatment
For an acute injury applying ice for 10 minutes every hour or so reducing frequency as required for the first 2 to 3 days can help reduce pain and inflammation. Rest is important so try to stay off your feet as much as possible. Wearing a heal lift or heel pad (in both shoes) can help reduce the strain on the tendon by shortening the calf muscle very slightly, although this should only be done as a short term measure. A simple achilles tendon taping technique can be used to take the strain off a painful Achilles tendon allowing it to rest more easily, especially if you have to be on your feet.
A long term chronic Achilles tendon injury may respond better to application of heat, again applied for 10 minutes every couple of hours as required. Applying gentle self massage to the achilles tendon may also be beneficial. If Achilles tendonitis has been a persistent problem then the Hakan Alfredson’s heel drop protocol exercises have been shown to be effective in up to 90% of patients. They involve performing a heel drop exercises 180 times every day for 12 weeks during which time pain may actually get worse before it gets better.
Gentle calf stretching exercises can help stretch the muscles and aid recovery. A plantar fasciitis night splint is worn in bed and is excellent for preventing calf muscles tightening up over night.
A Doctor may prescribe anti-inflammatory medication such as ibuprofen which might help with acute achilles inflammation and pain but has not been proven to be beneficial long term and may even inhibit healing. Application of electrotherapy such as ultrasound can also help reduce pain and inflammation and sports massage can help mobilize the tissues of the tendon and relax the calf muscles. They can also identify possible causes such as biomechanical problems with the foot which may be contributing to the chance of injury.
The Hakan Alfredson’s heel drop protocol exercises have been shown to be effective in up to 90% of patients suffering with achilles tendon pain and involve the patient dropping the heel to horizontal in a slow and controlled manner.
The athlete performs an eccentric heel drop exercise on a step going up with both legs and slowly lowering the heel to the horizontal position. Eccentric exercises are those where the muscles (in this case the calf muscles) get longer as they contract. Exercises are performed twice a day to a total of 180 repetitions and continued for 12 weeks. Pain may often get worse over the 12 weeks before it starts to get better.
10 Solutions for Achilles Tendonitis
For best results, a sore or achy Achilles tendon responds best to immediate attention and rest. Left untreated, Achilles tendonitis could cause persistent pain or cause the tendon to rupture. A ruptured Achilles tendon may require surgery to correct the damage. Ten commonly advised solutions for treating Achilles tendonitis include:
- Resting the calf muscles.
- Applying cold therapy or ice to minimize inflammation.
- Wearing a heel pad to raise the heel, thus taking some of the strain off the Achilles tendon.
- Wearing arch support insoles or orthotics to prevent overpronation and improve foot biomechanics.
- Taking anti-inflammatory medication.
- Taping the back of the leg to support the Achilles.
- Applying a plaster cast for more severe cases.
- Applying ultrasound treatment to encourage the tendon to heal.
- Administering sports massage to the lower extremities.
- Strengthening the calf muscle to help reduce the stress on the Achilles tendon. Toe raises, balancing on the toes and wall stretching are useful exercises.
Whenever discussing approaches to Achilles tendonitis with clients, always emphasize avoiding excessive stretching. Taking this action has the potential to aggravate an already stressed Achilles.
Achilles Tendonitis Massage
Massage has many benefits but specifically for achilles tendonitis it can help break down scar tissue, stimulate blood flow and therefore healing and aid in the stretching of the calf muscles.
Technique 1: Effleurage
Effleurage should be used at the start of any massage to spread the oil evenly and to warm-up the tissue in preparation for deeper techniques. Effleurage of the whole of the calf should be performed to ensure the whole of the tendon and the junction where the tendon joins the muscle, are covered. Apply pressure from the heel, up towards the knee. Once the knee is reached, move the hands to the outsides of the leg and gently return to the heel and repeat.
Technique 2:Transverse mobilization
With the first finger of one hand and the thumb of the other hand, alternate to apply transverse pressure. This pulls the tendon across one way and then the other. Too much oil can make this technique difficult to control so wipe off any excess oil. This technique will mobilize the tendon making it more supple.
Technique 3: Stripping the Achilles tendon
With the thumbs apply sustained pressure along the full length of the Achilles tendon.
Technique 4: Cross frictions
With the first two fingers apply gentle pressure in a transverse direction to the Achilles tendon. Again, too much oil and the therapist will find they are unable to apply the technique correctly. Apply frictions for between 2 and 5 minutes.
Technique 5: Circular frictions
Place a finger each side of the Achilles tendon and apply pressure in a circular direction. Aim to feel the tendon underneath the fingers. Massage may be uncomfortable but should not be so painful that the athlete tightens up. This is unlikely to be of benefit. Apply frictions for between 2 and 5 minutes.
The above techniques can help to reduce swelling, aid circulation and prevent the build up of adhesions (sticky bits that prevent the tendon from sliding properly in it’s sheath). It may also help to apply ice or cold therapy after treatment for 10 minutes.
Light massage can usually be performed daily, however for deeper techniques alternate days may be more appropriate allowing the tissues time to recover. It is important to assess the results of treatment both afterwards and the next day. Has pain and swelling increased? If so then discontinue.
Two sports massage techniques put bodyworkers on the top of the list for Achilles tendonitis treatment: transverse friction massage and strain-counterstrain techniques.
Transverse friction massage is a massage technique that is often used for tendonitis. The massage strokes of transverse friction massage are deep and applied directly to the affected area, perpendicular to the direction of the tendon. When done properly, transverse friction massage can help reduce pain, improve blood flow to the surrounding area, and prevent or reduce the formation of scar tissue and adhesions in the connective tissue.
Another sports massage technique, applying strain-counterstrain on the calf muscles can unload the excessive stress these tightened or weakened muscles place on the Achilles. As published in the September 2006 edition of The Journal of the American Osteopathic Association, researchers found that applying strain-counterstrain techniques on the soleus of those with Achilles tendonitis produced a 23.1 percent decrease in localized stress. The investigators noted a similarly significant response when strain-counterstrain was applied to the lateral and medial heads of the gastrocnemius.
While early and persistent attention to this injury often results in a full recovery, making sure the original cause of the tendonitis is addressed is the only way to prevent its recurrence. In addition to tackling the reason for Achilles pain, most practitioners recommend some combination of the above ten solutions to help an inflamed Achilles heal. A massage therapist using strain-counterstrain and transverse friction massage techniques can play an important role in the timely healing of an inflamed Achilles tendon – and can even help prevent this injury from turning into a hard-to-treat chronic case of tendoniti.
Howell JN, et al., Stretch reflex and Hoffmann reflex responses to osteopathic manipulative treatment in subjects with Achilles tendonitis, The Journal of the American Osteopathic Association, September 2006.
http://altmedicine.about.com, Natural Remedies for Tendonitis, Cathy Wong, About, Inc., 2008.
http://sportsmedicine.about.com, Achilles Tendonitis, Elizabeth Quinn, About, Inc., 2008.
www.mayoclinic.com, Achilles Tendinitis, Mayo Foundation for Medical Education and Research, 2008.
www.sportsinjuryclinic.net, Achilles Tendonitis, Sports Injury Clinic, 2008.
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