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  • Writer's pictureDaniel Selin

Achilles tendon pain

Updated: Apr 13, 2023

Achilles tendon pain, Achilles tendonitis, Achilles tendinopathy, calf pain, healing process, rest, stretching, strengthening exercises, physical therapy, sports injury, running injury.

Akillesjänteen kipu, jalka

Achilles tendon pain often results from degenerative changes to the tendon and increased stress due to either a single event or prolonged periods of stress. The Achilles tendon is the largest and strongest tendon in the human body, serving an important role in shock absorption and propulsion during movement.


Although Achilles tendonitis is commonly used to describe pain in the Achilles tendon, current knowledge suggests that inflammation is rarely present. Instead, pain is often due to degenerative changes in the tissue, including decreased fluid content, elasticity, and flexibility. The pain is the result of a combination of pathological changes affecting the tendon, which are usually caused by overuse and chronic stress. Achilles tendon degeneration can persist for a long time without pain, and pain may only appear when the degeneration is advanced.


Achilles tendon pain can affect both athletes and sedentary individuals. Lack of flexibility or stiffness of the tendon may increase the risk of pain, but they are not the only factors involved in the development of the condition.


Symptoms of Achilles tendon pain include pain felt in the Achilles tendon, the lower calf, or the back of the heel, which worsens during or after exercise. Starting pain and morning stiffness are also common, and the condition may begin with stiffness felt only in the morning. The location of the pain can be divided into two different categories: insertional Achilles tendon pain, which is felt either at the heel or very close to it, and non-insertional Achilles tendon pain, which is felt higher up in the Achilles tendon or in the lower calf. Distinguishing between these two types of pain is important because they have different treatment approaches.

 

Epidemiology

Higher age, male gender, higher body fat mass, and waist circumference have been linked to a higher likelihood of Achilles tendon pain. It has also been shown that individuals with chronic Achilles tendon pain exhibit signs of both peripheral and central sensitization to pain.

Increased stress, poor circulation, weakness or inflexibility of the muscle-tendon unit, gender, hormonal activity, and metabolic factors are associated with Achilles tendon pain. Repetitive stress disrupts the structure of the tendon, causing collagen fibers to slide past each other, leading to the breakdown of their cross-links and loss of tissue strength. This accumulated microtrauma is believed to weaken collagen cross-linking and affect the tendon's collagen matrix and blood vessels, ultimately leading to tendon pain.

 

Symptoms

When the Achilles tendon becomes painful, it is typical for symptoms to worsen during or after exertion. Initially, pain subsides quickly once the load is removed, but as the condition progresses, the pain lasts longer.

Morning pain is another characteristic symptom because fluid accumulates in the tendon overnight, increasing the internal pressure of the tendon. This pressure further increases when weight is placed on the foot and the tendon is loaded.

The Achilles tendon or its attachment to the heel bone is sensitive to touch and often thickened. Thickening may not necessarily be due to inflammatory swelling, but rather from the "entanglement" of collagen in the tendon and the formation of attachments. The tendon often shows ingrowth of blood vessels as the body tries to increase blood flow and oxygen supply to the affected area. However, these ingrown vessels appear to be poorly constructed, allowing blood to seep into the tendon structure, which is thought to worsen pain.

Activities that involve rapid vibration, stretching, and other types of quick loading of the tendon often provoke pain. The tendon appears to respond well to resistance training in which movements are performed slowly with sufficient resistance. This appears to strengthen the tendon structure, reduce pain, and increase the tendon's load capacity. Similar results have been obtained with strength training in the treatment of other tendon pain, and this should be tried before other options.

Incorrect foot postures have been shown to be weakly linked to the onset of pain, but pain also occurs without underlying foot postural abnormalities. Both over- and under-pronation have been shown to increase the prevalence of Achilles tendon pain. A personalized plan can be developed to correct these issues, and if necessary, individualized support insoles can be made to support the foot structure and reduce the load on the Achilles tendon. However, the use of only insoles has not been shown to have a significant impact on reducing symptoms, but they are an excellent addition to a rehabilitation program if underlying foot postures that can be linked to Achilles tendon pain are identified.

 

Risk factors

The development of Achilles tendon pain is associated with various risk factors, some of which are listed below:

  • Overweight or obesity

  • Running-related challenges such as running on a too hard surface, uphill running, or sudden increase in training loads

  • Biomechanical changes in the ankle and foot, such as high or low arches, or restricted ankle mobility

  • Metabolic and hormonal factors, such as overweight or obesity, diabetes, psoriasis, high blood pressure, or cholesterol levels

  • Medications and medical conditions, such as corticosteroids and rheumatic or degenerative diseases.

 

Treatment

The primary treatment method for this type of pain is conservative treatment. Resting the foot from activities that cause pain may be helpful at the beginning, but complete inactivity is not recommended as it can prolong the duration of pain.


To alleviate pain, cold therapy or pain and anti-inflammatory medications can be used. Deep massage of the calf muscles and mobilization of the ankle are effective ways to reduce pain temporarily, allowing for better performance during other training.


Sufficiently long and high-intensity strength training appears to form the basis for the treatment of tendon pain by reducing the duration and intensity of symptoms. With proper strength training, the tendon structure can be strengthened, making them more resistant to stress without becoming painful.


Stretching and mobility exercises may potentially change the direction of collagen structures to be more aligned with the direction of stretching, making them more resistant to pulling. However, caution should be exercised with stretching as it can increase pain, especially at the attachment point due to the compression caused by stretching.


The treatment plan used should always be individualized based on the patient's specific needs and circumstances. Therefore, consulting with a healthcare professional such as a doctor or physical therapist is recommended to determine the most appropriate course of action.

 

Secondary treatment options

If conservative treatment does not yield desired results within 3-6 months, secondary treatment options may be considered. These include:

  • Corticosteroid injections

  • Platelet-rich plasma therapy (PRP)

  • Extracorporeal shockwave therapy (ESWT)

  • Dry needling

  • Low-level laser therapy (LLLT)

  • Surgery

Surgical treatment may be considered if other less invasive treatments have failed or if the pain is severe and persistent.

 

Physical Therapy

Physiotherapy always begins with a thorough assessment of the background factors, based on which an individual rehabilitation program can be developed. The underlying factors must be distinguished from each other and it must be determined which factors have contributed to the development of the pain. No Achilles tendon or its pain treatment is completely identical.


Although the mechanism of pain generation is multifaceted and challenging, a few basic principles can be highlighted in the rehabilitation of pain. Previously, a sore Achilles tendon was mainly treated with rest, cold, stretching or medication. Nowadays, the aim is to load and exercise the muscle-tendon complex significantly earlier.


The cornerstone of treatment is fairly intense and progressive training, which aims to strengthen not only the muscles that attach to the Achilles tendon, but also the tendon itself. The tendon must be strong and elastic to withstand the load placed on it. Biomechanical factors and variables affecting the load are also taken into account. Rest and stretching without proper loading weaken the tendon's load-bearing capacity and increase pain.

The strengthening of the muscle-tendon complex often begins with isometric exercises, which involve no movement, followed by slow strength training. Training gradually progresses towards faster and more challenging exercises, while also not forgetting body control and biomechanics. Progressiveness and perseverance are important qualities in implementing the exercises. Training periods are often long and training is intense.


Learning to walk with a more forefoot-based gait also increases the work of the calf muscles and is an excellent way to increase the load on the area in daily life. A small amount of pain during training is allowed, as it has been shown that exercises or other activities performed against slight pain often accelerate rehabilitation.


Depending on the background factors, training can be facilitated with individual insoles, heel cushions, heel lifts or other supports and taping. Treatment that relaxes the calf muscles may reduce perceived pain and facilitate training. For example, manual treatment, acupuncture, or other similar methods can be used to relax the muscle-tendon complex while simultaneously reducing tension and pressure on the tendon and increasing blood circulation in the area.


In addition to training, nutrition and hydration may also play a role in supporting the healing process. Adequate hydration and a balanced diet that provides sufficient protein, vitamins, and minerals are important for tissue repair and recovery. Adequate protein intake and hydration are particularly important for the recovery and regeneration of damaged tissues, and physical therapist may also provide guidance on these aspects of recovery.


To obtain an individualized program, I recommend that anyone suffering from this condition contact a physiotherapist specializing in lower limb injuries.

 

Self care

  1. Rest: Avoid high-impact activities that put stress on the Achilles tendon and avoid activities that aggravate your pain. Resting the tendon can help reduce pain and inflammation.

  2. Ice: Apply an ice pack to the affected area for 15-20 minutes, three to four times a day. Make sure to wrap the ice pack in a towel to protect your skin.

  3. Stretching: Perform gentle stretches for the calf muscles and Achilles tendon. Stretching can help improve flexibility and reduce pain.

  4. Strengthening: Perform exercises to strengthen the calf muscle and the Achilles tendon. This can help promote healing, increase blood-flow and prevent future injury.

  5. Footwear: Wear shoes that provide good arch support and cushioning. Avoid flat shoes and high heels.

  6. Orthotics: Consider wearing shoe inserts or custom orthotics to provide extra support to the arches of your feet.

  7. Massage: Use a tennis ball or a foam roller to massage the calf muscles and Achilles tendon. This can help reduce pain and improve flexibility.

  8. Pain relief: Over-the-counter pain medications like ibuprofen or paracetamol can help reduce pain and inflammation.

Remember, if your pain persists or becomes severe, it's important to consult a healthcare professional, like a physical therapist, for further evaluation and treatment.

 

Summary

Achilles tendon pain, or pain in the back of the heel and ankle, is a common condition that can affect athletes and active individuals. It is often caused by overuse, improper footwear, or biomechanical abnormalities. Symptoms may include pain, stiffness, and swelling, and may worsen with activity.


The initial treatment for Achilles tendon pain typically involves rest, ice, as well as stretching and strengthening exercises to improve flexibility and support the tendon. In some cases, orthotics or other assistive devices may be recommended to help reduce stress on the tendon.


More advanced treatment options may include corticosteroid injections, shockwave therapy, and surgery in severe cases. However, these options are typically considered only after conservative treatments have been exhausted.


Early diagnosis and treatment of Achilles tendon pain are important to prevent further injury and complications. It is recommended to seek medical attention if symptoms persist or worsen over time.

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