In this post we will look into the most up to date evidence based management of Achilles tendinopathy.
I listened to a great Podcast last week where a former colleague of mine Brad Beer from the Physical Performance Show interviewed Peter Malliaras a world leader in lower limb tendon research and treatment. I was happy find my current treatment for these types of injuries is in line with current literature and evidence and how Peter is treating his clients.
Tendinitis, tendinopathy, tendinosis? Is it all the same.
Most of us are familiar with the term Achilles tendinitis ‘itis’ being inflammation. We know however inflammation is not the issue with tendon pathology but rather a structural change in its physical and biochemical properties. A blanket term for tendon pain is tendinopathy.
The Achilles tendon is the largest tendon in the body and is made of a connective tissue called collagen. The tendon is an extension of the gastrocnemius and soleus (calf muscles), running down the back of the lower leg attaching to the calcaneus (heel bone). The load through the tendon depends on the demand. A slow walk obviously places less loads than an explosive push off with sprinting for example.
How do Achilles injuries occur?
Generally we see an injury or pain response in the tendon when its load handling capacity has been exceeded. This may be a one of stress eg a use of the tendon with more force than its use too or a repetitive load that’s higher than its use to. Eg a runner might increase their weekly running distance by over 30% in one week and the tendons load tolerance or capacity has been exceeded causing a biochemical change in the tendon leading to sensitivity in the tendon causing pain with activity.
Diagnosing the injury?
A clinical assessment and certain functional outcome measures are the best indicators to guide management of symptoms. Eg testing the tendons ability to take load in certain movements or activities. The irritability can also tell us a lot- that is what the tendon can and cannot tolerate before it flares up. Cook and Purdon 2009 came up with this nice diagrammatic below illustrating the process of tendinopathy.
Imaging, is it needed?
Clinicians will often scan the injured tendon for assessment purposes. We now know however that structural changes seen on scans such as MRI and USS don’t have a good correlation with pain and therefore should not be used as a guide for treatment or severity of injury progress. With this disconnect between pathology and pain we often see tendons on scan with large pathology and structural change in people with no pain and then pain in people with little or no pathology seen on scan.
How do we effectively treat Achilles tendinopathy?
We know tendon injuries can be at times a lengthy process. The main thing to remember though is only ‘YOU’ can get your tendon better! And this is through a progressive loading program. No amount of massage, heat, acupuncture or medication will apply the load to the tendon tissue that is required for it to improve. Of course a health professional will guide you in the progressive rehabilitation needed depending on the individual needs.
We know most ongoing Achilles issues are due to poorly managed loading program that are either not done correctly or not done at all! It requires patience and persistence there are no quick fixes!
There are many different treatment options that ongoing sufferers may try in desperation especially if they have ‘failed’ a loading strength program. PRP (platelet rich plasma) injections, cortisone injections, SWT (shockwave therapy) are a few treatments often attempted but their efficacy has yet to be proven with many continuing to have ongoing symptoms after treatment or even more issues.
Where to start with treatment?
We know rest is not good for tendons! In the acute stage we may just need to modify activity only as much as needed to allow the tendon to settle and stop the flare up. You may be able to keep running for example but with less distances or speed. You may need to stop running but can keep walking while symptoms settle.
Progressive loading has been shown to be the most effective treatment in helping the painful tendon improve its pain free load capacity. Loading may begin with isometric type exercises – this is when the muscle and tendon unit is contracting but there is no movement through the ankle and progress to isotonic –contraction with movement. From here or in combination we move onto more functional task such as hopping, running, jumping and sport specific requirements.
Load progression is important and needs to be done in the correct manner for successful outcomes. A combination of isolated muscle exercises as well as functional exercises are normally needed.
Importantly exercise is also not just about helping the strength but also the pain threshold of the tendon structure and its response to loading. Pain during activity is not a bad thing as long as it stays below 2-3/10 and settles after activity to baseline levels.
It’s important to note that the brain can modulate pain. It can amplify the pain based on threat levels perceived. Stress, anxiety and frustration towards ongoing pain in the tendon can slow progress in certain cases.
Key points for successful Achilles tendinopathy management
Pain does not equal damage to tissue but more a sensitivity in the tendon
Pathology on scan does not dictate outcomes and has a disconnect with pain
Exercise is not just about getting stronger but also improving the tendons pain threshold
We can continue to train/rehab at acceptable pain levels- pain will fluctuate.
A positive mindset and confidence in your tendon and rehabilitation will have a positive effect.
‘YOU’ get your tendon better. (with the help of a informed health practitioner)
As always make sure you see your chosen health provider for an accurate assessment to work out your individual treatment needs.
Hamish The Physio