This is the first of two posts that will focus on a common foot problem: Achilles Tendinopathy. In this series we look to explain the process of Achilles tendinopathy, common risk factors, proven treatments, and new treatment ideas.
Achilles tendinopathy is one of the most common ankle overuse injuries. The disorder is more likely to be found in active individuals who participate in running and jumping sports. Achilles tendinopathy can be a frustrating condition because of the potential for pain to become persistent and significantly limit athletic participation and daily function. This blog post summarizes a review of the current concepts and treatment of Achilles tendinopathy. This is the first of two posts where we will delve into this often-frustrating condition.
First it is important to point out that we are using the term tendinopathy rather than tendinitis. Tendinitis had been used for decades but this is actually a bit of a misnomer. The term tendinitis implies that there is an inflammatory condition occurring. Recent studies however have found that tendon changes occur as a result of failed healing where inflammation and inflammatory cells are not found. The tendon itself, like most tendons, has a relatively low blood supply. In the Achilles the area of the tendon that is least vascularized is approximately 2 to 6 cm above its insertion into the heel. This explains why this is the most likely area of the tendon to be injured.
In normal tendon healing an injured tendon must go through the three phases of healing. The first phase, the inflammatory phase, typically lasts two to three days and is important in laying the ground work for healing to occur. After two to three days healing enters the proliferative phase where new fibrous like tissue is laid down in the area of injury. This typically occurs for 6 weeks until healing starts to enter the remodeling phase. In the remodeling phase new tissue starts to align itself in a direction that best absorbs the load through the tendon. This typically lasts another 4 weeks. Finally, if all goes well, after approximately 10 weeks the tendon will enter the final phase of healing, the maturation phase. In the maturation phase the new fibrous tissue gradually changes to scar tissue over the course of about a year. That means that if everything goes right it takes an injured tendon about a year to fully heal.
If everything doesn’t go right then you end up stuck in the proliferative phase of healing. Being stuck in the proliferative phase leaves a tendon with too many cells responsible for breaking down the tendon, fibrous tissue that is disorganized, and a blood supply that has no business being there long term. The tendon is now structurally weaker and painful. This doesn’t sound like something anyone wants.
The first question one might want to ask is, how can someone avoid getting Achilles tendinopathy? That is best answered by looking at a list of risk factors associated with the disorder. There are intrinsic factors associated with this disorder. Intrinsic factors include having a flat foot, a foot with too much arch, limited mobility of the subtalar joint (heel), and a leg length discrepancy. Systemic inflammatory conditions such as rheumatoid arthritis, hypertension, diabetes, obesity, hypertension, and certain medications can all increase the risk of developing Achilles tendinopathy. Extrinsic factors include excessive loading of the tendon through sport, training errors that include abrupt changes in frequency or intensity of training, change in training surface (hills or hard surfaces), poor shock absorption and uneven footwear may all contribute to Achilles tendinopathy.
There are a number of factors on this list that can be modified by training and lifestyle changes. Reducing your overall inflammatory lifestyle through diet could easily reduce the risk of developing Achilles tendinopathy. Likewise, smart exercise prescription including gradual progression of exercise and activity without huge jumps in training can significantly reduce your risk. There are plenty of risk factors on this list that are within your own control!
In Part 2 of this post we will discuss ways that physical therapy can help restart the healing process and reduce the risk for setback and future injury.
Li H & Hua Y. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Research International. 2016(6). https://dx.doi.org/10.1155/2016/6492597.
Chaudhry, F. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. Eur J Orthop Surg Traumatol. 2017(27). 441-448.