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Achilles Tendinopathy - Identification and Management

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Achilles Tendinopathy

Achilles Tendinopathy commonly presents in the form of posterior ankle pain and is the most common overuse syndrome of the lower limb, most frequently occurring in runners. Signs include tenderness on palpation of the tendon, a thickened tendon, palpable nodules and some swelling and wasting of the tendon. It can be the result of repeated injuries to the tendon, overuse of the tendon or wearing inappropriate footwear while exercising. This condition can be incapacitating in athletes and is a degenerative rather than an inflammatory condition. A.T. can be classified as mid-portion tendinopathy (2-6cm proximal to calcaneal insertion) or as insertional tendinopathy (occurs at the insertion of the tendon) with mid-portion tendinopathy being the most common presentation.


Differential Diagnosis

Occasionally, an athlete will complain of sudden onset of symptoms.  This could be a partial tear or a complete rupture of the Achilles tendon. A complete rupture would be most common in people involved in sports requiring a forceful push off with the foot, for example; tennis, sprinting, football etc. It can also happen in day to day life where a sudden change in surface places strain on the Achilles. Achilles Paratenonitis and Adhesive tendinopathy can sometimes be misdiagnosed as Achilles tendinopathy aswell as retrocalcaneal Bursitis. It is important that a practitioner attempting to manage Achilles Tendinopathy becomes familiar with each of these conditions. In order to accurately diagnose Achilles Tendinopathy, a detailed injury history must be conducted, a thorough knowledge of anatomy and biomechanics is required and often advanced diagnostic imaging must be conducted.


Biomechanical Causes

  • Tight Calves & Poor flexibility
  • Mechanical overloading of the Achilles Tendon
  • Wearing inappropriate footwear (especially during sport)
  • Poor exercising techniques
  • Uneven exercising surface
  • Sudden increase in mileage or intensity

Management

Most patients respond well to conservative measures although surgery is sometimes necessary to remove adhesions and degenerated areas. Collagen breakdown is generally due to mechanical overload therefore reducing the mechanical overloading on the Achilles should be the focus.

Addressing tight calves with stretching programs and nightsplints, should be a management priority. Eccentric exercise programs, are thought to stimulate mechanoreceptors in tenocytes to produce collagen, and thus help reverse the tendinous cycle.

Orthotics can also be effective at reducing the load on the Achilles tendon aswell as reducing pain.  Prevent any excessive rearfoot pronation or supination by using an orthotic device. The selection of orthotic device should depend upon the amount of excessive pronation or supination moment which you are attempting to control.

Relative rest is encouraged as well as protection and heeling of the injured structures. Temporarily using heel raises or increasing the pitch of the shoe will discourage an early heel lift, and take stress off a painful TA. However, this will be a hindrance to the stretching of the tight calves. The AirHeelTM brace is a useful rehabilitation tool. It has two interconnected air chambers at the TA and the plantar heel. Every time the heel strikes, air is pushed around the TA and massages the area, whilst also providing compression and support.

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