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Achilles Tendon Pain

The Achilles tendon is the combined tendon of the two calf muscles, the gastrocnemius and soleus.

What Causes Achilles Tendon Pain?

Although it is the strongest tendon in the body, it can sometimes be overloaded, which causes discomfort and even pain.

Achilles pain used to be called Achilles tendinitis but we now know that the Achilles does not get inflamed, so we use the term Achilles tendinopathy. Achilles tendinopathy is typically seen in running or jumping activities but can occur in people who don’t play sport.

General tightness can also be seen in summer months when people wear shoes with no heel e.g. flat sandals/flip flops that put an extra stretching load on the Achilles. Occasionally this can develop into a tendinopathy.

When the tendon is overloaded it tends to get thicker/swollen, usually in the middle of the tendon about 5cm above where the Achilles inserts into the heel bone (calcaneum). Typically the Achilles will feel tight and sore first thing in the morning and when you first start exercising. In the early stages that pain will often ease off once the Achilles is warmed up. During exercise the pain will usually recur as the Achilles gets tired and this pain may persist once exercise has stopped.

Insertional Achilles Pain

Pain at the insertion into the heel is more complex and can be related to tendinopthy, inflammation of insertion, inflammation of bursa, pressure from heel bone (calcaneum) on achilles tendon or shoe on calcaneum. Tendinopathy of the tendon at the point where it inserts into the heel bone is called “insertional tendinopathy”. This distinction is important because the exercises you do to treat insertional tendinopathy are slightly different. Eccentric loading has been proven to be very effective in treating pain in the mid portion of the Achilles tendon. These exercises have recently been modified for situations where the pain is not in the tendon itself, but where the tendon attaches to the bone.

Stage 1: Single Leg Heel Lowering Exercises

  • 1. Initially perform a gentle warm up by walking at a moderate pace for five minutes;
  • 3. Transfer your weight to the step/stair foot and straighten your knee. This will force you to stand on tip toe on your floor foot
  • 5. Keeping you knee straight SLOWLY lower your floor heel to the ground;
  • 7. Rest for 20 seconds;
  • 9. If both heels are painful, turn around and repeat the exercise as described;
  • 2. Stand with your right foot on a box or bottom step of a stair case and your left foot on the floor. If your right heel is painful, turn around with your left foot on the box/stair and your right foot on the floor.
  • 4. Now transfer your weight to the floor foot and lift the step/stair foot
  • 6. Repeat 14 more times;
  • 8. Carry out a second set of 15 heel drops, this time with the floor knee slightly bent. This strengthens the different calf muscles.
  • 10. Following the exercise programme, ice the back of the heel for ten minutes. You should carry out three sets of 15 repetitions three times per day, seven days a week

In the early stages this exercise MAY BE PAINFUL, but do not worry. This is normal and experience shows that the tendon will not rupture and, in most cases, will get better as a result of the exercise. When there is no pain during or after the three sets of repetitions then move onto stage 2.

Stage 2: Single Leg Heel Lowering Exercises with extra weight

  • 1. As in stage 2 but this time wearing a back pack adding 5kg weight
  • 3. Continue the exercises for a total of 12 weeks. If your symptoms are no better consult your doctor.
  • 2. When these exercises can be done with no pain, progress by increasing the weight by 2kg at a time to reach a new level of painful training.

Achilles Inflammation

Very rarely the outside sheath of the Achilles tendon (the paratenon) can be inflamed with diffuse swelling and a crunchy feel (called crepitus) when touched, but this condition is much less common and will not be discussed further. If you suspect you have this problem consult your GP.

Investigation of Achilles Pain

If pain persists ultrasound scan provides helpful information. Please note there is poor correlation between the severity of pain and abnormal findings on scans

Treatment of Achilles Tendinopathy

The Achilles is painful and thickened/swollen because it has been overloaded, i.e. it is too weak to cope with the load it is placed under. It therefore follows that rest is only going to make matters worse as the Achilles will get even weaker if rested. The treatment of Achilles tendinopathy is a very simple heel drop exercise, which in most cases will resolve the problem. This exercise is painful to start with, but must be done every day and should be viewed as a three months treatment. The most common reason for it not working is that patients don’t do the exercises often or regularly enough.

Eccentric loading

Eccentric loading has been proven to be very effective in treating pain in the middle of the Achilles tendon. Performing the Exercise

  • Go up onto both tip toes.
  • Return to the start position
  • The exercise should be performed in two ways, one set of 15 repetitions with the knee slightly bent and one without. This targets the different calf muscles.
  • In the early stages this exercise MAY BE PAINFUL, but do not worry as this is normal.
  • Continue your single leg exercises for 12 weeks. If your pain does not improve consult your doctor.
  • Lower your heels down in a slow and controlled manner, allowing your heels to drop below the level of the step to a point where you feel a resistance within the muscle.
  • You should do two sets of 15 repetitions three times per day, seven days a week
  • After two to four weeks, when you feel you have got used to the exercises, you should progress to one-legged versions of the described exercises. The exercise should be done on your painful leg or, if both are painful, both legs in turn.
  • Experience shows that the tendon will not rupture and, in most cases, will get better as a result of the exercise.

Although complete rest can be a bad thing, relative rest is encouraged, i.e. you should temporarily reduce or even stop the activity that has caused your problem. For example if you are a runner, you should stop running for the first six weeks of the heel drop exercise programme. After six weeks you can then gradually re-introduce your running.

If your Achilles is particularly sore when walking around, doing everyday things, then try wearing a shoe with a slight heel or putting a small heel raise in your shoe. This merely takes some of the stretching load out of the tendon.

Other Treatments

  • Use simple analgesia e.g. paracetamol as required, particularly during the first few painful weeks of the exercise programme.
  • Avoid steroid injections.

Prevention of Achilles Pain

  • Avoid stretching in isolation, but maintain strength in the Achilles by continuing to do some strength exercises even once recovered.
  • Review your footwear
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