What is the Achilles Tendon?

The Achilles tendon, also known as the heel cord, is a large, strong tendon located in the back of the leg. It connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneum). During walking or running, the Achilles tendon pulls on the heel, causing the foot to point downwards and push off the ground.

What is Achilles Tendinopathy?

Achilles tendinopathy is a common condition characterized by a degenerative process in the Achilles tendon. It is often seen in individuals in their 40s who have a pre-existing tight Achilles tendon. The condition is a result of repetitive small tears in the tendon that do not fully heal after each injury. Achilles tendinopathy can occur in the mid-portion of the tendon (non-insertional) or at the point where the tendon attaches to the heel bone (insertional). Insertional Achilles tendinopathy can be a component of Haglund’s syndrome.

What is Haglund’s Syndrome?

Haglund’s syndrome is a combination of conditions that involve insertional Achilles tendinopathy along with inflammation between the Achilles tendon and the heel bone (retrocalcaneal bursitis) and a bony prominence on top of the heel bone (Haglund’s deformity).

What are the Symptoms of Achilles Tendinopathy?

The most common symptoms of Achilles tendinopathy include gradual onset of pain, swelling, and stiffness in either the mid-portion or insertion area of the Achilles tendon. Symptoms can occur without a specific injury and are typically associated with activity or experienced in the morning. Over time, symptoms can become more constant. Pain worsens with activities such as jumping, running, and walking uphill. In some cases, the Achilles tendon may appear red, warm, tender to touch, or thickened. Insertional Achilles tendinopathy can lead to the development of a bony bump at the back of the heel.

How is Achilles Tendinopathy Treated?

While the following non-surgical treatments are effective for the majority of patients, this list is not exhaustive:

1. Appropriate Footwear: Wear supportive shoes that fit well. Consider using shoes with soft cushioning at the back.
2. Orthoses: Medical insoles can improve foot position and reduce the forces transmitted through the Achilles tendon while walking and standing. Consult an orthotist for a specialist opinion.
3. Pain Management: Simple painkillers like paracetamol, anti-inflammatory tablets (e.g., ibuprofen), or anti-inflammatory gels can provide relief. Consult your doctor or pharmacist for advice on taking anti-inflammatory medicines, as they may have side effects for some individuals.
4. Weight Management: If overweight, weight loss is an important part of the treatment plan. Consult your general practitioner for a possible referral to a weight loss program.
5. Activity Modification: Reduce or avoid activities that exacerbate Achilles tendinopathy symptoms, particularly high-impact activities like running. Consider engaging in low-impact exercises such as cycling or swimming to maintain fitness.
6. Physiotherapy: Calf muscle eccentric exercises are highly effective and form the mainstay of treatment to promote long-term resolution of Achilles tendinopathy. It is crucial to perform these exercises regularly. A referral to a physiotherapist for specialized input is recommended.
7. Extracorporeal Shockwave Therapy: This procedure is offered to patients who have not responded to first-line treatments. Shockwaves are low-energy sound waves that increase blood flow to expedite the body’s healing process. The therapy involves passing shockwaves through the skin to the Achilles tendon.

Can Achilles Tendinopathy be Treated with Surgery?

Surgery is considered a last resort when non-surgical treatments have failed. The decision to undergo surgery depends on the extent of the condition and any underlying medical conditions. It’s important to note that surgery carries risks and requires a prolonged recovery period.

Exercises

Here are some exercises that can aid in the treatment and rehabilitation of Achilles tendinopathy:

1. Gastrocnemius Heel Drop: Stand with one foot on a step and the heel raised. Slowly lower the heel down, keeping the leg straight until the foot is parallel to the ground. Push up to the starting position using your uninjured leg to assist and repeat. Perform 3 sets of 15 repetitions twice a day. Increase the load as you progress by wearing a weighted vest or rucksack to add weight or load to the Achilles tendon.
2. Soleus Heel Drop: Similar to the gastrocnemius heel drop, but keep your knee bent at approximately 45 degrees (half squat position).
3. Gastrocnemius Stretch: Place the leg to be stretched behind you and lean forward, ensuring the heel stays in contact with the floor. Hold the stretch for 20 to 30 seconds and repeat 3 times. This stretch can be repeated multiple times a day and should not be painful. You should feel the stretch at the back of the lower leg. Adjust the position if you don’t feel the stretch.
4. Soleus Stretch: Keep the back leg bent to stretch the soleus muscle. Place the leg to be stretched behind you and lean against a wall, keeping the heel down. You should feel the stretch lower down near the ankle at the back of the leg. If the stretch is not felt, a more advanced version involves placing the forefoot of the front leg against the wall with the heel on the floor and pushing the knee toward the wall.
5. Stretching on a Step: Repeat the above stretches with the knee bent to ensure you stretch both muscles.

When to Consider Seeing a Surgeon

While most cases of Achilles tendinopathy can be effectively managed with non-surgical treatments, there are situations where surgical intervention may be necessary. It is recommended to consult with a surgeon if:

1. Non-surgical treatments have been attempted for a significant period of time (several months) without significant improvement in symptoms.
2. The pain and functional limitations caused by Achilles tendinopathy significantly affect daily activities, sports participation, or quality of life.
3. The condition worsens or becomes chronic despite conservative treatments.
4. There is evidence of a severe or complete tear of the Achilles tendon.
5. Conservative treatments have been exhausted, and the individual is seeking further options for relief.

If surgery is deemed necessary, the surgeon will conduct a thorough evaluation, discuss the potential risks and benefits of the procedure, and develop a personalized treatment plan based on the individual’s specific condition and needs.

Remember, surgical intervention is typically considered a last resort and will depend on the severity and duration of the condition, as well as individual factors. The decision to proceed with surgery should be made in consultation with a qualified healthcare professional.

If you have any concerns or questions about the need for surgery or any other aspect of your Achilles tendinopathy, it is advisable to consult with your healthcare provider or surgeon for a comprehensive evaluation and personalized advice.

Wellbeing Advice

Maintaining a healthy diet, engaging in regular exercise, and refraining from smoking can contribute to a quicker recovery and more successful outcome from surgery. If you have concerns about your general health and well-being (diet, exercise, smoking cessation), discuss them with your GP, who can provide advice on available options.

For further information, you can visit the following link:
NHS Tendonitis Information

We hope this information sheet has addressed your questions. If you have any further inquiries, feel free to discuss them with the medical or nursing staff.