What is Achilles Tendinopathy?

Achilles Tendinopathy

Introduction

Achilles tendinopathy is a common condition that affects the largest and strongest tendon in the human body—the Achilles tendon. This tendon connects the calf muscles (gastrocnemius and soleus) to the calcaneus (heel bone) and plays a crucial role in walking, running, and jumping. Despite its strength, the Achilles tendon is vulnerable to overuse and degeneration, especially among athletes and physically active individuals. Achilles tendinopathy refers to a spectrum of tendon injuries that are primarily degenerative rather than inflammatory in nature.

Anatomy and Function of the Achilles Tendon

The Achilles tendon originates from the merging of the gastrocnemius and soleus muscles and inserts into the posterior surface of the calcaneus. It facilitates plantarflexion of the foot at the ankle joint, which is essential for locomotion activities like walking, climbing stairs, and sprinting. It also functions as an energy store and release mechanism during high-impact activities.

Pathophysiology

Contrary to the earlier term "tendinitis," which implies inflammation, Achilles tendinopathy is more accurately characterized by a degenerative process. It involves micro-tearing of the tendon fibers, collagen disorganization, increased ground substance, and neovascularization (new blood vessel formation), without the presence of typical inflammatory cells. Over time, repetitive stress and failure of tendon healing can lead to chronic tendinopathy.

Types of Achilles Tendinopathy

There are two primary forms of Achilles tendinopathy:

  1. Mid-portion Achilles tendinopathy – occurs approximately 2 to 6 cm above the tendon’s insertion into the heel bone, and is more common.

  2. Insertional Achilles tendinopathy – involves the lower portion of the tendon where it inserts into the calcaneus.

These two forms can have different causes, symptoms, and responses to treatment.

Causes and Risk Factors

Several intrinsic and extrinsic factors contribute to the development of Achilles tendinopathy:

  • Sudden increase in training intensity or volume

  • Poor footwear or hard running surfaces

  • Tight or weak calf muscles

  • Overpronation or poor biomechanics

  • Age-related degeneration (common in middle-aged individuals)

  • Systemic conditions such as diabetes or inflammatory arthritis

  • Use of certain medications like fluoroquinolone antibiotics or corticosteroids

Clinical Presentation

Patients with Achilles tendinopathy typically report:

  • Gradual onset of pain and stiffness in the Achilles region, especially in the morning or after periods of rest

  • Tenderness and swelling along the tendon, which may be localized (mid-portion) or at the insertion

  • Worsening pain with activity such as walking uphill, running, or jumping

  • In advanced cases, thickening of the tendon may be palpated

Pain usually improves with light activity and worsens with excessive load.

Diagnosis

The diagnosis is largely clinical and based on patient history and physical examination. Key clinical tests include:

  • Palpation tenderness along the tendon

  • Royal London Hospital Test – decreased tenderness with dorsiflexion of the ankle

  • Arc Sign – swelling moves with ankle motion, indicating mid-portion involvement

Imaging may be used to confirm diagnosis or rule out rupture:

  • Ultrasound – reveals tendon thickening, hypoechoic areas, and neovascularization

  • MRI – used in more complex cases to assess tendon integrity and detect partial tears

Differential Diagnosis

Conditions that can mimic Achilles tendinopathy include:

  • Achilles tendon rupture

  • Retrocalcaneal bursitis

  • Plantaris tendon pathology

  • Posterior ankle impingement

  • Referred pain from lumbar spine or peripheral nerves

Management

Treatment for Achilles tendinopathy is typically conservative, especially in the early stages.

1. Activity Modification and Load Management

Patients should reduce activities that overload the tendon and adopt cross-training options like swimming or cycling during recovery.

2. Eccentric Exercise Program

This is the mainstay of treatment. The Alfredson protocol, involving eccentric heel drops twice daily for 12 weeks, has shown excellent results in mid-portion tendinopathy.

3. Stretching and Strengthening

Gentle calf stretches, isometric loading, and progressive strengthening of the calf muscles help restore tendon function and resilience.

4. Orthotics and Footwear Modification

Use of heel lifts, proper shoes with adequate cushioning, and correction of biomechanical abnormalities can reduce strain on the tendon.

5. Manual Therapy and Modalities

Physiotherapists may use techniques such as deep tissue massage, ultrasound, or shockwave therapy to enhance healing.

6. Medications

Analgesics or topical NSAIDs may help manage pain. However, oral corticosteroids are generally avoided due to the risk of tendon weakening.

7. Platelet-Rich Plasma (PRP)

Some clinicians use PRP injections, although evidence for their efficacy remains limited and controversial.

8. Surgery

Reserved for cases unresponsive to conservative therapy over 6–12 months. Surgical options include debridement of degenerative tissue or tendon reconstruction.

Prognosis

With timely and appropriate management, the prognosis for Achilles tendinopathy is favorable. Most patients show significant improvement within 3 to 6 months. However, recovery can be slow due to the tendon’s limited blood supply. Persistence or recurrence of symptoms may occur, particularly if underlying biomechanical or training errors are not corrected.

Prevention

Preventative strategies include:

  • Gradual progression of training

  • Adequate warm-up and cool-down

  • Regular calf muscle strengthening and flexibility exercises

  • Proper footwear suited for the activity and individual foot structure

  • Addressing biomechanical issues such as overpronation

Conclusion

Achilles tendinopathy is a common yet complex condition that requires a multifaceted approach to treatment. Understanding its pathophysiology, clinical presentation, and management options is essential for effective recovery. With early intervention and adherence to a structured rehabilitation program, patients can return to their activities with minimal limitations and a reduced risk of recurrence.

References

  1. Maffulli N, Longo UG, Gougoulias N, et al. Achilles tendinopathy: aetiology and management. Journal of the Royal Society of Medicine. 2004;97(10):472–476. doi:10.1177/014107680409701007

  2. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–366. doi:10.1177/03635465980260030301

  3. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Sports Med. 1999;27(6):393–408. doi:10.2165/00007256-199927060-00004

  4. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46(3):214–218. doi:10.1136/bjsm.2010.081935

  5. PhysioPedia. Achilles Tendinopathy. https://www.physio-pedia.com/Achilles_Tendinopathy

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