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Article

Achilles tendonitis has become Achilles tendinopathy

This article about Achilles tendinopathy was originally printed in the magazine Kondis, issue 5-24.

Achilles tendinopathy

Achilles problems affect many people. In this issue you get an introduction to how you can try to diagnose yourself, and also how to think about treatment and rehabilitation. I hope this is a good guide, and I always recommend seeing well-qualified healthcare professionals if pain should arise, so that you can make a plan together with them. The advantage of having read this article first is that you know a little about what to expect when you meet a therapist.

What is the Achilles tendon?

The Achilles tendon is the largest and strongest tendon in the human body, and it connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). The tendon plays an important role in walking, running and jumping by storing and releasing elastic energy, which helps make movement more efficient. The structure of the Achilles tendon consists mainly of collagen fibres, which provide strength and elasticity, but it has limited vascularisation, which means that it has a relatively slow healing process compared with other types of tissue.

What is Achilles tendinopathy?

Achilles tendinopathy used to be called Achilles tendonitis. Today we know that it is not an active inflammation in the tendon, but a load-related clinical diagnosis involving pain and dysfunction in the Achilles tendon. The condition can arise from overload over time, and it affects both active and inactive individuals. The incidence is 2-3 per 1000. Achilles tendinopathy can occur in the middle portion of the tendon (mid-portion tendinopathy) or at the attachment to the heel bone (insertional tendinopathy). People often have a feeling of stiffness in the tendon with tendinopathy and want to stretch it, but you should try to avoid that, because the tendon actually has increased mobility with this diagnosis.

Criteria for the diagnosis include:

  • Local pain
  • Tenderness to pressure
  • Pain on loading
  • Possible local swelling or thickening of the tendon

Symptoms

Symptoms of Achilles tendinopathy include:

  • Pain that is often worst in the morning or at the start of an activity
  • Pain that eases during warm-up, but returns after activity, or possibly after a longer period of activity.
  • A feeling of stiffness and pain on palpation of the tendon.
  • Swelling and thickening can occur.

Causes and risk factors

The main cause of Achilles tendinopathy is overloading the tendon with too little recovery. This can be due to a sudden increase in training intensity or volume, the use of unsuitable shoes, or training on hard surfaces. Risk factors include genetics, metabolic conditions, inactivity, overweight, inflammatory diseases, hormonal imbalances, previous injuries, age and sex. Runners who increase their training load quickly without sufficient time to adapt are particularly at risk.

In running, we see that with a lot of hill running, fast intervals and, for example, the use of spiked shoes, the load on the calf muscles and the Achilles tendon increases considerably, and thereby the risk of tendinopathy also increases.

Treatment

  • Information and education: It is sensible to read up well on the diagnosis, the prognosis and how to listen to the pain. Rehabilitation will then make more sense and you get a sense of ownership of it. Know that it can take up to 24 weeks of training to achieve a change in tendon structure. It is important to have realistic expectations, and unfortunately to arm yourself with patience once the injury has happened.
  • It is sensible to read up well on the diagnosis, the prognosis and how to listen to the pain. Rehabilitation will then make more sense and you get a sense of ownership of it.
  • Know that it can take up to 24 weeks of training to achieve a change in tendon structure. It is important to have realistic expectations, and unfortunately to arm yourself with patience once the injury has happened.
  • Load management: First reduce painful activity and replace it with alternative activity. Then gradually reintroduce and increase the load. For runners, training volume, intensity and type should be adjusted carefully, taking into account the tendon's healing process, pain and perceived exertion. Minimal pain (1-2/10 on the pain scale) should be the goal before resuming running or jumping. In this case, it is therefore OK to run if you do not experience pain, but it is also important to remember that the pain the day after training should not get worse either. So if you run without pain, but experience increased morning stiffness and pain the day after, it was too much the day before.
  • First reduce painful activity and replace it with alternative activity. Then gradually reintroduce and increase the load.
  • For runners, training volume, intensity and type should be adjusted carefully, taking into account the tendon's healing process, pain and perceived exertion. Minimal pain (1-2/10 on the pain scale) should be the goal before resuming running or jumping. In this case, it is therefore OK to run if you do not experience pain, but it is also important to remember that the pain the day after training should not get worse either. So if you run without pain, but experience increased morning stiffness and pain the day after, it was too much the day before.
  • Training and exercises: The literature shows that active rehabilitation and training have small to moderate effects, but better results than doing nothing. Exercise therapy, especially heel raises, is effective because of its simplicity, low cost and few negative consequences. The exercises should include both eccentric (lengthening and braking) and concentric (contracting) components to promote tendon healing, reduce symptoms, and improve function and muscle strength. It is not absolutely necessary to follow the rigid protocols described below, but what we know is that we must load the tendon to change its structure. What is good about the protocols is that they all have a gradual increase in load. It should be heavy, and you can expect some increased pain at the start (max 4/10 on a pain scale) and not a major worsening the day after. You will very likely be able to run even if you have the condition, but it is also very likely that you will have to cut back considerably and gradually build up your tolerance again.
  • The literature shows that active rehabilitation and training have small to moderate effects, but better results than doing nothing. Exercise therapy, especially heel raises, is effective because of its simplicity, low cost and few negative consequences.
  • The exercises should include both eccentric (lengthening and braking) and concentric (contracting) components to promote tendon healing, reduce symptoms, and improve function and muscle strength.
  • It is not absolutely necessary to follow the rigid protocols described below, but what we know is that we must load the tendon to change its structure. What is good about the protocols is that they all have a gradual increase in load. It should be heavy, and you can expect some increased pain at the start (max 4/10 on a pain scale) and not a major worsening the day after.
  • You will very likely be able to run even if you have the condition, but it is also very likely that you will have to cut back considerably and gradually build up your tolerance again.

Exercise protocols and other approaches

  • Eccentric training (Alfredson protocol): Daily training in the morning and afternoon with 3×15 eccentric heel-raise repetitions (two exercises).
  • Isometric training: A static hold in a heel raise, or simply pressing statically into the ground with the toes. Primarily for pain relief and to build up the tendon's tolerance for load.
  • Heavy Slow Resistance (HSR) (Kongsgaard protocol): Three sessions a week of 3×15 repetitions with variations of heel raises, with fewer repetitions and more load as strength increases.
  • High-frequency combination: Daily training with 3×15 reps of both concentric and eccentric exercises with variations of heel raises.
  • Alternative measures:
    If there is no improvement after 3-4 months of standard treatment, alternative measures can be considered. These include injections (cortisone and PRP), shockwave therapy (ESWT), or surgery. It is, however, important to be careful with cortisone injections and NSAIDs, as these can have unwanted side effects on the tendon.

Conclusion

Achilles tendinopathy is a challenging condition that requires a thorough understanding of load management and rehabilitation protocols. With the right information, adjusted load and targeted exercises, most patients can expect considerable improvement in function and a reduction in pain. Early intervention and continuous follow-up are the key to successful treatment. Most important of all is that in the vast majority of cases you get completely well and get back to running at full strength again.