What is 'tendinopathy' and what can you do to help?
Tendinopathy is a broad name for pain in the tendon.
Tendons attach muscle to bone.
We have a couple of types of tendinopathy that can occur in any tendon:
- Reactive (when the pain starts suddenly after increase in loading or trauma)
- Degenerative (when the pain has been going on for >12 weeks & there are cell changes present.
There are two types of tendinopathy you can have in the Achilles:
Insertional: where the tendon pain is where the tendon connects to the bone
Mid portion: the mid part of the tendon
1. How we diagnose an Insertional Achilles Tendinopathy:
Symptoms localised to the Achilles tendon insertional region (within 2 cm of the insertion of the Achilles tendon).
Painful Achilles tendon insertional region on (sports) loading.
Local thickening of the Achilles tendon insertion (this may be absent in cases with short symptom duration).
Pain on local palpation of the Achilles tendon insertion.
2. How we diagnose a Mid Portion Achilles Tendinopathy
Symptoms localised 2–7cm near to the Achilles tendon insertion.
Painful Achilles tendon midportion on (sports) loading.
Local thickening of the Achilles tendon midportion (this may be absent in cases with short symptom duration).
Pain on local palpation of the Achilles tendon midportion.
So, what can help?
The research has shown that the following can help in the management and recovery from pain...
Modifying the load you are placing on the tendon (reduce or modify activities).
Monitoring post activity pain/stiffness - aim to settle within 24hrs if not sooner!
Research also shows that loading the affected tendon can help.
Loading in the form of strengthening exercise is usually the most beneficial.
Speaking to your physiotherapist will help you find what works for you.
Below, I will take you through some of the recent findings from the Dutch Multidisciplinary Guidelines on Achilles Tendinopathy (I would recommend reading it yourself also!)
Gradually build up activity.
Strengthen calf muscles prior to sports seasons.
Wear warm clothing during winter training.
Consider avoiding fluoroquinolone antibiotics if possible.
Treatment Should Involve the Following
Explanation about the condition.
Explanation about the prognosis.
Pain education and addressing psychological factors.
Possibly stop activities that worsen the pain for a short period of time.
Replace activites that provoke pain with activites that do not provoke pain for a short period of time.
Gradual increase of the load of exercise activities.
Use a pain scale to monitor the level of pain with exercise activities and adjust these activities based on the pain scale.
Progressive calf muscle strengthening exercises for at least 12 weeks.
Consider the role of: motivation, time constraints, pain monitoring and availability of facilities and resources.
For insertional Achilles tendinopathy, consider initially performing exercises on a flat surface.
IF exercise therapy is not working well on its own (needs to be tried for at least 3 months), the following options can be added as adjuncts to treatment:
Extracorporeal shockwave therapy.
Other passive modalities.
People must be cautious with using:
Non-steroidal anti-inflammatory drugs (e.g. ibuprofen, naproxen).
Do you need surgery?
Surgery should only be considered in people who have not improved with at least 6months of active treatment. That means 6 months of all of the above before even considering any type of surgery!
There is not enough evidence to say how well surgical treatment compares to non-surgical treatment.
Do you need a scan to diagnose Tendinopathy?
Imaging (scans) are not required for a diagnosis to be made.
Imaging may be used pre-surgery, if unsure of the diagnosis or if needed for additional information.
Ultrasound is the preferred imaging type to use.
X-ray may be used in insertional cases to rule out bony abnormalities.
Imaging will not help with prognosis.
What is the prognosis like?
The majority of symptoms recover, but some people will have ongoing symptoms that persist.
23-37% of people may have persistent symptoms that last up to 10 years despite treatment.
85% of athletes will return to sport.
Enough time should be spent on treatment before going back or increasing sporting activity which provokes symptoms.
A minimum of a few months of active treatment is neccessary before it is possible return to symptom free loading.
If you would like to learn more - I really recommend reading/watching some of the content Tom Goom has on Achilles Tendinopathy here.
The research currently supports an active approach to rehabilitation. So if you have an Achilles Tendon problem, make sure that you are getting the right education around the condition, and that you are having the right guidance and support with your rehab. We must not forget that there are modifiable as well as non-modifiable risk factors for tendinopathy - such as diabetes, high cholesterol, reduced strength, reduced mobility, and use of statins. Looking at your overall health will be a factor in managing your tendon pain and aiming to prevent it recurring again in the future.
Feel free to get in touch with me, or book an appointment if you are suffering with tendon pain!