What causes Achilles tendon pain?
Achilles tendon pain can be due to a number of conditions, however it is most commonly caused by two main conditions, namely Achilles tendonitis and Achilles tendinosis. Whilst these two conditions sound the same and perhaps have some overlapping causative factors, they have different characteristics.
Achilles tendonitis is the most common cause of Achilles tendon pain in patients. It describes an inflamed and irritated Achilles tendon. Achilles tendonitis is caused by repetitive or intense strain on the tendon, including:
- Suddenly increasing the frequency, intensity or duration of exercise or activity
- Not leaving enough recovery time between exercise sessions
- Inadequate warm up or cool down routine
- Wearing inadequate or inappropriate footwear during physical activity
- Seasonal change of exercise surface, or consistent running on uneven or hard surfaces
- Poor muscle flexibility, such as weak or tight calf muscles
- Reduced joint function, such as a stiff ankle joint due to other injury or complaint
- Over-pronation of the foot, where the force on the Achilles tendon is increased.
If your Achilles tendon pain due to tendonitis is ignored or left untreated, it may progress to the degenerative condition, Achilles tendinosis.
Achilles tendinosis is also commonly referred to as Achilles tendinopathy, and is a common chronic cause of Achilles tendon pain. It can occur when Achilles tendonitis is left untreated, and the tendon injury progresses from an active inflammatory process to a degenerative state.
Other than Achilles tendonitis and tendinosis (tendinopathy), tendon rupture can also cause Achilles tendon pain. Tendon rupture refers to a partial or complete tear of the tendon, which can happen if the tendon is stretched beyond its capacity. Activities that are forceful, such as jumping, pivoting, or very sudden accelerations when running can cause overstretching and tears or ruptures. Similarly, injuries, such as falls or trips can also lead to Achilles tendon pain due to tendon rupture. Rupture of the Achilles tendon can also occur following chronic Achilles tendinopathy, where the degeneration of the tendon is severe.
Less commonly, Achilles peritendinitis (paratenonitis, tenosynovitis) and retrocalcaneal bursisits may be diagnosed as the cause of the Achilles tendon pain.
Risk factors for Achilles tendon pain
There are numerous factors that may increase your risk of Achilles tendon pain caused by Achilles tendonitis and tendinopathy. These include:
- Your sex: occurs most commonly in men
- Your age: risk increases with age
- Your weight: overweight and obesity increases your risk
- Your lower-limb biomechanics: flat (over-pronated) feet and tight calf muscles increase your risk
- Some medical conditions: risk is increased in people with high blood pressure
- Some medications: a particular group of antibiotics (fluoroquinolones) have been associated with increased rates of Achilles tendonitis.
How is the cause of Achilles tendon pain diagnosed?
Your sports podiatrist is an expert in diagnosing the causes of Achilles tendon pain. Through careful and thorough history taking and clinical examination, they will be able to determine what is causing your Achilles tendon pain. In most cases, diagnostic imaging is not required in the diagnosis of Achilles tendonitis and tendinopathy, however in some cases, your sports podiatrist may order an MRI for detailed visualization of the tendon and the surrounding structures, allowing them to rule out other conditions.
Characteristics and symptoms of Achilles tendonitis
Achilles tendonitis presents as pain in the back of the heel. Patients may have difficulty walking and there is often swelling, redness and warmth around the Achilles tendon area. At a cellular level, there is an active inflammatory process occurring.
Characteristics and symptoms of Achilles tendinosis (tendinopathy)
With Achilles tendon pain due to tendinopathy, patients experience pain and stiffness in the affected tendon area, which is sometimes worse at night or first thing in the morning. There is usually a loss of strength in the affected tendon area, and some people simply describe the leg as feeling ‘sluggish’. Sometimes a lump may be present in the affected tendon and there may be localized swelling. At a cellular level, there is an absence of inflammatory cells. Increased protein production results in the separation of the collagen and disorganization of the cell matrix. If left untreated, eventually this can lead to what is medically referred to as ‘degenerative tendinopathy’, where the physiological changes in the tendon become irreversible, and prognosis for healing of the tendon is poor.
What are the treatments available for Achilles tendon pain?
Your sports podiatrist will expertly tailor a treatment plan for your Achilles tendon pain, which will aim to relieve the pain and reduce any swelling and inflammation, with a view to heal the tendon. The treatment plan they choose will depend on the severity of the condition, and number of other variables, including whether the patient is a competitive athlete or not.
You can begin treatment at home by utilizing the RICE protocol:
- Rest: give the tendon the opportunity to heal. Depending on the severity of the condition, this may mean increasing your rest intervals at exercise, right through to complete rest that is prescribed for days or weeks.
- Ice: wrapped cold packs can be applied to the area where you are experiencing Achilles tendon pain after exercise or at any time to relieve pain.
- Compression: seek advice from your sports podiatrist or health professional as to what type (if any) of compression bandage is suitable for your condition.
- Elevation: raise your foot above the level of your heart simply by lying down and lifting the foot up on some pillows, to reduce swelling.
Other treatments that your sports podiatrist may recommend for your Achilles heel pain, depending on your diagnosis and the severity of the condition may include:
- NSAIDs: Non-steroidal anti-inflammatory drugs, such as ibuprofen, help to reduce swelling and pain.
- Corticosteroid injections: usually ultrasound-guided to reduce the risk of tendon rupture. These injections work to reduce inflammation and pain.
- Extracorporeal shock wave therapy (ESWT): high-energy sound waves are directed into the injured tendon and used to stimulate the healing process and provide almost instantaneous pain relief.
Surgery: is not very common for tendonitis and is generally only recommended in severe cases where all other treatment options have been exhausted with little or no improvement. In cases where the Achilles tendon has ruptured, surgical intervention is sometimes required.
How can I prevent Achilles tendon pain?
Whilst it may not be possible to prevent Achilles tendon pain, by taking the following steps you can minimize your risk:
- Wear appropriate footwear for the type of activity you are participating in; your sports podiatrist can make recommendations for you, as there is a lot of confusing (and sometimes conflicting!) information out there
- Always aim to carry out correct technique when you exercise, so that you minimize the stress on the Achilles tendon
- Ensure that you take the time to warm up and cool down properly and appropriately for your chosen activity
- Incorporate stretching and strengthening sessions into your training regime, so that you can maintain muscle strength and flexibility
- Increase the intensity and duration of your exercise gradually, and allow adequate recovery time between sessions
- Strap or tape your ankle (if your sports podiatrist advises that it is safe and beneficial to do so); this may assist with keeping the ankle structure secure
- Avoid any activity that causes Achilles tendon pain and if you feel any sudden discomfort, stop exercising right away and begin the RICE procedure until you can seek medical attention.
Please note that the information detailed above should not be taken as general advice and is for informational purposes only. If you are experiencing Achilles tendon pain or suspect that you may have a tendon injury, you should consult with a qualified sports podiatrist to discuss your individual condition. You can make an appointment online at the following website www.sydneypodiatrist.net.au or by calling 93883322.