Achilles tendon is the strongest tendon in the body and attaches the calf muscles to the back of the heel bone. Achilles tendon is used with every single step we take in daily life. Due to being overused it becomes unable to adapt to the excessive strain that it undergoes. This results in micro-trauma within the tendon fibres, which then continually try to repair themselves leading on to develop an abnormal scar tissue and often a firm lump.
What are the symptoms?
Achilles tendinopathy commonly presents as pain behind the heel and stiffness in the ankle which is typically worse in the morning. This usually eases up in the following 1 to 2 hours and may become worse again towards the end of the day. It is a common condition and is generally seen in individuals who are very active in sports and running. It can affect people of all ages and both genders but has a higher incidence after the age of 30 years.
Usually associated risk factors include higher body mass index, diabetes, tight calf muscles, lower core strength in the lower limb muscles and high sporting activities. Inadequate running activities and poor choice of footwear aggravates the condition.
Tendinopathy can either involve the middle portion of the tendon or its insertion to the back of the heel bone. Localisation of the symptoms varies depending on the involvement of either part of the tendon.
Diagnosis is based on the history of symptoms and any associated factors, and is confirmed by an MRI scan, which also helps to exclude any other possible causes for symptoms.
You require an ankle specialist to assess your symptoms, help in making the correct diagnosis and guide you appropriately for managing your symptoms in a timely manner.
First line management is always conservative and helps in improving symptoms/resolution in over 90% individual in about 3 to 6 months provided an appropriate compliance with the suggested treatment methods.
This remains the main stay of the management of this condition and is best performed under supervision of a physiotherapist and home exercises on regular basis. This involves stretching of the calf muscles on a gradual basis. It gradually increases the strain on the calf muscles and the Achilles tendon in a controlled way. However, this requires a significant amount of effort and will only work if done properly with a good compliance for 3 to 6 months. Physiotherapy is likely to increase the symptoms initially but gradually eases them with continuation of exercises.
In addition to physiotherapy, the following methods supplement the management:
Applying an ice pack of ice in a towel locally to the painful area on regular basis usually helps. This should be applied for about 5 to 10 minutes 3 times a day taking care of the local skin.
Simple painkillers and anti-inflammatory, both oral and topical, assist in a gradual settlement of symptoms. These are particularly important to take before and after exercises to improve the compliance with physiotherapy. Unless any contraindications, you must not be hesitant in a careful use of painkillers as 'don't like to take painkillers' approach will not help the condition.
Use of soft heel cushions helps in raising the heel and taking some of the strain off the tendon. In combination with other treatments, a regular use of such insoles with a good compliance assists in resolving the symptoms.
Avoid strenuous activities:
During the recovery, adjusting the fitness activities can help. Avoid heavy impact running and significant load-bearing activities and replace them with swimming and cycling to prevent a constant load on the tendon. You can restart these activities as the recovery progresses with ongoing measures and symptom resolution.
As a next step in management, should the above measures fail to provide any benefit after a religious use for about 3 to 6 months, there is an emerging role of PRP (platelet rich plasma) injection; however, this must be at the discretion of your treating ankle surgeon and may not work in every case.
Steroid injections are best avoided in/around/close to any tendon due to causing a higher risk of spontaneous rupture of the tendon.
There is some emerging evidence in literature that addition of shockwave therapy may provide an added benefit (about 30% to 40%) in addition to the above measures. However, this treatment is not widely available in every hospital and may require exploring in the private sector.
More than 90% individuals make a satisfactory recovery of majority of their symptoms with a regular use of the above approach. Very few cases may be resistant and may require surgery.
Surgery for the Achilles tendon requires a thorough consideration and prolonged recovery duration with the regular input from a physiotherapist. It carries risks, primarily of wound related problems, in addition to other usual risks of any lower limb surgery that include blood clots, stiffness, reduced function, rupture of the tendon and incomplete resolution of symptoms. Recovery from surgery is expected to take 6 to 9 months to achieve an appropriate tendon strength and function.
In summary, Achilles tendinopathy is a common condition associated with certain risk factors. Treatment is primarily non-surgical and requires an appropriate advice and guidance from ankle surgeons and physiotherapists. Most individuals, with a good level of compliance, achieve a satisfactory level of symptom resolution in about 3 to 6 months.