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Named after the greek god Achilles, whose primary weakness was a wound on his heal, this tendon can present a significant barrier to regular exercise and daily functional life. The primary function of the Achilles tendon is to transmit and absorb energy from calf to foot and vice versa, as occurs during propulsion phase of gait and during the landing phase of running. As with all tendons, loading is the single most important factor in determining overall tendon health.

The term Achilles tendinopathy has superseded ‘achilles tendinitis’ and is an overuse injury that involves overloading of tendon tissue. As mentioned in a previous issue of fitstyler, tendon tissue is comprised of a collagen matrix, tendon cells, fluid and large protein molecules. A combination of compressive and tensile loading of tendon tissue can potentially irritate and cause hyperactivity of the tendon cells, and produce noxious chemicals that cause pain. This is termed reactive tendinopathy and is typically associated with an acute flare up over 1 to 4 weeks. An example of this is your novice fitness buff who decides to run 10km 5 x per week after an extended period of inactivity. Treatment for this stage of tendinopathy typically involves removal of the insulting load (rest from running), followed by a graduated loading program, correction of foot mechanics (if required), and strengthening of the shock absorbing muscles of the lower limb. If suitable management is implemented early, these tendons can resolve in 2-4 weeks.

If left untreated, reactive tendinopathy can progress into tendon dysrepair. This involves not only cellular hyperactivity and pain causing chemicals, but weakening of the collagen matrix. This stage can be anywhere from 4 weeks to 12 months, and is a lot harder to fix than the reactive type. Treatment involves a graduated tendon loading program to stimulate turnover in collagen, while increasing strength, muscle bulk and power of the calf and entire lower limb. It is typical to have global muscle wasting through calf, quads, and gluteals of the involved leg secondary to pain avoidance. Innovative techniques such as blood injections and shock wave therapy have become popular in recent times and can facilitate the rehabilitation process. These techniques must be approached with caution as they do not provide a ‘miracle cure’, rather, they can produce some pain relief in order to complete the rehabilitation process.

The end of the line for Achilles tendinopathy is the degenerative stage. These are the tendons that grumble away for 12 months or greater. There tends to be significant breakdown of the collagen matrix and micro-tears in the tendon start to appear. This stage is quite difficult to fix and involves similar management to the disrepair type. We may try some blood injections, graduate some loading and strengthen the lower limb. Sometimes this stage is irreversible (ie. 3-5 years with micro-tearing) and we simply aim at pain relief without fixing the intra-tendinous changes.

So it seems that early intervention is paramount in reversing the tendinopathy model, but how do we prevent it developing in the first place? The first and most crucial hint is to maintain a consistent load on the tendon and increase in a graduated manner. This may involve doing some calf raises, skipping etc. during any extended rest periods from running. It also implies increasing running volumes, intensity, frequency in a controlled manner, changing only one variable at a time. Maintaining a nice muscular leg through thigh, gluteals and calf will not only increase your level of attractiveness, it will prevent tendinopathy! Similarly some studies have linked an increase in abdominal girth with tendinopathy, so ditch the beer belly and you may avoid Achilles problems! Maintenance of a consistent aerobic program which includes lower limb strength training, with slow and steady increases in running load, equates to a happy pain free Achilles tendon.

Shane O’Sullivan

Sports Physiotherapist
Prahran Sports Medicine Centre