Posterior heel

Achilles Tendinopathy

Significant history and physical symptoms

Achilles tendon disorders are among the most frequently reported overuse injuries in the literature. While the majority of cases involve individuals who engage in recreational or competitive sport, inactive sedentary groups can be affected. There is an increased prevalence as age increases with a mean reported age of between 30 and 50. There is little evidence to suggest prevalence in any gender group.

The pathophysiology of tendinopathy remains unclear. Whilst primarily considered a repetitive overuse phenomenon, many other molecular processes including inflammation, apoptosis, hypoxia and neuronal dysfunction have all been implicated in the ultimate process of matrix dysregulation, which causes an imbalance in collagen production giving rise to the pathological tendon seen in tendinopathy.

Symptoms may also include swelling that is quite tender to the touch. Standing, walking, and constrictive shoe wear typically aggravate symptoms. Many patients with this problem are middle-aged and some may be slightly overweight. Another group of patients who suffer from this condition are young, active runners.

The terms tendinitis, tendonitis and paratendonitis have been used but are the collective term tendinopathy encompasses all these historical descriptions. Tendinopathy is clearly defined as painful conditions occurring in and around tendons in response to overuse.

• Pain at the insertion or mid portion of the tendon
• Intermittent pain related to exercise or activity
• Stiffness upon weight bearing after sleep or rest
• Relieved with exercise
• As condition progresses, pain occurs towards the end of activity and then during the activity until activity has to be suspended
• Resisted plantarflexion and passive dorsiflexion increases pain
• Crepitus in tendon which reduces in cases of tendonosis
• Painful to tip-toe or climb stairs
• Pain on palpation of the tendon 2-6 cm from its insertion
• Decreased plantarflexion strength on affected side
• Decreased plantar flexor endurance. Ask patient to perform repetitive unilateral heel raises on the affected side and the contralateral side
• Painful arc test to determine the location of the swelling within the tendon

Painful Arc test video

Intrinsic factors associated with Achilles tendinopathy:

• Abnormal ankle dorsiflexion range of motion
• Abnormal subtalar range of motion
• Decreased plantarflexion strength
• Increased subtalar pronation
• Abnormal tendon structure

Infographic on Intrinsic/Extrinsic factors

Tendinopathy can present in 2 different locations:

• Mid-portion - when pain occurs 2-6cm proximal to the calcaneal insertion
• Insertional - when symptoms occur at the insertion of the Achilles tendon

Achilles Tendon Rupture

Significant history and physical symptoms

As 30% of Achilles tendon ruptures are almost asymptomatic, these should be ruled out with immediate referral to orthopaedics if suspected.

• Sudden onset of pain
• Audible snap
• Inability to plantarflex ankle
• Visible palpable defect in tendon
• Positive Thompson’s squeeze test

Thompson test video

Less Common Differential Diagnoses not included in this pathway:

• Haglund Deformity (“Pump Bump”)
• Calcaneal Fracture
• Retrocalcaneal Bursitis
• Posterior ankle impingement
• Irritation or neuroma of the sural nerve
• Os trigonum syndrome
• Accessory soleus muscle
• Achilles tendon ossification
• Systemic inflammatory disease
• Tenosynovitis
• Dislocation of the peroneal or other plantar flexor tendons

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient. 

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

Leaflet on Achilles Tendinopathy

Reasons to Escalate to 2nd line intervention immediately:

• Suspected Achilles tendon rupture

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
  
  
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Increased width of heel sole / increase support around ankle
  • Give leaflet to reinforce verbal advice
  • NHSGGC Footwear Advice Leaflet
• Alternative Shoe Lacing Options
• Heel Raise
  • These can be given bilaterally so as to avoid Leg Length Discrepancy if required.
  • A heel raise may reduce the rate of loading and tensile stress on the tendon
  • They should only be used in the short term
• Orthoses/insoles
  • Orthoses and insoles are usually an adjunct to a loading based programme and should only be issued with a clear rationale.

• Exercise Prescription
  • Recent evidence suggests that the type of contraction (i.e.Concentric or eccentric) is not as important as was once thought, its the load that is important so loading based program to be selected on an individual basis to ensure compliance. See Alfredson, Silbernagel or Kongsagaard are all examples of exercise programs that may be used depending on the individual patient. Check evidence below for more information on these and other programs.
  • Isometric loading exercises may be useful in the early stages for pain relief but this has yet to be clearly proven for the Achilles tendon
  • Effect of eccentric exercise greater in mid portion Achilles tendinopathies compared to insertional, response to eccentric exercise appears much lower in insertional tendinopathies compared to mid-portion tendinopathy

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Low Level Laser Therapy LLLT
  • Some limited evidence but more research needed to determine optimum dosage to provide a significant effect
• Therapeutic Ultrasound
• Non-Steroidal Anti Inflammatory Drugs (NSAIDS) are not evidenced to be effective in Achilles Tendinopathy
• Acupuncture/dry needling
• Manual therapy
• GTN patches while not hugely researched may help some if conservative measures fail
• Shockwave. Emerging evidence may show this to be effective for pain relief.
• PRP (plasma rich protein) Injections
• Taping
• Corticosteroid injection
  • Potential risk of spontaneous tendon rupture if steroids are administered in or around the tendon (Speed, 2001) therefore not recommended. Steroid injection should be administered under ultrasound guidance to minimise risk of tendon rupture.
  • Studies have shown that corticosteroid injection may ease pain in the short-term, but long-term results show no significant difference.

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Biomechanical assessment and prescription of Foot Orthosis:

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records
• These should only be used as an adjunct to a loading based exercise programme
• While studies have shown that biomechanics are altered in the patient with Achilles tendinopathy, there is limited evidence for orthoses improving pain
• Night Splinting
  • Allows structures under strain to rest overnight in a functional position allowing any healing which takes place to be in a correctly loaded position.
  • Dorsal night splints apply the same functional effect as plantar splints but have been shown to be more effective due to better comfort and hence increased patient compliance.

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include: hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate.

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics:

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery).
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your ESP Orthopaedic Clinician if you are unsure whether to refer.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Alfredson, H. and Lorentzon, R., 2002. Chronic tendon pain: no signs of chemical inflammation but high concentrations of the neurotransmitter glutamate. Implications for treatment?. Current drug targets, 3(1), pp.43-54.
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Allison, G.T. and Purdam, C., 2009. Eccentric loading for Achilles tendinopathy—strengthening or stretching?. British Journal of Sports Medicine, 43(4), pp.276-279.
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Aström, M. and Rausing, A., 1995. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clinical orthopaedics and related research, (316), pp.151-164.
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Baxter, J.R., Corrigan, P., Hullfish, T.J., O'Rourke, P. and Silbernagel, K.G., 2020. Exercise Progression to Incrementally Load the Achilles Tendon. Medicine and Science in Sports and Exercise.
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Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M. and Magnusson, S.P., 2015. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. The American journal of sports medicine, 43(7), pp.1704-1711.
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Carcia, C.R., Martin, R.L., Houck, J., Wukich, D.K., Altman, R.D., Curwin, S., Delitto, A., DeWitt, J., Fearon, H., Ferland, A. and MacDermid, J., 2010. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 40(9), pp.A1-A26.
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Cook, J.L., Khan, K.M., Maffulli, N. and Purdam, C., 2000. Overuse tendinosis, not tendinitis: Part 2: Applying the new approach to patellar tendinopathy. The Physician and sportsmedicine, 28(6), pp.31-46.
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de Vos, R.J., Heijboer, M.P., Weinans, H., Verhaar, J.A. and van Schie, H.T., 2012. Tendon structure’s lack of relation to clinical outcome after eccentric exercises in chronic midportion Achilles tendinopathy. Journal of sport rehabilitation, 21(1), pp.34-43.
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Donoghue, O.A., Harrison, A.J., Laxton, P. and Jones, R.K., 2008. Orthotic control of rear foot and lower limb motion during running in participants with chronic Achilles tendon injury. Sports Biomechanics, 7(2), pp.194-205.
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Fenwick, S.A., Hazleman, B.L. and Riley, G.P., 2002. The vasculature and its role in the damaged and healing tendon. Arthritis Research & Therapy, 4(4), pp.1-9.
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Gill, S.S., Gelbke, M.K., Mattson, S.L., Anderson, M.W. and Hurwitz, S.R., 2004. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy: a safety study. JBJS, 86(4), pp.802-806.
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Grävare Silbernagel, K., Thomee, R., Thomee, P. and Karlsson, J., 2001. Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Scandinavian journal of medicine & science in sports, 11(4), pp.197-206.
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Jonsson, P., Alfredson, H., Sunding, K., Fahlström, M. and Cook, J., 2008. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British journal of sports medicine, 42(9), pp.746-749.
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Kannus, P., Jozsa, L., Natri, A. and Järvinen, M., 1997. Effects of training, immobilization and remobilization on tendons. Scandinavian journal of medicine & science in sports, 7(2), pp.67-71.
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Knobloch, K., 2007. Eccentric training in Achilles tendinopathy: is it harmful to tendon microcirculation?. British journal of sports medicine, 41(6), pp.e2-e2.
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Lowdon, A., Bader, D.L. and Mowat, A.G., 1984. The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial. The American Journal of Sports Medicine, 12(6), pp.431-435.
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Martin, R.L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J.W., McDonough, C.M., Paulseth, S., Wukich, D.K. and Carcia, C.R., 2018. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 48(5), pp.A1-A38.
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Nørregaard, J., Larsen, C.C., Bieler, T. and Langberg, H., 2007. Eccentric exercise in treatment of Achilles tendinopathy. Scandinavian journal of medicine & science in sports, 17(2), pp.133-138.
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Öhberg, L., Lorentzon, R. and Alfredson, H., 2004. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British journal of sports medicine, 38(1), pp.8-11.
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Paoloni, J.A. and Murrell, G.A., 2007. Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. Foot & Ankle International, 28(10), pp.1064-1068.
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Plinsinga, M.L., Van Wilgen, C.P., Brink, M.S., Vuvan, V., Stephenson, A., Heales, L.J., Mellor, R., Coombes, B.K. and Vicenzino, B.T., 2018. Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles. British journal of sports medicine, 52(5), pp.284-291.
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Roos, E.M., Engström, M., Lagerquist, A. and Söderberg, B., 2004. Clinical improvement after 6 weeks of eccentric exercise in patients with mid‐portion Achilles tendinopathy–a randomized trial with 1‐year follow‐up. Scandinavian journal of medicine & science in sports, 14(5), pp.286-295.
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Speed, C.A., 2001. Corticosteroid injections in tendon lesions. BMJ, 323(7309), pp.382-386.
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Thomas, J.L., Christensen, J.C., Kravitz, S.R., Mendicino, R.W., Schuberth, J.M., Vanore, J.V., Weil Sr, L.S., Zlotoff, H.J., Bouché, R. and Baker, J., 2010. The diagnosis and treatment of heel pain: a clinical practice guideline–revision 2010. The Journal of Foot and Ankle Surgery, 49(3), pp.S1-S19.
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Wasielewski, N.J. and Kotsko, K.M., 2007. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. Journal of athletic training, 42(3), p.409.
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Woodley, B.L., Newsham-West, R.J. and Baxter, G.D., 2007. Chronic tendinopathy: effectiveness of eccentric exercise. British journal of sports medicine, 41(4), pp.188-198.
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