Overcoming Your Achilles Heel: Understanding Achilles Tendon Injuries
In today’s blog we are going to explore Achilles tendon pain.
The Achilles tendon is the Big Kahuna as far as tendons go within the body so let’s take a deeper look at the anatomy, how we develop injuries there, and how to properly heal it so that your Achilles tendon does not become your Achilles heel!
Anatomy of the Achilles tendon
Tendons are made of fibrous connective tissue called collagen (for the most part) and attach muscle to bone (v. ligaments which attach bone to bone to form a joint).
The Achilles tendon attaches the calf muscles (the gastrocnemius and soleus) to the heel bone (the calcaneus). It is the largest and thickest tendon in the human body and can withstand great amounts of tensile load and stretch to allow us to perform activities like jumping or squatting.
The general term given to a tendon injury is “tendinopathy.” This is an umbrella term that includes various conditions such as tendonitis, tendinosis, or tendon rupture for example.
What is the difference between a “tendonitis” and a “tendinosis,” you ask?
Tendonitis is the irritation or inflammation of a tendon. This is typically considered an acute injury that can fully recover and heal to nearly its original state.
Tendonosis is a chronic non-inflammatory injury that has progressed to degenerative structural change of the tendon. This is often the result of repetitive stress or re-injury of the tendon if it is not given adequate time and treatment to heal.
You can essentially think about it like this: if you have frequent recurring tendonitis (that goes unaddressed) it may progress to a tendinosis.
How do we develop Achilles tendon pain?
Not all Achilles tendon pain is the same.
There are a few different ways in which we can develop Achilles tendon pain, all of which affect a different portions of the tendon.
Let’s break down how different mechanisms cause injury to different portions of the tendon.
1) Tensile Stretch Mechanism = Midtendon Tendinopathy
First, we can injure the Achilles tendon by a rapid tensile stretch like from jumping or performing different types of plyometric work. Volleyball and basketball players are more likely to develop pain in this manner.
Injury from jumping is most likely going to affect the middle of the Achilles tendon a few centimeters above where it attaches to the heel bone. This would be referred to as a Midtendon tendinopathy.
2) Compression Mechanism = Insertional Tendinopathy
Second, we can injure the Achilles tendon through compression of the tendon where it inserts on the heel bone. Compression over the tendon causes wear and tear over time. Activities that can result in this type of injury include squatting, lunging, or running uphill.
Compressive stress on the Achilles tendon is called insertional tendinopathy, as the irritated portion of the tendon is at the insertion point to the heel bone.
3) Friction Mechanism = Peritendonitis Tendinopathy
Third, we can injure the Achilles tendon by creating excessive friction along the tendon under low load. This type of friction can occur with long bike rides, with rowing or even high backed shoes that rub the Achilles.
This last form of injury caused by friction actually does not irritate the tendon itself but the connective tissue sheath surrounding it called the peritendon. While technically categorized as a peritendonitis, it still falls under the tendinopathy umbrella.
This image illustrates the location of each tendinopathy described above.
Treatment and rehab look different based on the specific mechanism of injury and which portion of the tendon is involved. For this reason, having an understanding of which portion of the tendon is involved and whether it’s more acute (tendonitis) or chronic (tendinosis) can help to be more specific in approaching treatment.
How to properly heal a tendon injury
The first step that your doctor should take toward healing an Achilles tendon injury is to determine the functional load capacity of the tendon.
What does that mean?
It means testing how much stress or tension your tendon can currently withstand.
This can be done with a series of different orthopedic and functional tests. For example, performing different types of heel raises or repetitive jumps.
Depending upon how the pain is reproduced and where the pain is felt, in addition to learning what mechanism caused the original injury, your doctor can determine how to move forward with treatment and rehabilitation.
Treatment should include manual therapies such as myofascial release or instrument assisted soft tissue mobilizations to the calf muscles and soft tissues surrounding the tendon (not applied directly to the inflamed tendon).
Evaluation of the ankle’s range of motion will also be important in determining why the injury occurred.
Here’s a quick screen you can do at home to check your own ankle mobility!
As with many other types of injuries (and what you might intuitively assume) you must eliminate any activities that are currently causing pain.
For example; jumping (box-jumps, jump rope, etc.), stretching (lunges, uphill running, etc.), or creating friction (rowing, biking, shoes that put pressure/rubbing on the Achilles, etc.) can continuously overload the tendon and prevent healing, so they should be avoided for the time being.
Pushing through pain with a tendon injury can lead to chronic pain and structural changes that make the tendon vulnerable to injury from consistent overloading over time.
NOW, that does not mean that the answer is to completely rest the tendon and to “let it heal on its own.” That is unfortunately not how it works with tendons.
Injured tendons require a delicate balance between rest and progressive loading in order to heal and regain strength.
If the tendon were to be completely rested it would slowly become weaker and weaker, which ultimately increases the risk of re-injury (or more significant injury) when you eventually return to your activity.
So what is the answer? Build the load tolerance of the tendon back up (aka exercise)!
Your doctor will be able to help form a home rehab program that allows you to progressively build strength and resiliency within the tendon by prescribing specific exercises. We often start with isometric exercises before progressing to isotonic and eventually eccentric focused exercises.
Gradually, as pain begins to decrease and the load capacity of the tendon increases we can start to re-introduce the activities that you love to do and get you back to moving like you used to.
If you have been struggling with heel pain that you think might be from an Achilles tendon injury don’t hesitate to reach out with questions or book an appointment with our easy online booking system.
