Achilles Tendinopathy

Sometimes as a practitioner it is good to suffer from an injury, intially to help understand the emotion that goes with the injury but also to experiment with treatment.   I have experienced Achilles tendinopathy over the last eight months.  Now it has recovered it is hard to say what helped most although I suspect that everything I tried contributed to some extent.


Last week at the first cross country (XC) league event of the year I was chatting to some of the other over 40 year old runners and we started to talk about footwear.   One runner who is new to the XC scene mentioned that he is about to buy some spikes,  inspired by seeing most of the younger members of the team wearing them.   I warned him to be careful (following personal experience) as you really need to be a natural forefoot runner to wear spikes.  After all, the spikes are set at the front of the shoe so if you land on your heel you are more likely to slip over in a pair of spikes.  Also there is no shape or support as they are designed to be as light as possible and effectively be a means of attaching spikes to your feet.    There is very little heel raise, which can potentially be important.   You need to have elasticity in your connective tissue – something that we lose as we age.   There are now plenty of hybrid shoes that have good rubber studs for grip on soft ground as well as providing some structural support and heel lift.


The most significant thing for 40+ runners in their training is ‘change’ – increasing distance, speed, frequency, shoes, style and technique.    While younger runners can simply increase their mileage it is important for older runners to carefully and gradually make changes.


So, a common issue for male runners over 40 is Achilles pain – pain just above the back of the heel.  This can mean several things but here we will assume that this is due to tendinopathy. Tendinopathy is changes to the actual cells within the tendon, a disease of the tendon resulting in thickening.  Rupture is actually less likely once the tendon has thickened.


The onset of this can be gradual with a typical awareness of discomfort after rest for a few steps or minutes and activity will improve the discomfort in the short term.    However it can be quite sudden and as mentioned above it will often follow a change to your training routine.   There will be localised acute tenderness to touch the Achilles and in more chronic cases there will be thickening at the site.  


Treatment is varied and there is no evidence to suggest that one particular thing fixes the problem.   A mixture of Biomechanics, manual therapy and loading exercises will give the best chance of recovery.   Rest from activity is not necessarily required, although management in relation to discomfort is important.   So perhaps reduced frequency, different running surface etc.  You must be honest with yourself.   I recently experienced use of an underwater treadmill at  in Groombridge that I found very interesting and I am sure will provide assistance for those wanting to combine loading with running.


Classic accepted treatment is to follow a regime of eccentric loading (stretching the tendon while loading it) such as lowering your ankle over a step.  More recent theories suggest using heavier weight training techniques three times per week.  Patience is required and a three to six month recovery period is normal.   Most athletes will be desperate for a quick fix but with true tendinopathy this simply will not happen.   I have heard people discuss that manipulating their back fixed their Achilles tendinitis.  However, if that is the case then the pain was referred from the back and was wrongly diagnosed as the Achilles.


It is helpful to ensure that the mechanics – such as position of the ankle and lower limb -are reasonable and that the joints all function to an acceptable level.

 If there are specific restrictions, it would be the same as trying to drive your car with the hand brake on – something will suffer.    As Osteopaths we are experts at improving function of joints through manual therapy and exercise prescription.


Ensure that the muscles of the lower limb, in particular the calf muscles, are kept relaxed through post exercise stretching and sports massage.    They are all part of the connective tissue attachments.   Acupuncture can also assist in keeping the muscle relaxed by working on the receptors.


Other theories that may or may not help are the use of a slight heel raise or using shoes with a higher heel angle. 


However, if conservative management has failed then these are the more radical options you might consider:


Different substances used in injections for the treatment of achilles tendinopathy include:

• Autologous blood (blood taken from you): stimulates a healing process.

• Platelet-rich plasma (centrifuged blood to separate the platelets): stimulates healing.

• Polidocanol: a sclerosant (encourages tissue irritation and subsequent fibrosis) that reduces pain.  

• Steroid mixed with saline at high volumes: stripped around the tendon.

Injections around, but not within, the tendon may help, but the research is really insufficient and inconclusive. The most popular type of injection given at the moment is a high-volume steroid and saline mix. But many are cautious about using steroid near the tendon because of the potential for weakening the surrounding tissue.


There have been quite big advances in surgery and it is possible to have a minimally invasive operation. However, this type of surgery is relatively new and more data is needed to evaluate its effectiveness.