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Achilles Tendinopathy

You have been training really well, you are feeling in great shape and then all of a sudden you start to get a little bit of pain in the Achilles.  You think nothing of it, you tell yourself ‘it will go in a while’, you think it’s just a sign of working your muscles hard so they are going to hurt a little.  Wrong!!  You are most likely on the pathway to Achilles Tendinopathy and it can be a turbulent ride.

What we aim to do here though is give a simple break down of what is actually happening in your tendon.

Go back to the 1990’s, any pain arising from a tendon was said to be ‘tendiniTIS’.  I use the capital letters here on purpose to highlight the changes we have seen in diagnosis.  The use of the term ‘IT IS’ refers back to late Greek Latin in which it meant ‘Inflammatory’.  So any medical term with the ending ‘ITIS’ is in reference to the inflammatory stages of a disease.  Back in the 1990’s the treatment of pain in the Achilles centred around the use of NSAID’s (things like Ibuprofen) and corticosteroids (usually injections) to control pain.

The argument developed though to say that in chronic tendinopathy there were are no signs of acute inflammatory cells in the load bearing regions of tendons. As time progressed it became more evident that rather than inflammation it was more likely to be collagen separation, thinning and disruption of the cells in the tendon that was causing the pain.  It therefore became widely accepted that chronic tendinopathy was not a result of inflammation but instead of a range of other factors.  This argument though has been criticised for being too simplistic and mis-leading to assume that all chronic tendinopathy has no inflammation present at all.

Over the past decade or so, it has become widely accepted that the chronic tendon conditions occur due to a degeneration of the tendon itself.  This, however, would be saying that no inflammation is present and would not explain why a course of NSAID’s can help reduce someone’s pain in Achilles tendinopathy.

Current treatments for Achilles tendinopathy centre around loading the tendon.  Sounds crazy right? You would think that surely that last thing you want to do is to work a tendon that already hurts. However, in the mid 90’s, Hakan Alfredson was a clinician who suffered from Achilles heel pain.  After conservative management, he made little or no progress and asked for surgery at the clinic he worked at.  The surgeon’s refused his requests as it was deemed ‘not serious enough’.  They said the only way surgery would be performed is if he ruptured his Achilles.  Hakan Alfredson then set about trying to do exactly this and embarked on an ‘eccentric’ load pathway to try and rupture his Achilles.  To his surprise though, the Achilles didn’t rupture, in fact it became pain free.  From here the eccentric heel drop protocol known as the Alfredson Protocol was invented.  Many clinicians have since used this as their main method of treatment but it has recently been challenged as to whether it is the ‘gold standard’ in tendon healing.  Things such as Heavy Slow Resistance Training (HSR) are being heavily researched at the moment and is being utilised by many clinicians too.

One of the common findings in tendons suspected of being a tendinopathy is something called neovascularisation.  This is basically an abnormal number of blood vessels entering the Achilles tendon when they shouldn’t be.  This entry of blood vessles leads to an increase of nerve endings too being present and it is believed by some that these nerves lead to a higher sensitivity to pain in the region and therefore produce the symptoms we feel.  It is these nerves that are argued causes an inflammatory response too which highlights why we cannot say that all tendinopathy’s are not a result of inflammation.

So what treatments are available to us?  We spoke earlier about the use of eccentric exercises and loading a tendon.  You would likely have heard of corticosteroids.  This is an injection, usually directly into the tendon itself and it helps eliminate pain allowing the performer to carry on with their activity.  It has very short term effects though and the argument always is that it actually increases the risk of further damage later in an athlete’s career (whether that be at amateur level or elite). You also have the classic NSAIS’s treatment (Ibuprofen).  The issue with this treatment though is that these drugs prevent inflammation.  Sounds good though right?  Again, wrong!  In order for muscle or tendon to repair it must have some form of inflammation present.  Inflammation is not necessarily a bad thing; it is needed for cell regeneration and repair.  NSAID’s block this and therefore block the repair pathways.

So to conclude, Achilles Tendinopathy must be a combination of inflammation and degeneration of cells.  Studies have also shown that once degeneration occurs, it cannot be changed.  This sounds daunting, but it shouldn’t be.  Images can be mis-leading.  The key is to ensure the global area of the body (whole of the affected leg in this case) is strengthened to share the load more equally.  Achilles are said to absorb up to 8 times your body weight on ground strike for each step! If greater global strength can be achieved then the demands placed on the tendon are not as great as it is effectively being ‘helped out’ by the other structures.  And remember, no matter what the doctor says, loading is good for tendons.  You need to overcome to reactive part first of course and allow the tendon to settle but long term, loading of a tendon is positive and essential to tendon healing.

Before undertaking any form of recovery/treatment programme, it is essential to see a medically trained professional first who will be able to advise you on the best steps forward for your particular case.  You should never carry these things out on your won without proper guidance. See a specialist clinician as soon as you can to start your road to recovery.

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