Achilles Tendon Injuries

CONSIDERATIONS IN THE MANAGEMENT OF ACHILLES TENDINOPATHY

As a general rule, clinical treatments directed at effecting change in tendon structure or pathology are the way to go. Treatment approach should vary depending on what stage of the continuum your tendon presentation is consistent with. Loading a reactive tendon will not be beneficial and resting a degenerative tendon will not promote the much needed cell activity and reorganization of the tendon matrix. 

Reactive tendon: Load management

• Load management will allow your tendon time to adapt and tendon cells to become less reactive. A reduction in load is also likely to have a positive impact on pain. This is particularly important for exercises with a high level of energy storage and release through the calf and achilles, such as hill running or speed efforts.
• Assessment and modification of the intensity, duration and frequency of load is the key clinical intervention.
• Tendon load without energy storage and release such as loaded calf raises can be maintained and should be considered in regards to injury prevention measures. 
• High load elastic or eccentric loading, particularly with little recovery time will tend to aggravate tendon cells at this stage. 

Late dysrepair / degenerative tendon: stimulation of cell activity / eccentric exercise 

• Treatments that stimulate cell activity, increase protein production and restructure the matrix are most appropriate. 
• Eccentric exercise has been shown to affect both tendon structure and pain and to increase collagen in abnormal tendons. 
• Eccentric exercise has also been shown to be an effective pain relief treatment. 
• Other, more invasive treatment options (Extracorporeal Shock Wave Therapy; Prolotherapy (ABI; PRP); Cortisone Injections; Surgery) exist, however the most appropriate choice is dependent on the individual tendon, person and response to conservative management.

PERITENDONITIS AND TENOSYNOVITIS

Peritendonitis and tenosynovitis are two similar conditions which may present as tendon pain, both characteristed by inflammation of different components of the outer sheath of a tendon. Both conditions may be present in conjunction with tendinopathy. Typically, peritendonitis and tenosynovitis will behave differently to tendinopathy and thus need to be managed in different ways. 

The role of the tendon sheath is to encase and allow proper movement of the tendon around surrounding tissues. Inflammation of the tendon sheath may even result in impaired movement of the encased tendon unit. This is typically caused by overload, however in rarer cases may also be the result of rheumatological or other non-musculoskeletal causes. As such, a detailed history is required to exclude these other potential causes.

Peritendonitis and tenosynovitis may present with inflammation surrounding the affected tissue. Pain provocation will typically occur with low load, repetitive movement. This is distinctly different from cases of symptomatic tendinosis, where higher magnitudes of load are typically required to aggravate symptoms. Where movement of the tendon unit within the sheath is affected, audible clicking (also known as crepitus) may be heard.

CONSIDERATIONS FOR MANAGEMENT OF PERITENDONITIS / TENOSYNOVITIS

SHORT TERM

• Non-steroidal anti-inflammatory drugs

Given that peritendonitis and tenosynovitis have distinct inflammatory properties, management will differ from those with isolated tendinopathy. Anti-inflammatories can aid recovery and settle the inflammatory process. Always consult your GP or pharmacist before taking any medication.

• Load management / rest

Unlike tendinopathy, tenosynovitis and peritendonitis often require a more significant reduction in load. In some instances, rest is required to allow the tendon sheath to recover. 

• Soft tissue techniques/dry needling

These modalities can assist with soreness and discomfort in surrounding tissues.

LONG TERM

• Load management

This may include scheduling rest days, reducing the frequency of high intensity sessions or programming de-load weeks, ultimately giving the tendon sheath more time to recover from training. 

• Strengthening/plyometrics

Rehabilitation will generally begin with isometric strengthening exercises (i.e., static holds where the calf is working without going through range of motion). This variation is a great starting point, as movement is a typical aggravator of tendon sheath pathology. 

• Run technique

There are variances in running technique which may increase load directed through the achilles. Modification of technique may reduce the magnitude of load going through the achilles during running.