Achilles Tendon Problems

Scroll Down
What is it?

Failure of the Achilles tendon to repair itself following injury. The Achilles tendon is the largest tendon in the body which connects the calf muscle to the heel. It may be Insertional (where it inserts into the heel bone) or Non-Insertional (in the mid portion of the tendon).

What causes it?

Repetitive stress to the tendon causing an ‘overuse injury’. This may be due to a sudden increase in activity or tight calf muscles placing extra strain on the tendon. Microscopic tears are produced and the body attempts to heal these with a painful inflammatory response.

What are the symptoms?

Pain in the tendon (Non-Insertional) or the heel (Insertional), in the morning or on activity. Pain the day after exercise. Due to chronic inflammation, the tendon may become thickened due to scar tissue or calcium deposits. If you experience a sudden painful ‘pop’ in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. You should see Mr Sugathan immediately.

How is it diagnosed?

Mr Sugathan will take a thorough history and examination and perform radiographs (x-rays) and this is normally sufficient to make a diagnosis. It is important to rule out other problems, which is why a review by an experienced foot and ankle specialist is often necessary. Sometimes an ultrasound may be required, this is useful to assess new blood vessel formation (neovascularity) which can guide treatment (picture below). Occasionally, an MRI scan may be needed to assess the tendon and other structures.

Ultrasound of Achilles tendon showing a thickened tendon and new blood vessel formation (neovascularity) (red and orange dots)

How is it treated?

There are a host of treatments purported to be of benefit in Achilles tendinopathy, many have very little scientific evidence to support their use. Mr Sugathan will recommend evidence based treatments for you and if these do not work, he will discuss with you other options, which may not have such strong scientific evidence, but are worth trying, after informed consent.

Activity Modification

In the first instance, treatment is by modifying your activities that are painful and taking anti-inflammatory tablets (Ibuprofen, Diclofenac). Ice packs can also give relief.

Eccentric Stretching Protocol

These are the most important exercise to do, performed under the guidance of a musculoskeletal physiotherapist. The aim is to stretch the Achilles tendon. Expect some discomfort and continue through it, unless severe. The protocol will gradually get harder as you get used to the exercises. Calf muscle soreness and increased pain in the Achilles insertion may occur during the first 2 weeks of the programme.

The Achilles Tendon Eccentric Stretch
  • Stand on a step with both feet, with the balls of your toes on the step and with your heels off the step
  • Keep your knees straight. Hold something if needed for balance
  • Stand just on the painful leg
  • Lower your painful heel down over the step, over a 2 second period. Hold the stretch for 5 seconds
  • Now stand on the other leg, taking your weight off the painful side and push up, straightening your knee
  • Bring the painful leg back onto the step, returning to the position in 1.
  • This is 1 repetition (knee straight)
  • Repeat 5 times in total
  • Repeat the stretch again but with the knee slightly bent (20⁰)
  • This is 1 repetition (knee bent)
  • Repeat 5 times in total
  • You have now completed a ‘set’ (10 repetitions done consecutively, 5 x knee straight, 5 x knee bent)
Week 2

3 set of 16 repetitions (8 x knee straight + 8 x knee bent). 1 minute rest between sets. Twice a day

Aim – to complete 3 sets of 16 repetitions with 1 minute of rest between sets, twice a day, 7 days per week, for 12 weeks.

Extracorporeal shock wave therapy (ESWT)

There is good evidence that ESWT works and in combination with an Eccentric Stretching Protocol, it is better than eccentric stretches alone. Three separate treatments spaced approximately a week apart are normally required, each lasting about 5-10 minutes. Significant resolution of pain takes up to 2 months after completing treatment. For private medical insurance purposes, the treatment (CCSD) code is 3 sessions of T7250.

PRP (Platelet Rich Plasma) injection

There is some evidence that PRP injection is effective for treating chronic Achilles tendinopathy not responding to conservative management

Surgical treatment

As a last resort, when the above treatments have not worked, certain surgical procedures can be performed on the Achilles tendon.