Assessing and Treating Achilles Tendinopathy: A Comprehensive Guide for Evidence-Based Chiropractors
Achilles tendinopathy (AT) is one of the most common overuse injuries, particularly among athletes. While the Achilles tendon is the largest and strongest tendon in the human body, it is also highly susceptible to strain and degeneration due to its crucial role in walking, running, and jumping. Understanding the etiology, clinical presentation, and evidence-based treatment protocols for Achilles tendinopathy is essential for chiropractors seeking to provide effective care. This blog explores the latest research on assessing and treating Achilles tendinopathy, focusing on non-invasive, evidence-based approaches.
Causes of Heel Pain
The Achilles tendon is vital for movement, especially during the push-off phase of gait. When a person runs, the Achilles can experience forces up to 12.5 times their body weight. These forces place the tendon at risk of injury, particularly during high-impact and repetitive stress activities. Achilles tendinopathy typically results from repeated overloading and microtearing of the tendon fibers. Unlike acute injuries that involve inflammation, tendinopathy leads to failed healing, with collagen fibers disrupted and restructured in an ineffective way. This leads to tendon degeneration rather than regeneration.
Achilles tendinopathy can occur in two primary forms:
Insertional Tendinopathy: This form affects the tendon’s attachment to the calcaneus (heel bone), often causing painful bony spurs known as Haglund’s deformity.
Non-Insertional Tendinopathy: This is more common and typically occurs 2-6 cm above the tendon insertion. The mid-portion of the tendon is more susceptible due to its relative lack of blood supply and repetitive strain.
Want to learn more about differentiating between Insertional and Non-Insertional Achilles Tendinopathy? Read this blog with the attached video.
Several factors can predispose individuals to Achilles tendinopathy:
Extrinsic risk factors include overtraining, improper footwear, running on hard surfaces, and poor warm-up routines.
Intrinsic risk factors include abnormal foot mechanics (e.g., hyperpronation), poor calf muscle flexibility, and limited dorsiflexion.
Systemic conditions like diabetes, hypertension, and the use of certain medications (e.g., corticosteroids or fluoroquinolone antibiotics) can also increase the risk.
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Athletes, particularly runners, are at the highest risk for developing Achilles tendinopathy, with running sports accounting for more than half of all cases. Notably, runners who use a forefoot strike pattern or who engage in speed training are more prone to injury. Interestingly, previous Achilles injuries significantly increase the risk of future tendon issues, particularly in the contralateral tendon.
Symptoms of Achilles Tendinitis
The clinical presentation of Achilles tendinopathy varies depending on whether the condition is acute or chronic. Patients typically report pain and tenderness in the tendon, particularly during activity. Pain is often most noticeable when walking, running, or performing exercises that involve standing on the toes. Morning stiffness and pain that worsen throughout the day, especially with increased activity, are hallmark symptoms. Tenderness can be localized to the mid-tendon or the calcaneal insertion, depending on the type of tendinopathy.
Diagnostic tests that can help confirm the diagnosis include:
Palpation: Localizing the pain can help differentiate between insertional and non-insertional tendinopathy.
Functional tests: Resisted plantarflexion (e.g., single-leg heel raises) often elicits pain. The Thompson test (calf squeeze) is useful for excluding Achilles rupture.
Imaging: While clinical assessment is usually sufficient, advanced imaging techniques like ultrasound or MRI can help confirm tendon thickening and identify structural damage.
Single Limb Heel Raise
Causes of Achilles Tendinitis
Proper assessment is crucial in identifying contributing factors that may perpetuate Achilles tendinopathy. Ankle range of motion (ROM) and strength tests can help determine areas of dysfunction. Limited ankle dorsiflexion, weakness in the posterior tibialis, and tightness in the gastrocnemius or soleus muscles are common findings in individuals with Achilles tendinopathy.
Hyperpronation: Runners with Achilles tendinopathy often display excessive subtalar eversion (hyperpronation), which places additional strain on the tendon. Observing for "too many toes" and assessing for navicular drop can help identify this issue.
Hip and knee dysfunction: Weakness or delayed activation of hip abductors (e.g., gluteus medius) and knee flexors (e.g., hamstrings) is another risk factor for Achilles tendinopathy. Functional tests like the Trendelenburg sign, overhead squat, and single-leg squat can help identify these deficits.
Hallux limitus: A limitation in dorsiflexion of the first metatarsophalangeal joint has been linked to Achilles tendon pain
Assessing for functional hallux limitus may help identify underlying foot stability issues.
Treatment of Achilles Tendinitis
The treatment of Achilles tendinopathy should be multifaceted, addressing both the symptoms and the underlying mechanical causes. Non-operative management remains the cornerstone of treatment, with conservative approaches often yielding excellent outcomes.
1. Eccentric Exercise Rehabilitation
Eccentric loading exercises have the most robust evidence supporting their effectiveness in treating Achilles tendinopathy. A well-researched program developed by Alfredson involves performing single-leg heel drops off the edge of a step. This exercise should be done with both a straight and bent knee to target both the gastrocnemius and soleus muscles. Repetitions should be slow (4-10 seconds per rep), with patients gradually progressing to higher volumes as tolerated. Studies suggest that eccentric exercises reduce pain, improve function, and promote tendon healing.
2. Soft Tissue Therapy
Myofascial release, stretching, and soft tissue mobilization can improve flexibility and reduce stiffness in the calf muscles. Techniques like foam rolling and instrument-assisted soft tissue mobilization (IASTM) are beneficial for releasing adhesions and promoting tendon healing. Stretching should target both the gastrocnemius (knee straight) and soleus (knee bent) muscles.
3. Correcting Biomechanical Deficits
Addressing underlying biomechanical dysfunction is crucial for preventing recurrence. Orthotics may be necessary to correct foot pronation, while heel lifts can help reduce tension on the Achilles tendon by minimizing dorsiflexion stress. For patients with hallux limitus, shoe inserts with a cut-out under the first metatarsal head may improve foot stability and reduce tendon strain.
4. Activity Modification
Reducing the intensity and volume of high-impact activities like running is key in the initial stages of rehabilitation. Switching to low-impact exercises like cycling or swimming can help maintain fitness without exacerbating symptoms. Runners should gradually increase their distance and intensity by no more than 10% per week to prevent overload.
5. Advanced Therapies
In cases of chronic tendinopathy that fail to respond to conservative treatment, therapies like extracorporeal shockwave therapy (ESWT) or platelet-rich plasma (PRP) injections may be considered. These treatments aim to stimulate healing by promoting fibroblast activity and collagen repair. However, the evidence for their efficacy remains mixed, and they should be considered only after conservative measures have been exhausted.
6. Surgical Management
Surgery is typically reserved for severe cases, such as those involving tendon rupture or significant structural damage. Recent studies suggest that conservative management may be as effective as surgery in many cases, with similar long-term outcomes.
Conclusion
Achilles tendinopathy is a complex condition that requires a multifaceted approach to treatment. Evidence-based strategies, including eccentric exercise rehabilitation, soft tissue mobilization, and biomechanical correction, are crucial for promoting tendon healing and preventing recurrence. Chiropractors who adopt these evidence-based practices can offer their patients effective, non-invasive treatment options for managing Achilles tendinopathy and improving long-term outcomes.
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