Brief Reflections On Achilles Tendon Pain

Achilles Tendonopathy

Many people experience problems with their achilles tendon. 24% of athletes suffer achilles injuries at some point in their lifes. As we progress in age, we are more prone to achilles issues, and men are three times more likely to have an achilles rupture than women.

The achilles is a common tendon, where three different muscles merge, gastrocnemius, soleus, and the lesser known plantaris. It is the strongest tendon in the body, and works a bit like a spring. When it is stretched during running as the heel hits te ground, it stores energy that is released as we push off the foot minimising the work the muscles have to do. 

The most common ailments are insertional tendinitis, mid-body tendinitis, and paratenonitis.

The first one refers to pain around the achilles attachment to the heelbone, the calcaneous. Mid-body tendinitis affects the achilles tendon further up, closer towards the calf muscles.

The paratenon affected in the latter is a thin sheet of elastin rich cells surrounding the tendon, bundling the tendon collagen fibres into a unit that still allows movement inbetween. Tenosynovitis and tenovaginitis fall in this category. When it gets inflamed, excess fibrin causes adhesions. In a chronic condition, this is simplified scar tissue, less of the healthy collagen type I and too much scar-like collagen III. 

Conservative management includes reducing activity, non-steroidal anti-inflammatory drugs, physiotherapy (eccentric stretching exercises, progressive tendon loading), change of aggravating footwear. 

Extracorporeal shockwave treatment has proven to reduce pain by 60% in persistent tendinopathies without the side effects and risks of surgery. Nevertheless, surgery has its place and is the recommended form of treatment if the tendon is ruptured by at least half. Surgical Therapy has about 80% of success but also depending on the study, up to 40% complications. 

Early treatment promises better outcomes. Extracorporeal shockwave was initially used to break up kidney stones, and has since shown impressive outcomes for musculoskeletal complaints, including achilles and other tendinopathies, and various other pains, such as but not limited to tennis or golfer’s elbow, rotator cuff tendinopathy, plantar fasciitis, and Morton’s neuroma (https://meridian.allenpress.com/japma/article-abstract/106/2/93/151426/Extracorporeal-Shockwave-Therapy-in-Patients-with?redirectedFrom=fulltext).

It is thought to improve blood flow to the area, and break up adhesions, facilitating the natural healing process. Another affected pathway is on the pain perception through activating serotoninergic systems increasing the pain threshold on a chemical level. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029898/?report=reader#!po=36.9565)

It is a safe treatment, even helping in the treatment of cancer patients. (https://link.springer.com/article/10.1007/s00520-019-05046-y) 

In clinical practise, as a rule of thumb we believe the longer you leave it and put up with your pains and niggles, the longer it will take to get rid of them. Seeing a specialist early, and not giving up if the physio exercises did not get you the promised release, will have better – and faster – outcomes.

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