Achilles Tendonitis: A New Approach To Treatment

Achilles tendonitis is one of the most frustrating injuries to heal from. Could stretching and rest actually be moving you in the wrong direction?

My right Achilles tendon has been hurting for months. I’ve been to see osteopaths, physiotherapists, chiropractors, massage therapists, acupuncturists, and fascia workers. I’ve used ice and Tiger Balm.While all have offered some benefit, none of the treatments have actually healed it.

Out of frustration, I started doing my own research into Achilles tendon issues.

What I found out was very surprising:

• Rest, ice, compression, and elevation (R.I.C.E) delays recovery.
• There is more than one type of Achilles tendonitis. Different types require different treatment.
• You’re more likely to have Achilles tendinosis than tendonitis. The treatment is different for each.
• Stretching the calf muscles does little to improve the function of the Achilles tendon.
• Shockwave, laser therapy, and other localized treatments do not address the root cause. Instead they can result in a recurrence of Achilles tendon issues.

So, read on to learn how to address the root cause of your nagging Achilles tendon pain.

What is Achilles tendonitis?

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon of the back of the leg, and the thickest in the human body. It serves to attach the calf and soleus muscles to the heel bone (calcaneus). Approximately 6% of the general population report Achilles tendon pain during their lifetime.

Tendonitis refers to inflammation or swelling of a tendon so it follows that Achilles tendonitis is swelling/inflammation of the Achilles tendon. If you have chronic pain or discomfort in your Achilles tendon, you, or your therapist, have probably referred to it as Achilles tendonitis. However, it’s far more likely that you have Achilles tendinosis.

Tendinosis is often misdiagnosed as tendonitis because of the limited understanding of tendon injuries. Classic characteristics of tendinosis include dull, aching pain and tenderness to touch. Often, swelling is not present in tendinosis.

In the late 1990’s sports medicine researchers discovered that the vast majority of people with Achilles tendon pain (aside from those with Achilles tendon ruptures) have Achilles tendinosis, not Achilles tendonitis.

Achilles Tendinitis

Achilles tendinitis refers to the inflammation of the tendon. It results from a sudden, heavy stretching of the Achilles tendon, causing micro-tears. To heal tendonitis, any activity that aggravates swelling should be avoided.

Achilles Tendinosis

Achilles tendinosis occurs when the collagen in the tendon declines due to overuse. To allow tendinosis to heal, new collagen cells need to be rebuilt. This is not done through stretching, icing, rest, or other conventional therapies.

As Achilles tendon problems may involve either tendonitis or tendinosis, I’ll refer to them as tendinopathies for the remainder of the articles.

What causes Achilles tendinopathies?

There are a number of things that can cause an Achilles tendinopathy:

• Activity level

  • A sedentary lifestyle combined with short, intense bursts of activity, whether through exercise or workplace requirements, can cause Achilles tendinopathy.

• Overuse

  • This is the most common cause of an Achilles tendon issues, especially in the running and CrossFit communities. However, the exercise by itself is not the problem. Instead, the problem is doing too much too quickly or resuming too quickly after a layoff.

• Misalignment

  • This occurs when one leg is longer than the other or if your feet turn in or out when you walk (pronation). In these cases, a custom fitted orthotic is likely all that is needed to correct the issue. Another possibility can be tight or weak calf muscles that place additional stress on the Achilles tendon.

• Improper footwear

  • I’m looking at you, CrossFit athletes. Running, jumping, and other explosive movements done in lifting shoes is a surefire way to place additional stress on both the calf and Achilles tendon. Other footwear issues include worn out shoes and shoes with too little or too much support.

• Medication

  • The quinolone group of antibiotics are used to treat a wide range of bacterial infections, but weaken some people’s tendons.
  • Examples of the quinolone group of antibiotics include:
    • Ciprofloxacin
    • Floxo
    • Gemifloxacin
    • Moxifloxacin
  • Cortisone injections are commonly done to help alleviate pain felt in the Achilles tendon. Unfortunately, when the pain is gone it’s possible to overexert the already weakened tendon, resulting in more damage or even a rupture.
  • Some studies have found links that cortisone steroid injections in general cause a weakening of the tendons. This increases the likelihood for future tendon injuries.
    • My general recommendation would be to avoid steroid injections.

• Genetics

  • Yes, your genes could actually increase your chance of developing Achilles tendinopathies. Individuals with the single nuclear polymorphism (SNP) TT genotype of the GDF5 rs143383 variant have twice the risk of developing Achilles tendon problems.

These are the most common causes of Achilles tendinopathies. Treatment will differ depending on the potential cause.

Are there different types of Achilles tendinopathies?

You now know the difference between tendinitis and tendinosis. Determining which one you have is an key first step. The next step is to determine the location of your Achilles tendon injury. The most common two are:

1. Insertional tendinopathy

An Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

2. Non-insertional tendinopathy

A non-insertional Achilles tendon injury can occur to any part of the Achilles tendon except where it inserts into the heel bone. This injury is more common.

How to heal from Achilles tendinopathies

Before any treatment begins, a correct diagnosis is essential. See your doctor or a well-trained physiotherapist/sports medicine practitioner to rule out an Achilles tendon rupture/tear.

Your second step should be to replace the footwear you were using prior to developing Achilles tendon pain. If new shoes are not in the budget, consider adding an orthotic like superfeet to your shoes.

Step three is perhaps the most important. You need to determine if you have Achilles tendonitis or Achilles tendinosis. This is because each have different treatment goals and timelines. The main goal for tendinitis is to reduce inflammation. Inflammation isn’t present in tendinosis, and in fact, some treatments to reduce inflammation should not be used with tendinosis.

Healing from Achilles tendonitis

The healing time for tendonitis is several days to 6 weeks, depending on whether treatment starts right away or after several months when the injury is chronic. The overall treatment goal is to reduce inflammation in the tendon.

Reducing inflammation is typically done through R.I.C.E – rest, ice, compression, and elevation. Unfortunately, this is old information. The new research suggests that icing an injury actually prolongs healing time.

Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells. The blood vessels do not open again for many hours after the ice is applied. This decreased blood flow can cause the tissue to die and even cause permanent nerve damage.

Here are 4 simple things to do when healing from Achilles tendinitis:

1. Decrease the aggravating activity

   • I don’t recommend stopping completely. But the quantity and intensity should be lowered so you don’t aggravate pain levels.

2. Check your footwear

   • Did pain levels begin after a new shoe purchase?
     • Try a new insole or a different pair of shoes.
   • Are your current shoes quite old?
     • Replace with new, well-cushioned shoes.

3. Apply heat

   • Tendons have minimal amounts of blood flowing to them. This is why applying ice will likely prolong recovery time – it stops blood from entering the tissue.
   • Instead, heat the tendon with warming liniments. A magic bag or Tiger Balm work well on achilles tendinitis.

4. Eccentric calf exercises for achilles tendinitis

   • These work wonders for both tendinitis and tendinosis.
   • 3 sets of 10 reps are not going to cut it. You need to go until you feel discomfort in the Achilles tendon. For some, that’s 10 reps, for others, that’s well over 100 reps.

Healing from Achilles tendinosis

If recognized early, treatment for tendinosis can be as brief as 6–10 weeks. However,  once the tendinosis has become chronic (older than 3 months), treatment can take 3–6 months, or even up to 9 months.

Tendons require more than 100 days to make new collagen fibers. That’s why it takes much longer to treat chronic tendinosis.

Do not try to reduce inflammation when healing from Achilles tendinosis. Ibuprofen can actually slow collagen repair. Steroid injections like cortisone slowed collagen repair in one study and were even found to increase later tendon tears.

Here are 3 activities to help heal from Achilles tendinosis:

1. Eccentric calf exercises for Achilles tendinosis

   • The research on this exercise is astounding. Even nearly 4 years later, patients who previously had Achilles tendinopathies reported no recurrence. I don’t think there is any other modality or treatment that can claim such high levels of success.
   • Using a proper eccentric regimen has also shown a decrease in tendon thickening, and an increase in type I collagen fibers. Type I fibers are the stretchy ones we want in our Achilles’ tendons.
   • Although physiotherapists recommend eccentric exercises, they generally don’t recommend enough of them. To have success with this, you need to go until the pain in the Achilles tendon is recreated. This can be well over 100 repetitions.

2. Improve your nutrition

   • Vitamin C, manganese, and zinc are all important for the synthesis of collagen production.
   • Adding a collagen or gelatin supplement to your diet will provide the body with additional amino acids needed to rebuild collagen.

3. Change your cadence

   • For the Achilles tendon to work properly you need to make sure your pace when moving is neither too fast or too slow. Your Achilles needs to be in the sweet spot to avoid aggravation.
   • If you move too fast for your ability, your Achilles will be overloaded.
   • If you move too slowly, you will be fighting against the natural, elastic rebound of your Achilles.

Other remedies to help with Achilles tendinopathies

This section details other treatments or remedies I’ve used personally or with patients that show promise.

Stretching

Calf stretching has shown to be of little benefit in Achilles tendinopathies. I believe this is because, much like our organ systems, our muscular system does not work in isolation. Achilles tendon issues are not due solely to tight calves. Instead, our muscles are connected through a dynamic network of fascia.

The fascia found over the calves also runs up the back of our body and onto the soles of our feet. It connects the base of our skull to the plantar fascia. Tension can occur anywhere in this fascial band. Chronic tension could result in Achilles tendon issues or even plantar fasciitis.

With this in mind, stretching and foam rolling should incorporate all of the posterior fascial line. I recommend the following stretches to help stretch the posterior fascial line:

• Downward dog
• Banded hamstring stretches
• Nerve glides for the hamstring

Combine these stretches with the activities I previously mentioned, especially the eccentric exercises.

Ok, now you know as much as I do about fixing chronic Achilles tendon injuries.

Now I want to hear from you!

What have you found to be the most beneficial remedy for healing Achilles tendon pain?