Emergency and Urgent Care - Achilles Tendinopathy

What is the Achilles Tendon?

A tendon attaches muscles to bone. The Achilles tendon is the biggest and strongest tendon in the body and is found at the back of your lower leg just above the heel bone; it attaches your 2 calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus) and helps you to stand on your tiptoes.

What is Achilles Tendinopathy and how common is the condition?

The cause of Achilles tendinopathy is not completely understood, but we know tendinopathy occurs when a tendon is unable to adapt to the strain being placed upon it. This leads to repeated micro-trauma to the fibres in the tendon, and result in the tendon attempting to heal itself in response to this strain. You may also hear this condition called Achilles tendinitis or tendinosis.

Achilles tendinopathy is a fairly common soft tissue injury, and can affect both athletic and non-athletic people. It can affect both men and women of all ages. It is more common in people who take part in sports that involve running such as football, tennis, middle or long distance running.

Risk factors for developing Achilles Tendinopathy

General Risks:

• Age: Achilles tendinopathy is more common in people over the age of 30
• Gender: more common in men
• Weight: increased risk of developing condition if you are overweight
• Diabetes: increases risk of developing condition
• Tight and/or weak calf muscles
• Poor endurance strength of calf muscles
• Poor core stability around knee and hip
• Stiff joints in foot

Certain aspects of exercise and training can also increase risk of developing the condition.

Common Training Errors:

• Running too far
• Running at too high an intensity
• Increasing running distances too soon
• Lack of variation in training
• Old or poor quality footwear
• Too much hill running

Common Symptoms of Achilles Tendinopathy

• Morning stiffness – this usually eases after a few minutes of walking, but sometimes may last longer
• Tenderness over Achilles Tendon – often when touched or gently squeezed; there may also be a tender lump and/or clicking from the tendon on movement
• Variable pain – some people may have pain that prevents them from exercising or doing sport, whilst other can participate as their pain settles during exercise but increases on resting

Treatment

• Ice – applying ice in a damp tea towel to the tendon helps to reduce pain. Apply for 20 minutes, 4 times a day and after exercise
• Analgesia – paracetamol and anti-inflammatory medication such as ibuprofen can be used to relieve pain
• Relative Rest – you can maintain your fitness by using different forms of exercise that do not involve stressing the Achilles tendon such as swimming, cycling, aqua-aerobics, aqua-jogging
• Stretching your calf muscles – further advice in leaflet
• Eccentric Exercise Program – this type of controlled exercise helps your inflamed Achilles tendon to return to normal and forms part of a rehabilitation program
• Physiotherapy – this may involve several treatment options which include manual techniques, specific exercises and stretches

Helpful Training Tips

• Only increase running time or distance by 10% each week
• Renew your trainers every 300-500 miles. It may be advisable to have 2 pairs of trainers on the go and alternate their use
• Vary your training – combine different speeds, distances and times during your training period. This will allow your tendon to adapt to the loads placed upon it.
• Plan your training regime
• Vary your exercise in different ways to train other parts of your body – “Cross Training”, and can help to reduce injury by redistributing the loads placed upon your body
• Other forms of exercise that you may find useful
  ○    Swimming
  ○    Spin classes
  ○    Pilates
  ○    Circuit training
  ○    Gym equipment
  ○    Rowing
  ○    Weight training
  ○    Aerobics
  ○    Cycling

Stretches

These help to lengthen the 2 muscles that are connected by the Achilles tendon to the heel bone. They are important as they will help to reduce abnormal tightness across the tendon.

Stretching the Soleus muscle

Using a wall for support, plant your foot flat on the floor behind you

• With your knee bent, lean forwards, reducing the angle between your foot and your shin until you feel the stretch in the back of your calf muscle in the leg you have planted behind you.
• Hold the stretch for 30 seconds to 1 minute
• DO NOT let your heel come off the ground

Stretching the Gastrocnemius muscle

Using a wall for support, plant your foot flat on the floor behind you

• With your leg straight, lean forwards, reducing the angle between your foot and your shin until you feel the stretch in the back of the calf muscle in the leg you have planted behind you
• Hold the stretch for 30 seconds to 1 minute
• DO NOT let your heel come off the ground

Eccentric Exercise Programe

Phase 1

Tiptoes on both legs, with legs straight

• Stand on both feet with your legs straight
• Use your GOOD leg to rise up onto your tiptoes
• Keeping both feet touching the floor, transfer your weight across onto your BAD leg and lower yourself down, using your good leg to help if required
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Tiptoes on both legs, with knees bent

• Stand on both feet with a slight bend in knees
• Use your GOOD leg to rise up onto tiptoes
• Keeping both feet touching the floor, transfer your weight onto your BAD leg and lower yourself down, using your good leg to help if required
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Progress to Phase 2 when these exercises become easier and you do not need to use your good leg for support when lowering yourself down.

Phase 2 

Tiptoes on one leg, with leg straight

• Stand on both feet with your legs straight
• Use your GOOD leg to rise up onto your tiptoes
• Transfer your weight across to your BAD leg, lift up your good leg, and lower yourself down
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Tiptoes on one leg, with knees bent

• Stand on both feet with your knees slightly bent
• Use your GOOD leg to rise up onto your tiptoes
• Transfer your weight onto your BAD leg, lift up your good leg, and lower yourself down
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Progress onto Phase 3 when these exercises become easier

PHASE 3

Heel drops over the edge of a step, with straight leg

• Stand on both feet with your heels over the edge of a step and your legs straight
• Use your GOOD leg to rise up onto your tiptoes
• Transfer your weight onto your BAD leg, lift up your good leg and lower yourself down so that your heel drops over the edge of step
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Heel drops over the edge of a step, with bent knee

• Stand on both feet with your heels over the edge of a step and your knees slightly bent
• Use your GOOD leg to rise up onto tiptoes
• Transfer your weight onto your BAD leg, lift up your good leg, and lower yourself down so that your heel drops over the edge of the step
• Repeat
• Aim for 3 sets of 15 repetitions TWICE a day

Guidelines

• You are likely to experience an increase in your pain when you first start the exercise programme, especially when you progress to a new phase of the regime. Your pain should not be more than 4 out of 10 (0 being no pain, 10 being worst pain ever)
• You should expect to have pain levels of 3-4 out of 10 whilst doing your exercises; if your pain is less than this you can safely progress to the next phase; however, if your pain level is greater than 4 out of 10 you will need to reduce your repetitions and use ice packs, take some analgesia until your pain is less than 4 out of 10, you can then resume your set exercise programme
• The programme should be done every day for at least 12 weeks. You may not initially feel the benefit of the programme to begin with, but it is important to persevere with the programme
• If your morning stiffness in your ankle starts to last longer as a result of doing the exercises, you will need to reduce your repetitions until this settles down. If reducing your repetitions does not help try to rest for 2-5 days

Physiotherapy

If you are unsure about what to do and feel you need support with your rehabilitation, then you can always go to see a Physiotherapist.

If you live in the Heywood, Middleton and Rochdale area, you can refer yourself by using the following link:
www.physiodirect.northerncarealliance.nhs.uk

Work

If you do not feel capable of working either due to pain or reduced movement/mobility, you are able to self-certify sickness for the first 7 days.

You must complete a self-certification form found on the government website and give this to your employer. This entitles you to statutory sick pay from your employer for up to 7 days.

To access the self-certification form follow this link:
https://www.gov.uk/government/publications/statutory-sickpay- employees-statement-of-sickness-sc2

If you feel you need longer than 7 days off work, you must contact your GP for a sick note. The Urgent Treatment Centre does not issue sick notes.

Possible complications

If follow up has been arranged you should attend this.

If your injury does not require follow up you will have been given an approximate recovery time during your visit to the Urgent Treatment Centre.

• If the pain is ongoing despite treatment and analgesia
• You experience tingling/change in sensation to the foot or lower leg
• You develop hard, painful swelling and redness to your calf, or signs of a DVT please contact Rochdale Urgent Treatment Centre on 01706 517023 or return to the department.