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Achilles tendinopathy

Achilles tendinopathy is injury to the band of tissue (tendon) that runs down the back of your lower leg to your heel. You may get pain, stiffness and sometimes swelling that makes it difficult to move freely.

Achilles tendinopathy can make it hard to walk and may stop you carrying on as normal. It can affect anyone, but particularly people who do activities that involve running and jumping. It’s thought that around 150,000 people are affected by Achilles tendinopathy every year.

Image showing the Achilles tendon

Details

  • About About Achilles tendinopathy

    Tendons help bones and joints to move when your muscles contract. Your Achilles tendon is the thickest tendon in your body and is very strong and flexible. It connects your calf muscle to the bone in the heel of your foot. This enables you to go on tiptoe or move forward when you walk, run or climb.

    You can get Achilles tendinopathy through a specific injury or by overuse. The tendon can deteriorate gradually over a period of time.

  • Symptoms Symptoms of Achilles tendinopathy

    The main symptoms of Achilles tendinopathy are increasing pain and stiffness, usually at the back of your ankle. You may also notice some swelling. This is sometimes called tendonitis.

    Your Achilles tendon might feel tender when you touch it. There may be a grating noise or creaking feeling (crepitus) when you move your ankle.

    The pain can come and go. It may be worse first thing in the morning or after you’ve done any exercise or activity. Your Achilles tendon may feel particularly stiff when you first get up or if you haven’t moved for a while. The stiffness may ease off when you start moving again.

    Achilles tendinopathy can interfere with your day-to-day life. It may mean you need to take time off work or studies. You may not be able to do so much activity, including sports, but talk to a physiotherapist about this for advice.

    Sudden pain in your heel or calf, which quickly becomes swollen, bruised and sore, can mean you’ve torn the tendon. You may actually hear it snap. This is called an Achilles tendon rupture. You should get urgent medical attention if this happens.

  • Diagnosis Diagnosis of Achilles tendinopathy

    Your GP or physiotherapist will ask you about your symptoms and examine your leg, heel and ankle. A series of movements or exercises will help them see how well you can move your leg. They may squeeze your calf muscle to check the movement of your foot.

    They may also ask you about your medical history and rule out other causes or conditions.

    An ultrasound scan or MRI scan will confirm if there are tears in your Achilles tendon. But often scans aren’t necessary for a diagnosis.

    If you need to see a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility), there are several ways you can do this. Depending on where you live, you may be able to refer yourself to see a physiotherapist, or there may be one who works at your GP surgery. Sometimes, you may need to see your GP first to make the referral if you need it. Another option is to see an expert in sports medicine, which you can arrange privately or your physiotherapist may be able to refer you.

    If there’s a chance you have an underlying condition, you may be referred to see an orthopaedic surgeon who specialises in bone surgery. Or they may refer you to a rheumatologist who specialises in arthritis and other diseases that affect muscles and bone.

  • Self-help Self-help for Achilles tendinopathy

    There are a number of things you can do to help Achilles tendinopathy. The most important, is to rest the tendon. Modify your activity, at least for a while. Your physiotherapist can advise how much it’s safe to do. Gently stretching your lower leg can help too.

    An insole in each shoe that lifts your heel slightly reduces the stress on your Achilles tendon. So does wearing well-padded and supportive shoes.

    Ice can ease the pain and reduce any swelling. But don’t apply it directly to your skin. Use a proper ice pack, or ice wrapped in a towel.

  • Treatment Treatment of Achilles tendinopathy

    Achilles tendinopathy gets harder to treat the longer you leave it before getting a diagnosis. The type of treatment will depend on how serious it is. Generally, you should see an improvement after three months.

    Medicines

    If you need pain relief, you can take over-the-counter painkillers, such as paracetamol. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen may also help with pain. But Achilles tendinopathy is a degenerative problem, not an inflammatory one. So try not to take NSAIDs for very long.

    Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    You may be offered a type of nitroglycerin on a patch you put on your leg where it hurts. This may reduce the pain and strengthen your Achilles tendon so you can move more easily.

    If you’re taking antibiotics, talk to your doctor. This is because you might be taking an antibiotic that belongs to a large group called the quinolones. If so, you’re recommended to stop taking it immediately if you have Achilles tendinopathy because there’s a chance it could make your condition worse. Your GP can advise you on the type of antibiotic you’re taking and whether you need to stop or change your medication.

    Physical therapies

    Physiotherapists are health professionals who specialise in maintaining and improving movement and mobility.

    Physiotherapy can help strengthen and stretch your Achilles tendon. If your symptoms haven’t improved after a week or so, you can refer yourself to a physiotherapist, or ask your GP to.

    Your physiotherapist may give you exercises to do every day. These may include ‘eccentric exercises’ that include stretching and heel-lowering movements. These help reduce pain and make your tendon work better. Other exercises use resistance to get results.

    Your physiotherapist can also help you correct problems with your posture and the way you walk. These are problems that can cause Achilles tendinopathy or make it worse. ‘Night splints’ can hold your feet in a better position while you sleep.

    Non-surgical treatments

    If your condition hasn’t got any better after six weeks, this is called chronic Achilles tendinopathy. But there are still other treatments to try even if the common self-help, medicines and physical therapies haven’t helped.

    Some of these are relatively new and may only be available as part of a research programme. You’ll probably still have exercises to do as well.

    Your physiotherapist or sports medicine specialist may recommend any of the following, if they’re available and suitable for you.

    • Extracorporeal shockwave therapy. A machine passes shockwaves through your skin to the affected area of your tendon. You may need several sessions.
    • Blood or platelet-rich plasma (PRP) injections. These use part of your own blood that’s rich in growth factors and may help your Achilles tendon heal faster. Ultrasound can guide the blood or plasma to where it’s most useful.
    • Low-level laser therapy. This may help repair damage to the tendon.
    • Dry needling. A thin needle stimulates the healing process and can also relieve pressure on the tendon.

    Surgery

    Surgery may be an option if other treatments haven’t worked after several months, especially if your symptoms are seriously affecting your everyday life.

    Your GP can refer you to a specialist foot and ankle surgeon. They may want to do a scan to check the state of your tendon.

    The operation may involve removing damaged areas of your tendon and repairing what’s left. The surgeon may need to use tissue from higher up your Achilles tendon, or from another of your tendons, to do these repairs. The wound may take time to heal and leave scars.

    For more information about recovery time, see our FAQ: Recovery time.

    Bupa On Demand: Musculoskeletal services

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  • Causes Causes of Achilles tendinopathy

    Achilles tendinopathy gets worse over time if not treated. It’s usually caused by overusing your Achilles tendon. Very small tears can start to develop. Without treatment, these won’t heal and your tendon can become weaker.

    Age makes Achilles tendinopathy more likely. As you get older, your Achilles tendon becomes less flexible and less able to cope with strain on it. People over 60 are more prone to tendon damage.

    Your overall health and fitness can be another cause. You’re more at risk of Achilles tendinopathy if you:

    Your feet and the way you walk make a difference too. Wearing the wrong sort of shoes, or ones that don’t fit properly are both bad news for your Achilles tendon. Continual wearing of high heels is not good for the Achilles tendon.

    You may have ‘flat feet’ with arches lower than they should be. These can make your whole foot roll inwards when you walk or run. This is called over-pronation and can contribute to Achilles tendinopathy. High-arched feet can cause problems as well.

    Sports and other activities can put a lot of stress on your Achilles tendon. Running is the biggest risk but anything that involves jumping – like dancing, tennis or basketball – may damage your tendon. Extra problems can be caused by:

    • poor equipment, including inappropriate footwear
    • poor technique, like suddenly increasing how much exercise you do
    • poor posture or alignment
    • hard, slippery or high-friction surfaces
    • extreme weather conditions, particularly the cold
  • Prevention Prevention of Achilles tendinopathy

    There are a number of things you can do to help prevent Achilles tendinopathy.

    If you have underlying problems that put you more at risk, it’s important to get these sorted. Losing weight if you’re obese may reduce the strain on your Achilles tendon as well as being good for you generally.

    A podiatrist is someone who specialises in conditions that affect the feet. Podiatrists can analyse the way you walk and advise on things to avoid. For example, high-impact sports that involve jumping and landing, like basketball, are risky if you have flat feet.

    Orthotic devices or orthoses can help both treat and prevent Achilles tendinopathy. These include special insoles. These particularly effective if the shape of your foot arch increases the stress on your Achilles tendon or one leg is longer than the other. You can buy these off-the-shelf or they can be custom-made for you. Ask your physiotherapist or podiatrist for advice.

    You should wear well-fitting shoes that suit the activity you’re doing (For more information, see our FAQ: The right footwear).

    Whether you’re working or exercising, make sure you use the right equipment and techniques. For example, cyclists can get Achilles tendinopathy by setting their saddle too low. You should limit repetitive motions that overuse the tendon.

    Whatever exercise you do, build up slowly. Gradually increase the intensity and the length of time you spend being active. It’s good to warm up your muscles before you exercise and cool them down after you’ve finished. Toe curls and heel raises stretch your feet, calves and Achilles tendons.

  • FAQ: Recovery time How long will it take my Achilles tendon to get better?

    Recovery can take weeks or months. It depends how quickly you get it treated, and what treatment you need. It will take longer to recover if you have surgery.

    The sooner you're diagnosed and start your treatment, the more effective it will be. Generally symptoms should improve three to six months after you start treatment. In most people, the pain and movement will improve after 12 weeks of treatment.

    It’s important to rest your damaged tendon properly. Too much activity while you’re having treatment may delay your recovery. And you’ll need a period of rehabilitation after any non-surgical intervention.

    Your physiotherapist will want to keep an eye on how you’re doing. You may need two to three physiotherapy sessions a week for about six weeks. It can take time to build up the eccentric exercises your physiotherapist gives you to do. You should expect to do them daily for at least three months for the best result, probably longer.

    It can also take time to evaluate and correct poor technique that contributed to your Achilles tendinopathy. You may need to switch to a different playing or running surface.

    It's important that you return to physical activity gradually and have rest days. If you need an operation to repair your tendon, you may not be able to return to the level of activity you were doing before. The tendon may not be as strong or as flexible as it was previously.

  • FAQ: The right footwear What shoes will help avoid Achilles tendinopathy?

    Choosing the most suitable footwear for what you’re doing – and where you’re doing it – can help prevent Achilles tendinopathy. It can also stop it coming back.

    Running or playing sports can put a lot of strain on your feet and your Achilles tendon. This is why it’s important to wear the right shoes.

    Sports shoes are all different. For instance, running shoes need cushioning in the midsole and a flared heel for stability. But they won’t give you the right support for playing racquet sports. Squash or tennis shoes should give you better stability when moving and stopping suddenly round the court. Go to a specialist sports shop for advice and a proper fitting.

    Trainers and other footwear don’t last forever. Change them if they stop giving you enough support or cushioning.

    Make sure shoes fit properly. There should be 1mm of space from the top of your longest toe to the end of the shoe so you can wiggle your toes. But they shouldn’t slip. Try both shoes on and walk round to make sure they don’t pinch or rub.

    Wearing high heels can put strain on your Achilles tendon so try not to wear high heels all the time. It helps to stretch your calf muscles regularly.

    If you have Achilles tendinopathy, you may be able to reduce any pain by wearing orthotic devices like insoles or heel lifts in your shoes. Custom-made insoles can help to correct the shape of your feet and put less strain on your Achilles tendon. Your physiotherapist may refer you to a specialist to have these made or you can arrange to see a podiatrist or specialist privately.

    Heel lifts raise your feet by a small amount to take some strain off the tendon. Buy shoes with removable insoles so there’s enough room for orthotic devices to fit comfortably.

    It’s tempting to wear slippers at home because they’re soft and comfortable. But many slippers don’t give you enough support. Choose ones with a cushioned sole and a fastening to hold them securely, or wear ordinary shoes.

  • Other helpful websites Other helpful websites

    Further information

    Sources

    • Achilles tendinopathy. NICE Clinical Knowledge Summaries. cks.nice.org.uk, revised January 2016
    • Achilles tendinopathy and rupture. PatientPlus. patient.info/patientplus, last checked 2 June 2016
    • Quinolones. NICE British National Formulary. www.evidence.nhs.uk/formulary/bnf/current, accessed 25 October 2016
    • Tendinopathy. BMJ Best Practice. bestpractice.bmj.com, last updated 11 December 2015
    • Stephenson A, Wu W, Cortes D, et al. Tendon injury and fluoroquinolone use: a systematic review. Drug Safety 2013; 36(9):709–21. doi:10.1007/s40264-013-0089-8
    • Pes planus (flat feet). PatientPlus. patient.info/patientplus, last checked 19 January 2016
    • Sporty feet. The Society of Chiropodists and Podiatrists. www.scpod.org, published 2013
    • Musculoskeletal problems: Ankle and foot problems. Oxford handbook of general practice (online). Oxford Medicine Online. oxfordmedicine.com, published April 2014
    • Gambito E, Gonzalez-Suarez C, Oquiñena T, et al. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: A systematic review and meta-analysis. Arch Phys Med Rehabil 2010; 91(8):1291–305. doi:10.1016/j.apmr.2010.02.008
    • O’Neill S, Watson PJ, Barry S. Why are eccentric exercises effective for Achilles tendinopathy? Int J of Sports Phys Ther 2015; 10(4): 552–62. PMCID: PMC4527202
    • Beyer R, Kongsgaard M, Hougs Kiær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: A randomized controlled trial. Am J Sports Med 2015; 43(7):1704–11. doi:10.1177/0363546515584760
    • Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic Achilles tendinopathy: a systematic review. Foot Ankle Int 2013; 34(1):33–41. doi:10.1177/1071100712464354
    • Extracorporeal shockwave therapy for refractory Achilles tendinopathy. National Institute for Health and Care Excellence (NICE), August 2009. www.nice.org.uk
    • Autologous blood injection for tendinopathy. National Institute for Health and Care Excellence (NICE), January 2013. www.nice.org.uk
    • Ferrero G, Fabbro E, Orlandi D, et al. Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy. J Ultrasound 2012; 15(4):260–66. doi:10.1016/j.jus.2012.09.006
    • Platelet-rich plasma injections. GP Update (online). GP Update Ltd, gpcpd.com, accessed 25 October 2016
    • Kearney RS, Parsons N, Metcalfe D, et al. Injection therapies for Achilles tendinopathy. Cochrane Database of Systematic Reviews 2015, Issue 5. doi:10.1002/14651858.CD010960.pub2
    • Tumilty S, Munn J, McDonough S, et al. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg 2010; 28(1):3–16. doi:10.1089/pho.2008.2470
    • Yeo A, Kendall N, Jayaraman S. Ultrasound-guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2016; 24(7):2112–8. doi:10.1007/s00167-014-3458-7
    • Achilles tendon. British Orthopaedic Foot & Ankle Society. www.bofas.org.uk, accessed 24 October 2016
    • Munteanu S, Scott L, Bonanno D, et al. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 2015; 49(15):989–94. doi:10.1136/bjsports-2014-093845
    • Scott L, Munteanu S, Menz H. Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review. Sports Med 2015; 45(1):95–110. doi:10.1007/s40279-014-0237-z
    • Shoes for sporting activities. The Society of Chiropodists and Podiatrists. www.scpod.org, published July 2015
    • Footwear: A guide to choosing the best shoes for your feet. The Society of Chiropodists and Podiatrists. www.scpod.org, published 2009
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