Treating Achilles Tendonitis

Painful heel problems have not only affected Achilles the mythical hero of the Trojan war – it is reported that Achilles tendon injuries account for 7-9% of all injuries in runners. Achilles tendon injuries can affect people of all ages, however today I’ll focus on the group of pathologies that seem to affect the 25+ year olds – the common but debilitating Achilles tendinosis. You may have already heard from your doctor or physio that the term tendinosis has replaced the commonly used term tendinitis, as the ‘itis’ component means that the pathology has a component which is inflammatory.

It is now known through countless studies on the pathology of chronic tendon problems that inflammation is not the primary issue, but degeneration is the big factor in pathology. The latest and greatest research suggests that as the tendon degenerates due to compressive forces of the heel bone, new blood vessels grow into the area around the degenerated spot. The purpose of these new blood vessels is to fuel new tendon growth in the areas immediately surrounding the degenerated tendon. It is these blood vessels that actually produce the pain chemicals that we eventually feel. It takes time for the blood vessels to infiltrate the affected area which means that by the time we feel pain, the problem has most likely been there for months – we just have not felt it yet. Therefore, the management of Achilles tendon problems can then take months to settle the pain.

Some clever doctors have used what are called sclerosing injections into the blood vessels (Polidoconol being the most common). The purpose of these injections is to ‘kill off’ the blood vessels so the pain diminishes. However, without correction of the precipitating factors, the painful heel invariably returns as the blood vessels regrow. The mainstay of chronic Achilles tendon management has been the Hakan Alfredson ‘eccentric’ training program. Rumour has it that Dr Alfredson was a long term sufferer of Achilles tendinosis. In his extreme frustration at not being able to cure himself he thought he would be better off working the tendon with the purpose of snapping it. He could then have it surgically fixed and 6 months later would be painfree. So he went into the gym and performed heavy sets of calf raises in the hope of snapping the poor Achilles tendon. What happened? It got better. This then fuelled a lot of studies into how ‘eccentric’ exercise benefits tendon injuries. The readers digest version as to what ‘eccentric’ exercise does is that it stimulates tendon cells to lay down more collagen and create a functionally stronger tendon (the process for those who want to Google it is called ‘mechanotransduction’). The degeneration stays but the rest of the tendon gets stronger to ‘offload’ the degenerated spot.

So what is ‘eccentric’ exercise? It’s not push ups performed by a crazy scientist but it relates to how muscles can maintain tension whilst being lengthened. In the case of the Achilles tendon, it’s where one stands up on tip toes and lowers oneself down with control. The calf and Achilles are getting longer but still have tension. And the trick with the ‘eccentric’ program is to keep it eccentric. Don’t worry about lifting yourself up onto tip toes again using your calf, use your other one or use both together. It is the lowering part which has the beneficial effect. The common program starts with the injured person on flat ground. They come up on both tip toes then take away the good side and lower using the affected side. They do 3 sets of 15 reps every day, twice per day. Once this is achievable, they can move onto a step and increase the amount of stretch applied to the calf/Achilles at the bottom of the movement. This program will usually need to be done for 3 months before you can relax and do it every second day as maintenance.

In Fitness