Where is the Achilles tendon?

The location of the Achilles tendon is the bottom part of the calf muscle (technical terms: gastrocnemius, soleus and plantaris muscles), which joins the back of the heel bone (calcaneus).

What is Achilles tendinopathy?

Achilles tendinopathy happens through irritation of the tendon sheath, or paratendon, which can trigger pain and swelling on the back of the heel. This is a typical trigger in athletes, runners and hikers^1,2. The majority of Achilles tendinopathy instances happen in males, typically in 15% of leisure athletes, and is the trigger of 24% of life-time injuries in athletes. Even so, a third of chronic Achilles tendinopathy cases are reported in less physically-active individuals³. In addition, 30% of individuals who have Achilles tendinopathy undergo surgical procedures³.

How does Achilles tendinopathy happen?

There are two main causes of Achilles tendinopathy: the intrinsic (inside to the body) or the extrinsic (from the environment or outside of the body)³. Occasionally it is a combination of both⁴.

Intrinsic variables incorporate previous injury to the Achilles (which can trigger degeneration of the tendon), gene variations, male hormonal imbalance³, weight problems, diabetes, and age can also provoke degeneration of the tendon if not active^3,4. Peri-tendinopathy (which affects the tissues surrounding the Achilles tendon) can trigger scar tissue development in the tendon⁴.

Extrinsic variables involve weight-bearing on hard, slippery or uneven surfaces, poor workout regimes, bad footwear, certain medicines (for example, fluoroquinolones, that are medicines which destroy bacteria)^3,6 or hyperpronation of the ankle (where the heel is rolled inwards and the little toe is raised from the ground)⁴.

Research has shown that hyperpronation or pronation of the ankle can adjust the synchrony between the joints of the ankle and foot, and therefore the tendon may be put under extreme pressure, triggering a ‘wringing effect’. The wringing effect can reduce blood flow to the tendon and the tissues close to the tendon (paratendon)³. This can lead to possible degeneration of the tendon in the future³.

Underlying mechanisms and ideas

An Achilles tendinopathy may adjust the tendon’s appearance, cell structure, and types and quantities of cells. Research proposes that an Achilles tendinopathy may appear to look more yellow-colored/brown when looking through the microscope, compared to that of a healthy tendon, which may look white colored⁴. Collagen in the tendon would be disrupted by increasing weaker collagen being created in the area which occurs when an injury is present. There may be a decreased number of cells in some regions of the tendon itself⁴.

Peri-tendinous tissue (tissues around the tendon) in persistent Achilles tendinopathy has revealed two major types of cell: myofibroblasts and fibroblasts. Both of these cells help with restoration and re-modelling of the tendon, and the addition of contractile cells⁴. Nevertheless, the myofibroblasts lay down a lot of collagen in the peri-tendinous tissues, but these cells have been reputable for shrinking peri-tendinous tissue and scar tissue development⁴. Alongside the irritation of the Achilles tendon, ‘neovascularisation’ occurs, which implies the formation of new vessels, which has been considered to impact treatment performance⁵.

Signs and symptoms of Achilles tendinopathy

Typical signs or symptoms include:

• discomfort in the back of the heel
• pain in the calf muscle half way down the leg
• reduced range of movement in the heel
• exercising may lead to discomfort
• swelling localised to the ankle (redness may be observed in early stages).

Diagnosis of Achilles tendinopathy

In addition to being looked at by an Osteopath or a Physiotherapist at Perfect Balance Clinic, Achilles tendinopathy can be officially examined by:

• MRI scans
• CT scans⁵.
• ultrasound, which is becoming a very good analysis tool and is designed to be the first method of diagnosis⁵.

Treatment of Achilles tendinopathy

Procedures used by Osteopaths and Physiotherapists at Perfect Balance Clinic inlcude:

• soft tissue massage
• articulations of the ankle and foot joints
• myofascial release (calming the muscles and increasing circulation) of surrounding tissues
• dry needle/acupuncture
• mobility workouts
• rehabilitation using our specialised trainers and pilates instructors
• specialised physical exercise prescriptions
• injections of collagenase or saline into the tendon⁵.

References

1. Solomon, L., Warwick, D., Nayagam, S. (2010). Apley’s system of Orthopaedics and Fractures. 9^th edition. London: Hodder Arnold, pp.614–615.

2. Sarimo, J., Orava, S. (2011). Fascial incision and adhesiolysis combined with radiofrequency microtenotomy in treatment with chronic midportion Achilles tendinopathy. Scandanavian journal of surgery, 100(2), pp.125–129.

3. Munteanu, E.S., Barton, J.C. (2011). Lower limb biomechanics during running in individuals with Achilles tendinopathy: a systematic review. BioMed Central, 4(15), pp,1–16.

4. Van Sterkenburg, N.M., Van Dijk, N.C. (2011). Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surgery, Sports Traumatology, Arthroscopy, 19(1), pp.1367–1375.

5. Wang, Po-H., Luh, J-J., Chen, W-S., Li, M-L. (2011). In vivo photoacoustic micro-imaging of microvascular changes for Achilles tendon injury on a mouse model. Biomedical Optics Express,2(6), pp.1462–1470.

6. Durey, A., Baek, Y.S., Park, J.S., Lee, K., Ryu, J-S. (2010). Levofloxacin-induced Achilles tendinitis in a young adult in the absence of predisposing conditions. Yonsei Medical Journal, 51(3), pp.454–456.

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