Achilles tendinopathy is a common overuse injury caused by repetitive loading over time or a sudden increase of load to the Achilles tendon.
Achilles tendinopathy can be divided into two categories –
Midportion Achilles tendinopathy – where the injury is located in the middle part of the tendon.
Insertional Achilles tendinopathy – where the injury is located in the heel where the tendon inserts into the heel bone.
Symptoms of Achilles Tendinopathy
Common symptoms of Achilles tendinopathy include:
- Pain in the tendon or heel – this can be an ache or a sharp pain, which may get worse after increased activity, such as walking and running.
- Stiffness of the tendon which is felt first thing in the morning or after a period of inactivity.
- Thickening of the Achilles tendon or swelling at the back of the heel.
- Creaking feeling when moving your ankle.
- Tenderness to touch the Achilles tendon or heel.
Causes of Achilles Tendinopathy
Achilles tendinopathy is usually caused by repetitive stress to the tendon caused by a rapid increase of load. It is a very common condition found in runners, one in twenty runners will develop Achilles tendinopathy (Lagas et al, 2019).
This may be caused by a sudden increase of mileage or frequency, wearing unsupportive shoes with poor shock absorption or excessive hill training (Li et al, 2016).
Risk Factors that can increase your risk of developing Achilles tendinopathy include (Vlist et al, 2019) (Li et al, 2016):
- Weakness within your feet and lower leg.
- Training during cold weather without wearing appropriate clothes.
- Prolonged use of oral corticosteroids or certain antibiotics – such as fluoroquinalone.
- Inflammatory conditions such as rheumatoid arthritis or gout.
- Older age.
The Achilles tendon (also known as tendon calcaneus) is the strongest and biggest tendon in the body. It attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). The blood supply to the Achilles is low and therefore has a slower healing rate following an injury.
How to diagnose
Your physiotherapist will take your history and ask a number of questions about your symptoms. They will then examine and assess the area – looking at your range of movement, strength and biomechanics. The physiotherapist will then advise on the diagnosis and explain the cause of your injury.
An ultrasound scan can also be performed in our clinic to confirm the diagnosis.
The majority of Achilles tendinopathy injuries will resolve with physiotherapy. The key for recovery is load management and following a progressive heavy resistance loading program. This will decrease pain, promote tissue remodelling and improve calf strength and endurance.
Our physiotherapists can guide you and provide a plan to ensure you safely return to exercise or sports, whilst minimising your risk for re-injury.
You may want to use a heel raise insert in your shoe to reduce the strain on the tendon and reduce pain whilst walking (Wulf et al, 2016).
If your pain is located towards your heel, it is important to avoid stretching the calf – for example hanging your heel off the edge of a step, as this can aggravate your symptoms.
Extracorporeal Shockwave Therapy
Extracorporeal Shockwave Therapy (ESWT) is a non-invasive treatment which sends acoustic waves into the injured tissue which then stimulates the healing process. It also provides a temporary reduction of pain.
ESWT has been found to significantly reduce pain and improve function in those who have been diagnosed with Achilles tendinopathy (Santamato et al, 2019).
We can perform Shockwave therapy for your achilles tendinopathy in clinic if you would prefer to try conservative treatment prior to progressing to an injection procedure. Treatment usually requires 4-6 treatments over consecutive weeks and more information can be found about this treatment here:
For cases that do not improve with physiotherapy and ESWT, there are several injection techniques that can be used alongside your physiotherapy treatment.
Ultrasound guided Hyaluronic Acid Injection
Ultrasound guided Hyaluronic Acid Injections can be an effective treatment for mid-portion or insertional Achilles tendinopathy. A small amount of hyaluronic acid is injected into the soft tissue surrounding the Achilles tendon and can provide a reduction in pain and improve gliding of the tendon by removing adhesions.
Research has found that this is a safe and an effective treatment option for those who have failed conservative treatment. A study by Ferraz et al (2021) found that after one injection for insertional Achilles tendinopathy there was an improvement in function and pain for at least 6 months.
Another study by Fogli et al (2017) found that an ultrasound guided injection of Hyaluronic Acid resulted in a significant improvement of pain and reduced tendon thickness. The same study also found no serious adverse effects.
High Volume Ultrasound-guided Injections
High volume image guided injections (HVIGI) also known as tendon hydro stripping, is a technique which involves injecting a high volume of saline and local anaesthetic into the space between the tendon and the sheath that surrounds it. This solution gently separates the tendon sheath from the tendon to help reset the healing process and reduce pain.
There has been mixed research for the effectiveness of HVIGI for Achilles tendinopathy. A study concluded that it is an effective treatment which can significantly reduce pain when other conservative treatments have failed (Kakkos et al, 2021). Conversely, two randomised controlled trials by Barker-Davies et al (2022) and Van der Vlist, et al (2020) found that HVIGI for Achilles tendinopathy was no better than a placebo. In conclusion, HVIGI should not be used as a first line of treatment, however it can be an effective treatment option to significantly reduce pain if previous measures have failed and can be used to delay or prevent surgery.
If you are experiencing symptoms similar to those described above and want to find out what is causing your pain, please get in touch and one of the team will assess, diagnose and advise on the best treatment option for you. Please contact us on 0207 636 5774 or email email@example.com
Barker-Davies, R., Baker, P., Watson, J., Goodall, D., Wheeler, P., Nicol, A., Fong, D, Lewis, M. and Bennett, A. (2022) High-Volume Image-Guided Injections in Achilles and Patellar Tendinopathy in a Young Active Military Population: A Double-Blind Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine. 10(4) doi: 10.1177/23259671221088326.
Ferraz Ferreira, G., Carrucio, F., Bou Assi, J., Pedro, J., Santos, T., Arliani, G., Filhoa, M. (2021) Ultrasound-guided hyaluronic acid injection for the treatment of insertional Achilles tendinopathy: A prospective case series. Foot and ankle surgery. S1268-7731(21)00244-7. Advance online publication. https://doi.org/10.1016/j.fas.2021.12.004
Fogli, M., Giordan, N. and Mazzoni, G. (2017) Efficacy and safety of hyaluronic acid (500-730kDa) Ultrasound-guided injections on painful tendinopathies: a prospective, open label, clinical study. Muscles, ligaments and tendons journal. 7(2) pp.388-395.
Kakkos, G., Klontzas, M., Koltsakis, E. and Karantanas, A. (2021) US-guided high-volume injection for Achilles tendinopathy. Journal of ultrasonography. 21(85) pp.127-133.
Lagas, I.F., Tryntsje, F.B,. Jan, A.N., Verhaar, A., Sita, M.A., Bierma-Zeinstraa, B., Marienke, V.M and Robert-Jan, D.V. (2019) Incidence of Achilles tendinopathy and associated risk factors in recreational runners: A large prospective cohort study. Journal of science and medicine in sport. 23(5 )pp.448-452.
Li, H-Y. and Hua, Y-H. (2016) Achilles Tendnopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Research International. Published online 2016 Nov 3. doi: 10.1155/2016/6492597.
Santamato, A., Beatrice, R., Francesca, M., Fortunato, F., Panza, F., Bristogiannis, C., Cleopazzo, E., Macaroni, L., Picelli, A., Baricich, A. and Ranieri, M. (2019) Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles. Ultrasound in medicine and Biology. 45(5) pp. 1316-1323.
Van der Vlist, A., van Oosterom, R., van Veldhover, P., Bierma-Zeinstra, S., Waarsing, J., Verhaar, J. and de Vos, R-J. (2020) Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial. British Medical Journal.doi:10.1136/bmj.m3027.
Vlist, A., Breda, S., Oei, E., Verhaar, J. and Jan de Vos, R. (2019) Clinical risk factors for Achilles tendinopathy: a systematic review. British Journal of Sports Medicine. 52(21) pp. 1352-1361.
Wulf,M., Wearing, S., Hooper, S., Bartold, S., Reed, L. and Brauner, T. (2016) The Effect of an In-Shoe Orthotic Heel Lift on Loading of the Achilles During Shod Walking. Journal of Orthopaedic and Sports Physical Therapy. 46(2).pp. 79-86.