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Professor Jill Cook ( PhD ) Professor in musculoskeletal health , La Trobe Sport and Exercise Medicine Research Centre , La Trobe University , Melbourne , Victoria .
Copyright © 2021 Australian Doctor All rights reserved . No part of this publication may be reproduced , distributed , or transmitted in any form or by any means without the prior written permission of the publisher . For permission requests , email : howtotreat @ adg . com . au .
This information was correct at the time of publication : 3 December 2021
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BACKGROUND
ACHILLES tendinopathy is the most common lower-limb tendon problem presenting to GPs for management . 1 It can affect anyone , from young active athletes to older sedentary individuals . The Achilles tendon is highly loaded in sport , but it is also loaded through simple movements in daily life like walking , running , climbing stairs and changing direction .
This How to Treat discusses
the diagnosis and management of mid-Achilles tendinopathy and aims to ensure GPs can correctly diagnose and manage uncomplicated cases and refer when appropriate .
What is tendinopathy ?
Tendinopathy is defined as pain and dysfunction in a tendon , without defining the pathology in the symptomatic tendon . 2 Tendinopathy is the preferred term ; tendinitis and tendinosis are now discouraged . An inflammatory component exists in tendon pathology , but from a clinical perspective it does not drive pain or pathology , and anti-inflammatory approaches such as rest , ice and medication are mostly
unsuccessful . 3
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End-stage pathology is termed degenerative and may occur without symptoms . Thus , ‘ spontaneous ’ tendon ruptures do not ( and cannot ) occur in normal tendons . The regression or progression of symptoms is not linked to changes in pathology ; symptoms occur in a pathological tendon in response to changes in load .
In most tendons , pathology develops from persistent and excessive load over time . Achilles tendinopathy is
therefore more common in older people and those who have been active . Age itself alters tendon structure and properties but does not cause pathology ; older people can develop tendon pathology because they have been exposed to greater load over their life . 5 , 6
What loads a tendon ?
Tendons experience several types of load , and it is not as simple as transferring muscle activity to bone ( see box 1 ).
Tendon pain
The sensory nerves are mainly in the peritendon and at the tendon attachments , so the reason why a tendon itself becomes painful is not known .
The pain is not necessarily related to
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abnormal pathology seen on imaging ; pain-free and highly functioning athletes can have tendon pathology on ultrasound and MRI imaging . 7
What is clinically important is that tendon pain causes profound unloading , more so than other musculoskeletal conditions because there is a direct link between loading the tendon and feeling pain . Tendons do not hurt substantially when unloaded , unlike some musculoskeletal conditions . Therefore ,
tendon pain and consequent unloading will decrease muscle strength and power , causing muscle wasting and loss of function . Reduced function will complete the cycle by increasing pain at lower loads .
CLINICAL PRESENTATION
ACHILLES tendinopathy most commonly occurs in the mid-tendon but may occur at various points along the tendon , including the attachment to the calcaneus . Classic mid-tendon Achilles tendinopathy is more common than insertional tendinopathy , the latter provoked by compressive loads and more often linked to systemic inflammatory
conditions . 8 , 9
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Achilles tendinopathy may be chronic and low-grade or have a more acute , painful onset . Acute onset occurs after an unusual load is placed on the tendon , such as the first game of tennis in 10 years or a bush walk to the top of a mountain . The tendon may be minimally painful during the exercise , with increased pain after a period of rest , and is worse the next morning on first getting out of bed . The person can often identify the exact activity that
induced their pain .
Achilles tendinopathy may come and go , ‘ grumbling ’ in the morning for a few steps and not bothering the patient . These symptoms may worsen after a change in activity , which may be subtle or obvious . In active people , it may be as simple as a change in shoes , a different running route or a change in routine that demands more walking . Achilles tendinopathy can also change sides , with the patient recalling mild previous pain in the contra-lateral tendon that did not prompt them to seek attention .
Signs and symptoms
Achilles tendinopathy is classically
stiff and sore in the morning on
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