The Achilles Heel – What is that pain at the back of your heel?
The term Achilles heel is used to reference a weakness or vulnerability. Based off the Greek mythology hero, who was struck down from his one weakness; an arrow through the heel. Anatomically it is known as your calcaneal tendon, however the myth of Achilles was too good for it not to receive this eponym.
Achilles injury is typically separated into the acute traumatic Achilles rupture and the overuse Achilles tendinopathy. When it comes to the Achilles tendon it is important that your practitioner can differentiate between the pathology of the tendon. I once treated someone who was told they sprained their ankle only for it to be an obvious Achilles rupture injury (the injury was 3 weeks old at that stage)!
The tendinopathy which is largely seen to be an overload injury is also separated into the insertional Achilles tendinopathy and the mid-portion Achilles tendinopathy. It is imperative that again your healthcare professional can identify which pathology it is, as the treatment approach for both has important differences. For the remaining of this blog, I will discuss the chronic overloaded Achilles tendinopathy.
How common are Achilles tendinopathy injuries?
The Achilles tendon is the largest and strongest of all our tendons in the body. It is an energy storage and release tendon, as such it is very important for walking, running (especially sprinting), jumping, hopping and changing direction. Like most musculoskeletal tissues in the body, it has a load capacity. Therefore if this capacity is exceeded without adequate recovery, a training load error occurs and a reactive tendinopathy can develop. In elite runners the lifetime risk of injury is approximately 52% (Kujala et al, 2005). So it is certainly a running related injury. Although further studies have found that one third of all Achilles tendinopathy patients have a sedentary lifestyle (Rolf & Movin, 1997).
What is the Cause then?
To make matters more confusing is that from all the clinical research over the years, there is no absolute certainly on what are the risk factors for this injury. A recent high quality research review had a look at all the reported risk factors, with inconclusive and conflicting evidence. Although with low supporting clinical evidence, factors that are known to affect tendon health play a part in Achilles tendinopathy onset. Being obese/overweight, diabetes, high cholesterol, high alcohol intake, smoking, fluoroquinolones (antibiotics) or statins use have all been linked. There is further conflicting evidence on ankle range of motion, calf muscle strength and even advancing age (Van der Vlist et al, 2019). Clearly there needs to be more high-quality research into this area!
Treatment Options
The good news is that there is hope. There are multiple treatment options available that are all much better than just pushing through the pain and hoping it will go away (Van der Vlist et al, 2021). As the Achilles tendon is so important for everyday movement and physical performance, beating this overload condition should incorporate exercise therapy! There has been numerous studies showing the effectiveness of strengthening the tendon in not only overcoming pain but overcoming performance/structural deficits as a result of the injury. A well structured heavy, slow resistance program is great for tendon health and outcomes associated with tendon pathology.
The goal of rehab should be to restore the elastic energy storage and release capabilities of the Achilles tendon and decrease pain/symptoms. Furthermore, the structure of the tendon is important, and this remodelling can take up to a year even in now non-painful tendons. This is why being consistent with tendon loading is imperative even once the symptoms are gone.
This is certainly a big area of injury concern and prevalence. It is also one of my favourite injuries to help manage in the clinic. Here at The Reform Lab Osteopathy, I am fortunate enough to work with the great team at Project Reform and have access to their elite facilities to help my patients in their rehabilitation journey. If you are over heel pain, book in and we can help.
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