Pain in the Heel: Achilles Tendinopathies
“It’s my Achilles heel”. Literally. Most of us have heard of someone experiencing Achilles “tendinitis” or have experienced it ourselves. Through our Internet searches, most of us are familiar with the “rest, ice, anti-inflammatories, stretch” protocol. Although this may help some, sometimes the remedy is not that simple.
There are different types of Achilles tendinopathies, which require their own unique treatment approaches. Tendinitis is an acute injury to an otherwise healthy tendon. This is where we see the signs of inflammation: pain, heat, redness, and swelling. This type of tendinopathy can respond well to the usual recommendations of rest and ice. Most often we attribute this condition to “overuse” (e.g. running, jumping too much). However, there can be underlying causes to this “overuse” that I will touch on later. Tendinosis is a chronic condition where the tendon progressively degenerates gradually over time.
The degeneration can occur at the middle of the tendon or where it inserts into the bone at the heel. Unlike tendinitis, tendinosis usually does not present with the same signs of inflammation (e.g. swelling and heat). Therefore, this type may not respond to icing and anti-inflammatories. The tendon may appear thickened or have a bump due to weak scar tissue developing as the tendon tried to heal itself over time. Then, there is Achilles insertional tendinosis. This is also a degenerative condition that develops over time. The pain is localized more at the heel where the tendon inserts and worsens after activity, especially with running, jumping or short bursts of movement. There is usually a mechanical cause causing the irritation, which may include boney deposits forming within the tendon or where it attaches to the bone (aka Haglund’s Deformity).
Other than “overdoing it” with our activities, there can also be other mechanical causes of Achilles tendinopathies. Having worked with a lot of Division I college-level runners, I always wondered why the athlete would develop symptoms on one side and not the other considering they are running the same mileage on both. Deficiencies in the mobility and/or the stability of other parts of the foot can lead to abnormal foot/ankle mechanics leading to increased stresses at the Achilles tendon. For example, if we can’t extend sufficiently at our big toe, we can change the way we push off our foot with walking and running. Or if we lack the strength in our arches to prevent excessive motions, we change the alignment at the Achilles tendon, which can tension the tendon asymmetrically or cause repetitive friction. In cases of tendinosis, controlled tissue loading through resistive exercises has been proven to be effective, given no other impairments need to be addressed.
Our experienced physical therapists at Howard Head Sports Medicine can help identify the possible mechanical causes and provide more insight to your recovery other than the generalized “rest, ice, stretch” approach. We also have the knowledge to help educate you in proven treatments that extend beyond physical therapy.