What is a mid-portion Achilles tendinopathy?

Achilles tendinopathy is a common complaint often seen in both the sporting population and more sedentary individuals.

It has been shown that 7.4% of all marathon runners and 1.4% of the UK military population suffer from its effects (Baker-Davies et al, 2017).

Longo et al. (2009) stated that between 6-17% of all running injuries are directly caused by a mid-portion Achilles tendinopathy.

Achilles tendinopathy can be a very debilitating condition and can be a difficult issue to resolve with up to 50% of clients still experiencing pain at one year. This is why it is essential to get a clear diagnosis and a focussed treatment programme as soon as possible.

Achilles tendon issues can be categorised into insertional and mid-portion problems (see image below).

Insertional Achilles pain (green circle) relates to the lower part of the tendon, where the tendon attaches onto the heel bone (known as the calcaneum). This can also involve a structure called the retrocalcaneal bursa.

  • Mid portion Achilles pain (blue circle) involves the middle portion of the tendon only.

Location of pain of mid portion Achilles pain (blue circle) &  insertional Achilles pain (green circle).

Repetitive or unaccustomed activity of the Achilles can cause the tendon to become irritated and inflamed. This causes the tendon to swell and become painful. Tendon inflammation is termed tendinitis. The hallmark sign of this is extreme tenderness when you touch or squeeze the tendon.

If the tendon does not have enough time to recover and is subjected to further activity, the healing process can become compromised, resulting in a thickened, weakened and painful tendon. This repetitive process of acute inflammation and poor tendon healing results in tendinopathy (Almekinders et al, 2007).

What are the symptoms of mid-Achilles tendon issues?

The most common symptom of a mid-Achilles tendinopathy is pain. Pain is usually felt at the beginning and at the end of exercise, be it a walk or run, with a reduction of symptoms whilst completing the exercise itself. Many patients report being able to ‘exercise through’ their pain but report a return of symptoms after completing their walk or run.

As a mid-portion Achilles tendinopathy develops this reduction of pain during exercise rescinds resulting in a continuously painful tendon. If this is allowed to continue the pain experienced with a mid-portion Achilles tendinopathy can spill over into everyday life. Activities such as walking or ascending and descending stairs or often described as painful in severe cases.

Many people describe a swollen, thickened tendon which is painful to touch. The most common location being 2-3 inches above the calcaneus (heel bone) (Almekinders et al, 2007).

Common symptoms of mid-portion Achilles tendon tendinopathy:

1. Pain and swelling of the tendon

2. Pin-point extreme tenderness on touching the tendon

3. Pain with activities such as running, skipping and jumping

4. Pain and stiffness worse in the morning or after sitting still

5. Pain eases with gentle activity

6. Pain increases a few hours or the day after an activity such as a run

We believe it is important to gain a more specific diagnosis and for this we carry out a diagnostic ultrasound scan.

Gaining more information about exactly which part of the tendon is affected and the severity of the condition is important to implement the most effective treatment plan for your specific problem.

Diagnostic ultrasound is the gold standard imaging tool for assessing tendon structure not only in the Achilles also in other areas of the body including the shoulder (Stenroth et al, 2019). It is superior to MRI for this condition and many tendon complaints.

A diagnostic ultrasound scan will be able to answer these key questions:

1. Which part of the tendon is injured?

If the tendon itself is swollen and inflamed then it is diagnosed as a tendinopathy. If the thin layer of tissue surrounding the tendon (known as the paratenon) is swollen and inflamed it is known as a paratendinitis. These two conditions are treated differently and so gaining this information is vital.

2. Do you have a tear in the tendon?

This cannot be established through clinical assessment alone and requires a scan. A scan will not only inform us whether there is a tear or not, but also the size and location of the tear. Again, this can influence the optimal treatment programme for your Achilles tendon.

3. Are there other structures involved?

A diagnostic ultrasound scan will also demonstrate whether or not other structures involved in your problem. Such as:

  • a nerve (called the sural nerve), which is located on the outside of the tendon
  • a small tendon (called plantaris), which is located on the inside of the tendon
  • or the bursa (called the retrocalcaneal bursa) located at the heel bone

4. How inflamed is your tendon and how severe?

A scan will determine how much inflammation there is in the tendon and also the stage of the injury. The ultrasound has a mode called power Doppler, which can assess how many new blood vessels have formed as a response to the change in the tendon structure (more later). These new blood vessels can form a target for one of the injection techniques (more later).

The information we can gain from an ultrasound scan is essential to optimise your recovery.

At Complete we will carry out an ultrasound scan as part of your assessment. We do not charge extra for the scan. If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

How is a mid-portion Achilles tendinopathy treated?

Most people respond very well to conservative management of a mid-portion Achilles tendinopathy. This commonly involves a specific set of home exercises designed to strengthen your Achilles and calf muscles. Approximately, 50-60% of clients will improve with a specific, tailored exercise programme.

Exercise prescription should be prescribed and supervised by a physiotherapist.

If you are a runner here are a few tips which might help;

  • Reduce the activities which irritate or increase your pain. For example, if you get pain running, consider reducing your training load by 50% for 2 weeks.
  • How old are you will trainers? If you wear trainers over 6 months old or you have run over 500 miles in them, it may be time for a new pair.
  • Applying a small bag of frozen peas in a tea towel over your Achilles for 10 minutes will help reduce your pain. Be careful not to cause an ice burn.
  • Eccentric heel raise exercises can help strengthen your Achilles tendon and calf muscle. Here is an exercise that can help – try this exercise 3 sets x 15 reps everyday for 4 weeks. If this exercise does not help after a month or makes the pain worse then we would suggest you are assessed by one of our expert clinicians.
  • Try applying a topical anti-inflammatory gel such as Voltarol however, speak to your pharmacist first.

What if physiotherapy has not helped your Achilles pain?

In some cases, conservative management may not resolve your pain. If this is the case there are two main treatment options.

Extracorporeal Shockwave Therapy (ESWT)

Shockwave therapy is an effective treatment modality and is supported by a large body of research. Approximately, 70% of Achilles issues will improve with shockwave therapy (Korakakis et al, 2017). It is an effective and safe treatment for Achilles tendinopathy.

Shockwave therapy produces a small dose of controlled microtrauma to the Achilles tendon by means of powerful pulses of soundwaves. This stimulates the body’s natural healing process, allowing the tendon to repair. Local nerve endings surrounding the painful tendon become desensitised by these pulses, resulting in further pain reduction.

Recent evidence suggests positive results with the application of 3-5 shockwave sessions running concurrently with a progressive loading exercise program for the treatment of all lower limb tendinopathies.

All clinicians at Complete are trained to deliver shockwave. If you would like more information concerning shockwave therapy, please contact us.

Ultrasound guided injections

There are a few injection techniques available for treating mid-portion Achilles tendinopathy. These are reserved for cases that are not improving with exercise based physiotherapy.

All these injections are designed to be carried out alongside your rehabilitation exercises. Injections are not stand-alone treatments.

Furthermore, we do not recommend injections to be carried out into the tendon itself. The injections we use target the structures surrounding the tendon, which have been shown to be the source of the pain in mid-portion Achilles tendon problems.

1. High volume/’stripping’ technique

This is a novel injection technique which we have been using for many years at Complete. It accounts for approximately 80% of the injections we carry out for mid portion Achilles issues.

It involves injecting a large volume of saline (sterile water) mixed with local anaesthetic, with or without steroid, to ‘strip’ the surrounding fat and vessels (known as neovascularisation) away from the Achilles. This procedure must be carried out with ultrasound guidance and can be an affective remedy.

When a tendon becomes tendinopathic the internal structure of the tendon is altered. The tendon becomes thickened and a process called neovascularisation occurs. Neovascularisation is the growth of new blood vessels in response to an injury to the tendon. These new vessels bring with them small nerves, which have been shown to be one of the causes of the pain in Achilles tendon problems.

High volume ultrasound-guided injection is designed to disrupt the neovascularisation and reduce the pain to allow you to accelerate your recovery  (Barker-Davies et al, 2017).

Current research shows that ultrasound guided high-volume injection for Achilles tendinopathy can significantly reduce pain and increase function when accompanied by a progressive exercise loading program (Walkley et al, 2019 and Maffulli et al, 2012).

The decision to inject steroid or not is dependent on many factors and will be discussed at your appointment once a scan has been carried out. Steroid, also known as corticosteroid, is a strong anti-inflammatory and is excellent at reducing pain in the short term. However, this has to be carefully considered as there are reports of tendon rupture following corticosteroid injection around load-bearing tendons (the Achilles tendon is a primary load-bearing tendon).

A systematic review of randomised control trials completed in a study conducted by Coombes et al (2010) concluded that only one case of tendon rupture was observed in the 991 participants.

2. Plantaris related pain

If you have pain on the inside of the Achilles tendon and an ultrasound scan reveals that your Achilles pain is related to the plantaris tendon, the plantaris tendon can ‘rub’ on the Achilles tendon causing pain.

We would then plan to carry out a high volume injection technique described above but it would be slightly modified to target Plantaris. The injection technique aims to separate the plantaris tendon away from the Achilles.

Complete Physio has a team of highly experienced physiotherapists who are fully qualified musculoskeletal sonographers, independent prescribers and injection therapist clinicians, fully qualified physiotherapists and musculoskeletal sonographers. Complete are able to offer a same day service for all guided injections. There is no need for a GP referral.

For further information please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

References

ALMEKINDERS, L. and MAFFULLI, N., 2007. The Achilles tendon. London; New York: Springer.

BARKER-DAVIES, R.M., NICOL, A., MCCURDIE, I., WATSON, J., BAKER, P., WHEELER, P., FONG, D., LEWIS, M. and BENNETT, A.N., 2017. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskeletal Disorders, 18(1), pp. 204-12.

BOESEN, A.P., LANGBERG, H., HANSEN, R., MALLIARAS, P. and BOESEN, M.I., 2019. High volume injection with and without corticosteroid in chronic midportion Achilles tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 29(8), pp. 1223-1231.

COOMBES, B.K., MPhty, BISSET, L., PhD and VICENZINO, B., Prof, 2010. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet, The, 376(9754), pp. 1751-1767.

KORAKAKIS, V., WHITELEY, R., TZAVARA, A., & MALLIAROPOULOS, N. 2018. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med, 52(6), 387-407.

MAFFULLI, N., SPIEZIA, F., LONGO, U.G., DENARO, V. and MAFFULLI, G.D., 2013. High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Physical Therapy in Sport, 14(3), pp. 163-167.

MALLIARAS, P., BARTON, C.J., REEVES, N.D. and LANGBERG, H., 2013. Achilles and Patellar Tendinopathy Loading Programmes: A Systematic Review Comparing Clinical Outcomes and Identifying Potential Mechanisms for Effectiveness. Sports Medicine, 43(4), pp. 267-286.

WALKLEY, D., 2019. High-volume peritendinous injections in the management of Achilles tendinopathy. Ultrasound in medicine & biology, 45, pp. S7.