The first in our new series of Pathology of the Month is: Achilles tendinopathy, this is when the Achilles tendon at the back of the ankle, becomes irritated.
Symptoms: pain, swelling, redness around the back of the ankle.
Onset: gradual onset over a period of time, commonly with a change in activity levels or can be more sudden as a reaction to a change in load.
Treatment: Rest to settle symptoms in the reactive phase, gradually building into mobility exercises alongside pain management techniques and strengthening exercises as tolerated.
Tendon attaches muscle to bone in order to allow us to move our joints.
The Achilles tendon inserts onto the Calcaneus which is the bony prominence at the back of the ankle. The two muscles which converge to form the Achilles are the Gastrocnemius and the Soleus.
The Gastrocnemius is the more superficial of the two and we can load these muscles differently depending on our position.
By contracting this causes us to point our toes or stand on tiptoes. For this reason the Achilles is very important in tasks such as walking, running, climbing stairs and jumping.
1. Start on the edge of a step (for mid portion only) or standing on the floor.
2. Gradually raise your heel up off the step/floor to the highest point that feels comfortable.
3. If performing on step you can lower into dorsiflexion to challenge range of movement.
*This can be altered for the reactive stage or position of tendinopathy by taking away the step and limiting movement to plantarflexion.
*If patient gets to a stage in their rehabilitation that we can start to load the tendon this should be done gradually with a manageable weight, we should also be able to test the patients capacity of exercise with their 1 rep max
Achilles Tendinopathy can be divided into different stages:
Reactive—this is the first stage of the tendon continuum which is a non-inflammatory response as a result of tendon overload. This can cause the cells to change shape due to the protein production and can be a relatively short adaptation but helps to thicken the tendon to reduce stress but increases stiffness. This stage occurs after sudden in case of stress or levels of impact to the tendon but at this stage the tendon has to potential to return back to normal.
Dysrepair—this progression can happen if the tendon isn't offloaded and allowed to return to a normal state. During this phase there is a continued increase in protein production as the tendon continues to try and heal from the first phase. Diagnosing this stage is the most difficult so recording of history is essential, this stage is reached by frequent overloading in the reactive stage and is more common In older and stiffer tendons.
Degenerative—this is the final stage of the continuum as the outcome is that the changes made to the tendon are now irreversible, the cells are documents to be generally disorganised and can appear thick with nodular sections on palpation. Typically this tendon is found in an older patient who has ongoing problems with a tendinopathy or a younger patient who continues to overload the tendon.