Achilles tendinitis
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Achilles tendinitis is a term used for pain, stiffness, and reduced load-bearing capacity of the tendon. In most chronic cases, a more accurate medical term is Achilles tendinopathy, as disruptions in extracellular matrix remodeling, collagen fiber disorganization, altered tenocyte activity, and local neovascularization predominate, while the inflammatory component is of variable severity. A distinction is made between mid-portion tendinopathy, located a few centimeters above the heel bone, and insertional tendinopathy, involving the junction where the tendon attaches to the heel. The cornerstone of treatment is controlled loading of the tendon, gradual rebuilding of calf muscle strength, and correction of factors leading to overload.
Achilles tendinitis - who is at risk
The Achilles tendon transmits forces generated during walking, running, jumping, and rising onto the toes. During running, its load can exceed body weight multiple times. Tendinopathy most often develops when the cumulative load exceeds the tissue's current capacity for regeneration and adaptation.
Groups particularly at risk include:
- runners, triathletes, and people engaging in sports with frequent accelerations, jumps, and changes of direction;
- people who abruptly increase distance, pace, the number of uphill runs, or training frequency;
- people returning to sports after a prolonged break;
- patients with previous tendinopathy, lower limb injury, or weakness of the gastrocnemius and soleus muscles;
- middle-aged and older individuals, including those engaging only in recreational activity;
- patients with diabetes, dyslipidemia, obesity, chronic kidney disease, or inflammatory diseases from the spondyloarthropathy group;
- people using glucocorticosteroids or fluoroquinolone antibiotics, especially with coexisting metabolic diseases and renal failure.
Limited ankle joint mobility, reduced plantar flexor strength, impaired lower limb control, and insufficient recovery may also be significant. Foot structure or a single running technique feature rarely explains the problem on its own. Tendinopathy is usually multifactorial in nature.
Achilles tendinitis - how to recognize
Midportion tendinopathy is suggested by four co-occurring features:
- pain located approximately two to seven centimeters above the tendon insertion;
- worsening of pain during running, jumping, climbing stairs, or rising onto toes;
- localized tenderness to pressure;
- tendon thickening, which may be subtle in the early phase.
In insertional tendinopathy, symptoms are concentrated within the lower two centimeters of the tendon, directly adjacent to the calcaneus. Typical features include stiffness upon waking or resting, pain with the first steps, and temporary symptom relief after warming up. As the condition progresses, pain may persist during daily walking.
The examination includes palpation assessment, ankle range of motion, calf muscle strength and endurance, single-leg heel raise quality, and the response to hopping. The VISA-A questionnaire, among others, is used to monitor function.
Ultrasound is the preferred imaging modality in cases of doubtful clinical presentation, an atypical course, or when planning procedural treatment. Magnetic resonance imaging helps in more complex cases. Structural changes visible on imaging also occur in individuals without pain, which is why the diagnosis relies primarily on symptoms and functional examination.
A sudden pop, an abrupt loss of push-off strength, a palpable gap along the tendon, or the inability to perform a heel raise require urgent evaluation for rupture. Differential diagnosis also includes partial tendon tear, deep bursitis, posterior ankle impingement, Haglund's disease, sural nerve irritation, and inflammatory rheumatic diseases.
Achilles tendonitis - what to avoid
During treatment, it is advisable to limit factors that increase compression or rapidly exceed tendon tolerance:
- sudden increases in mileage, intensity, the number of hill runs, and speed workouts;
- sprints, bounding, and uphill running during periods of high pain reactivity;
- weeks of complete unloading, which reduces the capacity of the tendon and calf muscles to transmit forces;
- aggressive stretching of the painful Achilles insertion;
- dropping the heel deep below the level of the step in insertional tendinopathy;
- randomly combining numerous therapies without a progressive loading program;
- masking pain with medication in order to continue full training;
- local glucocorticoid injections into the tendon area, due to the potential weakening of its mechanical properties;
- returning to full activity too quickly after a brief reduction in pain.
The acceptable level of discomfort during exercise is determined by the physiotherapist based on the body's response. The condition the next day is crucial. A marked increase in morning stiffness, pain, or functional limitation indicates the need to reduce the load dosage.
Surgical treatment is usually considered only after at least six months of properly conducted conservative management. The decision is preceded by a re-evaluation of the diagnosis and the quality of rehabilitation to date.
Achilles tendonitis - exercises and rehabilitation
The basis of rehabilitation is progressive tendon and calf muscle training conducted for at least twelve weeks. Eccentric, concentric-eccentric, or resistance training with a heavy, slowly performed load can be effective. The choice of method depends on the location of the lesions, the severity of symptoms, and the activity level.
The program progresses in stages:
- Symptom control: activity modification, isometric plantar flexion exercises, and maintaining endurance through tolerated forms of movement.
- Strength rebuilding: double-leg calf raises, followed by single-leg calf raises, performed with a straight and bent knee. Bending the knee increases the involvement of the soleus muscle.
- Increasing the load: calf raises with added weight, slow work through the full tolerated range of motion, and exercises for the entire lower limb.
- Energy storage and release: hops, jumps, skips, and plyometric exercises.
- Return to sport: run-walk, easy running, intervals, hill runs, sprinting, and sport-specific tasks.
For insertional changes, calf raises on a flat surface are initially used, and deep dorsiflexion of the foot is restricted. Temporary heel lifts can reduce compression and tendon load.
At Ambasada Urody, therapies complementary to rehabilitation are available: INDIBA Active and INDIBA Med, also combined with manual therapy, manual and myofascial therapies, sports endomassage, including ICOONE MED, as well as lymphatic drainage and pressotherapy for athletes. INDIBA uses 448 kHz radiofrequency to support microcirculation, pain management, and the biological environment for regeneration. Manual therapies and endomassage can improve tissue mobility and reduce excessive calf tension. Drainage is mainly used for coexisting swelling and a feeling of heavy limbs. These procedures serve a supportive function, while tendon adaptation is primarily ensured by appropriately dosed mechanical load.
Achilles tendonitis - how long does recovery take
The first noticeable improvement often appears after six to twelve weeks of systematic rehabilitation. Returning to full running and dynamic sports usually takes from three to six months, and chronic insertional tendinopathy may require a longer course of management. The rate of recovery depends on the duration of symptoms, the location of the lesions, comorbidities, athletic demands, and the consistency of therapeutic training.
Returning to activity should be based on functional criteria:
- daily walking and climbing stairs cause minimal discomfort;
- morning stiffness remains stable;
- single-leg calf raises demonstrate proper height, control, and endurance;
- calf strength approaches the parameters of the healthy limb;
- hopping, running, and sports tasks are well tolerated;
- training load remains without distinct worsening the next day.
Pain improvement precedes the full restoration of the tendon's mechanical capacity. For this reason, strength exercises should be continued even after the resolution of symptoms. Most patients regain function, but in some, symptoms persist or recur for many years. Gradually increasing loads and continuing calf muscle training reduce the risk of recurrent overloading.
