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Achilles tendinopathy.

The lower leg consists of two bone pieces, namely the tibia (tibia) and fibula (fibula). At the bottom (near the ankle) we find consisting of different bone pieces then the lower ankle joint and the upper ankle joint. In the lower ankle joint, movements such as inversion and eversion take place. In the upper ankle, plantar flexion and dorsal flexion/extension take place. The musculature at the back of the thigh is popularly called the calf muscles. This is a muscle group consisting of the soleus muscle and the larger, overlying gastrocnemius muscle with a lateral and medial head. The m. gastrocnemius is bi-articular. This means that the muscle crosses over two joints and therefore exercises a function in two joints. Both the soleus muscle and the gastrocnemius muscle run over the upper ankle joint and are therefore mainly responsible for the plantar flexion movement (standing on the toes). The difference is that the gastrocnemius muscle also runs over the knee, causing the knee to bend. Ultimately, these muscles flow into the Achilles tendon and attach to a piece of bone called the tuber calcanei. 

Like everywhere else in the body, something can go wrong with the calf muscles/achilles tendon. There are actually two possible problems. A muscle (or tendon) can become overloaded or it can develop a (partial) rupture. Both problems have a different origin and a different pattern of symptoms. Making a distinction is therefore basically good to do with the physical therapist.

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What is an Achilles tendinopathy 

Achilles tendinopathy involves overuse of the tendon. This overuse usually occurs in the middle of the tendon or at the insertion. Therefore, these are the places where often recognizable pain is indicated. During every movement in which these muscles must be active, forces are transferred to the tendons and insertions on the bones. If this happens too often in a certain time frame, it can lead to irritation. Often Achilles tendinopathy is a symptom where people develop symptoms over time. In other words, this is because the tendon does not get enough rest after strain to recover properly. Hairline tears develop in the tendon, and as the body's attempt to keep the tissue in order, tendon tissue of poorer quality develops (tendinosis). These changes in tendon structure occur when the symptoms have been present for a longer period of time and would be visible on imaging studies. From the outside, you are not going to be able to feel or locate such changes.

Risk factors 

The most well-known risk factor for developing Achilles tendinopathy is repeating the same movement frequently. Think especially of activities such as running. In addition, history related to tendinopathies can be a predictor for the development of an Achilles tendinopathy and increasing exercise load can be a risk factor. Furthermore, weakness of the calf muscle and sinking the foot inward during walking are known to increase the risk of developing tendon overload. Furthermore, Achilles tendinopathy complaints have been found to be more common in winter than in summer. Research groups indicate that this seems to be related to the cold outside temperature during the winter period. So it is important to dress appropriately! 

Complaints and symptoms

The symptoms of Achilles tendinopathy consist of a convergence of several factors. We often see people playing sports that demand a lot from the tendon, such as running. Further fitting the clinical picture is;

  • Pain 2-7 centimeters above the insertion of the tendon. 
  • Complaints that develop slowly and increase over time.
  • Sometimes a thickening/swelling is visible locally.
  • Often first complaints after activity and when starting after rest, later sometimes at rest.
  • Demanding strength or just stretching the tendon can cause recognizable pain.

 

Research

Often the diagnosis of Achilles tendinopathy can already be made clearly following all the information from the intake interview. The therapist can use palpation to determine which part of the tendon is involved in the complaint. Further tests such as a stretch test and strength test can be performed, but have little further value in making the diagnosis. It would then be more about determining whether it is possible to perform these movements. 

Palpation

By palpating the Achilles tendon, it can be determined whether there is recognizable pressure pain here and any thickening in the tendon can be felt. A thickening is also visible in many cases, by the way. In addition, by palpation, a distinction can be made between midportion tendinopathy and insertion tendinopathy. 

Additional imaging studies

Performing imaging studies in the form of X-rays or ultrasound is basically not necessary when an Achilles tendinopathy is suspected. In general, the diagnosis is in fact easy to make and further examination does not change the policy to be followed. If there are doubts about the correct diagnosis or if an abnormal course of treatment is seen over time, additional imaging studies can be used. Both mid-portion tendinopathy and insertion tendinopathy can show long-term abnormalities in tendon structure and quality on ultrasound. If osseous (bone) abnormalities are suspected, an X-ray may be considered. This is in case of doubt in an insertion tendinopathy. 

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Treatment and forecast

The expectation in recovery from an Achilles tendinopathy is basically good. It is just hard to say how long recovery will take because it varies tremendously from one individual to another. A large proportion of people experience a significant decrease in symptoms within 3 months. This combined with proper handling of the symptoms and the right guidance. Unfortunately, there is also a fairly large proportion of people whose recovery can take up to 1 year or even longer. Do not be alarmed, because this does not have to mean that you will experience a lot of discomfort during this entire period and will not be able to perform your daily (sports) activities. Because recovery from Achilles tendinopathy can generally take a long time, it is important not to let it distract you from your goal. Make sure that even if things are down for a while, you still stay on track. Also, recovery will not be a straight line upward. It goes with ups and downs. Keep in mind that if you feel a little more again you won't have relapsed right away, but make sure you deal with it in the right way even then.

When you come to the physical therapist and the tendon problem has been diagnosed, you naturally begin treatment of the complaint. The first step in the process is to provide the right information and advice. Important for recovery is that you start making (temporary) adjustments in daily use of the tendon. So determine if the sports and activities you are currently doing are appropriate for your recovery process. If this is not the case, you will have to rearrange them or sometimes drop activities temporarily.This will give the tendon more time to rest. How long this advice applies depends on the course we will see over time. Assume in advance that it will be a process of months, then it might not be so bad. 

In the further treatment process, the physical therapist has several methods/techniques to help shape the treatment. The following treatment methods are best known for Achilles tendinopathy:

Massage/friction

There is some evidence in the literature about positive effects related to deep tissue massage in Achilles tendinopathy. However, the advice is to apply it in conjunction with an active exercise policy. 

Exercise Therapy

Literature advocates the use of exercise therapy in tendon complaints such as Achilles tendinopathy. In particular, eccentric loading of tendon tissue (loading while lengthening the muscle) seems to be able to provide the right stimulation to reduce symptoms over time. The idea is that controlled high tension on the tendon will stimulate it to start laying strong new fibers. In addition to taxing exercises, stretching the muscle is also used within the realm of exercise therapy. Holding the muscle/tendon in a stretched position for an extended period of time could produce pain-relieving effects. It is important that exercise therapy is applied with proper regularity and also sufficient rest to recover from the given strain.

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Heel elevation/tape/dry needling/shockwave 

The use of a heel raise has no scientifically proven effect. In practice, patients' experiences are mixed. Some say they noticed a difference when using a heel lift, others did not. The question is whether, if a difference was noticeable, it was based on the use of a heel lift. Based on insufficient scientific evidence to date, we cannot directly recommend its use.

Kinesio tape has gained greatly in popularity in recent years for a variety of physical complaints. For the treatment of Achilles tendinopathy, studies have not described a positive effect. On this basis, the use of this treatment method for these complaints is also not recommended. The same can be said about dry needling, shockwave and other forms of therapy. None of these will be successful if the complaints are dealt with adequately in combination with an appropriate exercise program. 

Medicated

Analgesic medication may be part of the treatment. This is especially advisable for people who experience a lot of pain. It should be noted, however, that it is of course the intention to comply with the given advice. Depending on the symptoms and the severity of pain, a choice of medication can be made. Never just go ahead with this. Your general practitioner is the best person when it comes to medication use. So always consult them before starting medication. 

A corticosteroid injection is not recommended for an Achilles tendon injury, but other types of injections can be used when exercise therapy, load adjustment and proper adherence to the rules of life do not produce sufficient results over time. An injection is not preferred as it does not improve the quality of tendon tissue. However, if natural recovery does not succeed, it is sometimes the best option. 

Conclusion

Several treatment methods are known for the treatment of Achilles tendon pain. The literature always recommends a foundation of load adjustment combined with an adequate exercise program for at least 12 weeks. Furthermore, there are several treatment methods that can be used in conjunction with this foundation. Mainly, these are advised to be used if insufficient results are achieved over time. The role of the physical therapist lies in advising and guiding this course. Perhaps the greatest challenge lies in that the injury may require considerable patience. 

Well, there are no short-cuts when it comes to tissue repair. Above all, be patient and make sure you deal with your symptoms as well as you can. Then you will have the best recovery over time. 

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