Achilles Tendon Pain
Achilles Tendinopathy - An MSK Therapy perspective
Achilles Tendinopathy is a common sports injury that can be very painful, severely hamper daily activities and can prove hard to resolve once Chronic. The injury is typically characterised by myofascial pain, swelling and general stiffness just above the heel bone (1 - 2 inches). One does not have to participate in sport to develop Achilles Tendinopathy symptoms. Most runners will have experienced Achilles Tendinopathy or know somebody who has. As with many conditions with an inflammatory component, symptoms are usually worst first thing in the morning and appear to improve with movement. Hence, it is quite common for people to push through the discomfort and or even run through the pain. However, the tissues then usually feel far more painful after the activity, and the pain, stiffness and swelling come back after rest or a nights sleep.
Common Causes of Achilles Tendinopathy include:-
- Blunt force trauma.
- Excessive calf muscle tension.
- Not warming up or cooling down sufficiently.
- Failing to stretch tissues effectively.
- Ankle injuries and unresolved tissue damage.
- Changes in joints, structures and or soft tissues affecting the "Kinetic Chain" (biomechanics).
- Unsuitable or damaged footwear.
- Changes in training and tissue adaptation.
- Changes in running style or surface (barefoot running, cross country, hills etc.).
- Changes in training affecting distance, speed, duration or load.
The Achilles Tendon deals very well with forces along its length, though it tends to react poorly to horizontal shearing type forces. Such loads can create damage/microtrauma to the collagen fibres within the Achilles Tendon matrix and even the muscles and fascia forming the tendon. Damage to the tissues results in the initiation of the bodies natural healing processes and the inflammatory tissue response (see Soft tissue repair, healing and scar tissue article). The inflammatory response leads to an accumulation of fluids and swelling around the Achilles Tendon, which partly acts as a cushion. However, one can view inflammation as a “double-edged sword”. On the one hand, the inflammatory process is a necessary aspect of tissue damage control and healing, and yet too much inflammation can create additional tissue/cell damage. Hence, this is why in the early stages of the vast majority of soft tissue injuries R.I.C.E. (Rest, Ice, Compression and Elevation) is advised and at least within the first 72 hrs post injury.
The Achilles Tendon is in essence made up of two lower leg muscles, the Gastrocnemius and the Soleus via the Musculotendinous junction. Each muscle has a separate origin (start point) and similar insertion (endpoint), though join at the Musculotendinous junction to form the Achilles Tendon. Research has also shown that myofascial trigger points may play a part in Achilles Tendionopathy. The image below shows the Gastrocnemius muscle above, or superficial to the Soleus Muscle. The Musculotendinous junction can be found in the lower one-third of the two muscles and forms the Achilles Tendon.
Image of Gastrocnemius and Soleus
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
(Copyright © 2018 - 2023 3D4Medical. All rights reserved.)
The Gastrocnemius muscle attaches at the (distal) lower portion of the upper leg and crosses the posterior portion or behind the knee joint and attaches to Calcaneus (heel). Hence, the Gastrocnemius muscle passes over two joint structures, (provided you class the entire foot and ankle complex as one joint).
Image of Gastrocnemius
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
(Copyright © 2018 - 2023 3D4Medical. All rights reserved.)
Unlike the Gastrocnemius, the Soleus muscle is connected to the posterior portion of the lower leg and the Calcaneus (heel) and thus only passes over one joint structure.
Image of Soleus
Images produced with kind permission of 3d4medical.com from Essential Anatomy 5
(Copyright © 2018 - 2023 3D4Medical. All rights reserved.)
The importance of specific calf stretching
One can often encounter problems with the calf and Achilles Tendon if one does not stretch these two muscles separately. In essence, the muscles have similar, but slightly different actions due to the attachment point locations. The fascial network within the tissues of the body will allow non-dysfunctional and hydrated tissues to slide across each other without pain or restriction, a critical factor in running and activity. Even with regular stretching one may still find that areas of tissues can become stuck, as self-stretching has limits. Changes to tissue structures can occur in both active and non-active people due to (see Soft Tissue Adaptation to activity and injury article for a more detailed explanation).
Seek professional advice
Once an Achilles Tendon injury has occurred, it is well worth seeking professional help or advice. The pain of an initial injury can start to affect how one moves, as the body tends to adapt to avoid pain as with most physical injuries. Over time these avoidance adaptation patterns can become learnt and create other problems in the kinetic chain. Furthermore, the longer the problem is left unaddressed, the harder it can prove to resolve, due to multiple tissue changes (see Biotensegrity and how everything is connected article). Identifying, the reason for symptoms of the problem is always crucial if one wants to have a speedy recovery. There is a multitude of therapists who regularly see and treat Achilles type injuries including; Sports Medicine Doctors, Myotherapists, Sports and Remedial Massage therapists, Chiropractors, Physiotherapists, Osteopaths, Sports Therapists, Acupuncturists and more. Each type of profession tends to have a different way of looking at a problem due to differences in training, experience and even philosophy. See the article on Finding a good, ethical Musculoskeletal health professional - An MSK Therapy perspective which offers some tips on finding a good patient-centred practitioner. Many runners will have met people with chronic Achilles tendinopathy, as it is easy to interrupt the healing process and re-injure tissues. Although the runner with the injury may not view the injury as chronic, it will certainly reach a point of preventing running, (see the article on Persistent Pain for further details on aspects of such conditions and treatment).
Self-treatment options
In some, cases, it may be possible to self-treat. As with any self-treatment technique, it is essential to understand the limits of any given technique. There should also be no contraindications to using the technique and one needs to be able to apply that the method correctly. It is also essential to have identified the reason for symptoms of a pain/problem or symptom, as this impacts when one would use a given technique and even if it is safe to do so. It would be easy to make symptoms far worse by applying the wrong technique. Hence why it is always good to see a professional in the first instance. Standard self-treatment techniques include foam rollers (see article) or stick rollers which both attempt to stretch tissues. Self-stretching is yet another option, though again tissues are usually already under load and so stretching tissues can place a further load on already damaged tissues. Self Trigger Point Therapy (TPT) (see article) can also prove useful when applied correctly and in the correct situation.
Combined Musculoskeletal and soft-tissue therapy
The author has found a combination of musculoskeletal, advanced Soft Tissue Therapy (STT) techniques (Sports Massage, Remedial Massage, IASTM, Dry Needling) and a graded rehabilitative programme to be highly effective in resolving Achilles Tendinopathy injuries, acute and chronic. However, that said it is better to avoid damage in the first place by following reasonably simple preventative measures. Injuries can still occur for unforeseen reasons, though preventative measures can help manage or minimise some of those risks.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
The Morningside clinic occasionally runs promotional treatment rates for new and existing patients, which are available via the online booking calendar. If you liked this article or found it interesting, feel free to share the content with others. There are lots more articles available via the TotalMSK main Health, Wellness and Sports Injury blog page, which has a brief description of all the articles to date.
About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession due to a planned move back to Australia, where his training and education are not recognised. Terry no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. He developed an early interest in soft tissue therapy techniques and advanced myofascial release methods in 2006 for treating various conditions. Terry's interests in human performance and trauma have naturally led to him developing a specialism in treating work and sports-related musculoskeletal injuries and Chronic Pain symptoms.
The author possesses an unusual background for somebody who trained in the McTimoney Chiropractic technique. His education, training, and practical experience span over two decades and relate to health's physical and mental aspects. He also needed to push his body and mind to the limits of physical and psychological endurance as part of his time serving in Britain's elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications (see the about section for more details). His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. He has also taught as a senior course coach at the Advanced Diploma level (Myotherapy / Musculoskeletal Therapy) in Australia, both theoretical and practical aspects, including advanced Myofascial Release Techniques and has certification in training and assessment. Terry will have taught many of the first students to train as Myotherapists in Brisbane. Terry's combination of knowledge through education, training, elite military service, and personal injury history has paid dividends for the patients he sees and has treated over the last 16 years. Terry is still extremely active and enjoys distance running, kayaking, mountain biking and endurance-type activities.