Overview
Tendon heel pain is correctly named tendinopathy not tendinitis. There is no evidence of inflammatory cells but rather a degenerative condition due to overloading. This can be repetitive overloading or in a single episode. Predisposing factors can be excessive foot pronation (flat feet ) muscle weakness, Type 2 diabetes and years of overuse, such as running.
Presentation
Morning stiffness/pain at the base of the heel or middle of tendon is typical of tendinopathy. Pain post loading such as jogging or tennis is another symptom. This presentation can by enough to confirm diagnosis without use of x-ray/ultrasound and MRI .
If these hallmark symptoms are absent it may be necessary to consider non musculoskeletal causes.
Mid Portion Tendinopathy
This occurs 2-6cm above the base of the heel. At this point reduced blood supply occurs. The tendon can also rupture at this level. When compared to the non effected side swelling is noted and pain is reported when the tendon is palpated.
Insertional Tendinopathy
Not as common as mid portion tendinopathy but a more problematic management. The tendon can split and bone spurs can develop where the tendon inserts into the heel. Swelling is not as obvious compared with mid portion tendinopathy and pain is reproduced on palpation at the base of the tendon.
Management
Rest
Like many musculoskeletal (MSK) my advice is rest. If running 15-20 km per week or playing tennis once or twice weekly rest for at least a couple of weeks if not 6 weeks is recommended. Acute injuries are usually within 6-12 weeks before classified as chronic. The chronic Achilles Tendinopathy can be problematic to manage.
Can Physio help?
Traditional in rooms treatment may include soft tissue massage, ultrasound and ice. This aims to reduce swelling and improve range of movement. The rooms treatment is balanced with specific home exercises aiming to improve strength and endurance. The exercise programme is progressive becoming more challenging as strength improves.
Adjunct Treatments
Taping
Tape is applied over Tendo Achilles and calf muscle giving sensory feedback when walking. There are many brands ( Victor Pro-K Tape, Maxiplast K-Tape Rock Tape and Dynamic Tape ) but they all achieve basically the same effect.
Orthotics
Orthotics are used when the foot is pronated or rolling in. A pronated foot not only effects the biomechanics of the ankle and tendons but can effect the knee particularly Patella or knee cap.
Fitting orthotics is the equivalent to a wheel alignment on your motor vehicle. If the pronation is mild ,off the shelve orthotics can be fitted which alter the angle of the Tendo Achilles. With more severe pronation we recommend consultation with a Podiatrist who will custom fit orthotics.
Shockwave therapy (ESWT)
ESWT hypothesizes to promote blood supply particularly in insertional tendinopathy. It is generally viewed ESWT is more effective in the treatment of insertional tendinopathy than mid – portion tendinopathy.
Non Physio Treatments
Nonsteroidal anti-inflammatory medication (NSAI)
This include Nurofen, Mobic and Celebrex. There is not strong evidence to support the use of NSAI medication. Over the counter analgesia should be tried first.
Steroid injections
The effectiveness is controversial. Steroids are anti-inflammatory and as the tendon is not inflamed but rather degenerative their effectiveness is questionable. Generally the injection should be around the tendon rather than into the tendon.
Platelet –rich Plasma injections ( PRP)
PRP solutions aimed to harness the healing effects of blood and stimulate regenerative processes. This is controversial with some papers showing no evidence comparing to a exercise programme . However clinicians using PRP injections claim reasonable results and PRP injections may bridge the gap between conservative treatment and surgery.
Surgical Options
This basically involves debridement of the tendon and removal of bone spurs.
References Bruker & Khan’s Clinical Sports Medicine- Pain in the Achilles region with Hakan Anderson ,Jill Cook Karin Silbernagel, and Jon Karlsson
Dr. George Konidaris
MB.BS
(NSW) F.R.A.C.S (Otho )- Foot & Ankle, Hip & Knee Surgery
Dr. Paul Annett M.B.B.S (Hons 1) FACSP.
Sports and Exercise Medicine Physician
Dr. Peter Malliaras- Mastering Lower Limb Tendinopathy