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1st Oct

2014

Effective Physical Therapy for Insertional Achilles Tendon Pain

Overuse injuries to the Achilles tendon are common.  The resulting pain may occur in the mid-portion of the tendon, or at its attachment onto the back of the heel.  The latter is referred to as the insertion of the tendon, and the overuse injury is called insertional Achilles tendinopathy.  Both mid-portion and insertional Achilles tendon injuries are found to be a result of wear and tear degeneration of the tendon, with tendon thickening, tendon weakness, and ingrowth of new blood vessels and fatty tissue.
In the case of insertional Achilles tendon pain, we are also dealing with an abnormality of the transition from the tendon to its bony attachment.  This is quite a complex tissue organ, referred to as the enthesis, where the tissue transitions from tendon, to fibrocartilage, to bone.  In the Achilles tendon, we also have a bursal fluid sac, called the retrocalcaneal bursa, which has walls made up of fibrocartilage as well.  These walls often degenerate as well, in cases of Achilles heel pain, with fissuring, fragmentation and calcification.  Eighty percent of people with insertional Achilles tendon pain have bumps on back of their heels, called Haglund’s deformity, and 70% have been found to have calcification within the tendon.  The changes that occur at the Achilles tendon attachment onto the bone, have been likened to changes we see in osteoarthritic joints.

Because the Achilles tendon has different tissue make up in the mid-portion and its heel attachment, the two types of Achilles tendon pain have to be treated differently.  The mid-portion type of pain has been found to be effectively treated with lengthening (eccentric) contractions in 1-2 sets of 10-15 repetitions at relatively high intensity, progressed over 2-3 months, to where the tendon can tolerate repeated strong contractions from a fully stretched position, e.g. with loaded heel drops off a step.

Insertional Achilles tendon pain, however typically fails such treatment in 2/3 of all people with this type of injury.  This is because the fibrocartilage at the heel insertion gets compressed with excessive strain, and in particular with full stretch put on the tendon.  This type of problem should not be treated with stretching, or with heel drop exercises into full stretch.  Instead, it is important to at first, add a heel lift to reduce stretch and strain on the tendon attachment, start exercising with relatively low intensity without putting stretch on the tendon, and it may be necessary at first to wear shoes without a heel counter, to avoid compressing the irritated retrocalcaneal bursa.
An appropriate exercise may be a modified heel raise exercise, wearing shoes with a small heel, with weight on both legs and leaning forward to put some weight on forearms, placed on a counter.  This exercise can be performed with 20-25 repetitions, in 3-4 sets, at first daily.  This can gradually be progressed by standing more upright and putting less weight on arms, to where all the weight eventually is put on the legs.  If this can be tolerated without increase in pain, further progressions would include one legged heel raise, at first again in the forward leaning position, and gradually progressed to where full weight can be tolerated, without the use of arms, in 3-4 sets of 12-20 repetitions, three times per week.  However, it is important not to let the heel drop down from a step throughout this process, so as not to put excessive stretch and strain on the tendon, which would cause excessive cartilage compression at its attachment on the heel.
You may know of someone with Achilles tendon pain, so feel free to forward this newsletter.

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