What is Achilles Tendinopathy?
Achilles tendinopathy encompasses three chronic conditions which cause pain behind the heel. Insertional Achilles tendinopathy (IAT) and retrocalcaneal bursitis (RB) occur where the Achilles meets the heel bone whereas non-insertional Achilles tendinpoathy (NIT) occurs further up the tendon. IAT and RB can be associated with age, obesity, new or unaccustomed activity, abnormal limb biomechanics, inflammatory arthropathy or gout. NIT has been associated with long distance running but in 30% of cases sufferers are sedentary. The conditions may co-exist.
What are the Symptoms?
IAT and RB cause pain and swelling at the back of the heel. NIT causes pain and swelling about 2-6cm further up the tendon. Pain is worse with activity. As the condition progresses pain can be present at rest and at night especially with IAT and NIT. RB may be worse immediately on walking after rest. Discomfort in shoes is common.
What is the Treatment?
Seventy percent of people will respond to non-operative treatment. IAT and NIT are not inflammatory processes so anti-inflammatory medication provides an analgesic role only. Any form of injection should be avoided, particularly steroids due the risk of rupture. Simple heel lifts from the chemist can be helpful and are a cheap alternative to orthotics. The only two forms of non-operative treatment with strong evidence to support their use are eccentric strengthening exercises and shock wave therapy (similar to that used to treat kidney stones). A physiotherapist or an appropriate podiatrist is a good place to start.
Failing non-operative treatment, surgery can be considered. The procedure depends on the condition. IAT requires an open operation to allow Achilles insertion reconstruction. Advances in suture anchor technology make detaching the entire Achilles tendon from the bone quite safe enabling complete debridement of diseased soft tissue and bone. The tendon is then reattached and mobilisation is commenced at two weeks. RB can be treated with Achilles tendoscopy (keyhole surgery) as a day procedure and walking is commenced in two weeks. There is growing evidence that the pain of NIT comes not from the tendon itself but from the sheath surrounding the tendon and the tiny nerves and blood vessels that have formed between them. The majority of NIT cases can be treated successfully with Achilles tendoscopy and stripping of the sheath from the tendon.