Achilles Tendinopathy and Shockwave Therapy

What is the Achilles Tendon? 

The Achilles tendon is the largest and strongest tendon in the body and plays an important role in walking, running and jumping. Achilles tendinopathy is a persistent tendon problem commonly associated with changes in load and tendon capacity. Shockwave therapy may be considered for some persistent cases after assessment, but it is not required or appropriate for everyone.

What is Achilles Tendinopathy and What Causes It? 

Achilles tendinopathy (AT) is caused by repetitive stress and overuse of the tendon. Activities that involve running, jumping, or sudden changes in direction are common culprits. Runners are particularly at risk because of the repetitive load placed on the tendon with each stride. However, it can also affect non-athletes who engage in activities like walking or climbing stairs. 

Who’s at Risk? 

Several factors can increase your risk of developing AT. Being aware of these can help you prevent the injury: 

• Age: Achilles tendinopathy is most common in people aged 30 to 50. As we age, tendons naturally lose flexibility and strength, making them more susceptible to injury. Regular stretching and resistance training can help maintain flexibility and strength, reducing the risk of injury. 
• Sudden Increase in Physical Activity: A sudden increase in exercise intensity or volume can put additional stress on the Achilles tendon. Poor technique can also contribute to AT. Make sure to monitor your exercise routine and ensure you are using proper technique. If you’re unsure, visit our YouTube channel for helpful exercise videos. Runners may also benefit from a gait analysis to improve running form and reduce the likelihood of injury. 
• Muscle Tightness: Tight calf muscles (gastrocnemius and soleus) can increase stress on the Achilles tendon. A simple knee-to-wall test can help assess this. Stretching and soft tissue massage can help release tension and reduce stiffness. 
• Previous Injury: If you’ve had an Achilles injury in the past, you’re at greater risk of experiencing tendinopathy again. It’s important to maintain strength and flexibility through consistent exercise to prevent further issues. Consider following a home exercise plan to help track your recovery progress. 

Symptoms of Achilles Tendinopathy

The most common symptom of AT is pain along the back of the lower leg, near the heel. This pain may start as mild discomfort and worsen over time, particularly with activities like running. Other symptoms include: 

• Swelling of the tendon, which may be tender to touch. 
• Stiffness, especially in the morning or after periods of rest. 
• In severe cases, small tears in the tendon can develop, leading to intense pain and functional limitations. 

If you experience any of these symptoms, it’s important to seek treatment as soon as possible to prevent further damage. 

Diagnosis Process for Achilles Tendinopathy

To diagnose Achilles tendinopathy, your healthcare provider will begin with a detailed assessment of your medical history and current condition. The practitioner will then perform a clinical examination to assess pain, swelling, and movement. A few common diagnostic tests include: 

• Range of Motion Tests: These help assess any limitations in movement, especially during dorsiflexion (lifting the foot upward). 
• Palpation: The tendon will be gently pressed to check for swelling or thickening, particularly in the mid-section of the tendon. 
• Functional Tests: A single-leg heel raise, following the Alfredson protocol, is often used to assess the tendon’s response to stress and help guide treatment. 

Additionally, a tool called the VISA-A scale may be used to assess the severity of your tendinopathy and track improvements over time. 

Treatment for Achilles Tendinopathy

Treatment for Achilles tendinopathy usually begins with progressive loading exercise, education and appropriate management of activity. The aim is to manage symptoms and gradually restore the tendon’s capacity, finding a workable balance between underloading and overloading.

• Underloading: When the tendon isn’t stressed enough, it may not regain strength. This lack of stimulation can prevent the tendon from healing properly. 
• Overloading: Too much stress placed on the tendon too soon can aggravate the injury and delay healing. 

The goal is to gradually increase the load to strengthen the tendon without causing further damage. This is often done through: 

• Progressive loading exercises: Exercises like eccentric heel drops, calf raises, and strength training that allow the tendon to gradually adapt to increasing loads without overstraining it. 
• Stretching: Gentle stretching of the Achilles tendon and surrounding muscles can help improve flexibility, reduce tension, and aid in the healing process. 

Medication decisions should be discussed with an appropriate healthcare professional. Pain medication is not a substitute for a progressive loading and rehabilitation plan.

Shockwave Therapy for Achilles Tendinopathy 

For persistent Achilles tendinopathy that has not improved with an appropriate period of usual care, shockwave therapy may be considered after assessment. It applies acoustic waves to the affected area, but the precise mechanisms and individual response vary.

Benefits of Shockwave Therapy

• Improves blood circulation to the injured tissue, which helps deliver oxygen and nutrients for healing. 
• Stimulates collagen production, which is essential for tendon repair. 
• Reduces pain by blocking pain signals and promoting the release of endorphins, the body’s natural painkillers. 
• For calcific tendinopathy, it can help break down calcium deposits that contribute to pain. 

The number and spacing of sessions should be decided after assessment and may vary. When shockwave is used, it is normally combined with an ongoing exercise and load-management programme rather than offered as a stand-alone treatment.

When Should You Consider Shockwave Therapy? 

Shockwave therapy is not necessary for everyone with Achilles tendinopathy. It is typically recommended for people with chronic tendinopathy who have not responded well to traditional treatments, such as physical therapy and home exercises. It is important to consult with your healthcare provider to determine if shockwave therapy is suitable for your specific case. 

Clinical Evidence Supporting Shockwave Therapy 

Research findings are mixed. NICE reports that evidence on effectiveness for Achilles tendinopathy is inconsistent and recommends specific arrangements for clinical governance, consent and audit or research. Rare Achilles tendon rupture has been reported, so benefits, uncertainties and risks should be discussed before treatment.

Shockwave therapy does not provide a guaranteed or linear recovery. Response differs between individuals and it should sit within a broader plan that addresses loading, strength, activity and the person’s goals.

References:  

1. Alfredson, H. & Lorentzon, R., 2000. Chronic Achilles tendinosis: Recommendations for treatment. Sports Medicine, 29(2), pp.135-146. 
2. Cacchio, A., De Blasis, E. & Barile, A., 2016. Efficacy of shock wave therapy in the treatment of chronic Achilles tendinopathy: A systematic review and meta-analysis. Clinical Orthopaedics and Related Research, 474(5), pp.1311-1318. 
3. Chiu, J.H. & Hsu, C.J., 2007. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis. The Journal of Foot and Ankle Surgery, 46(6), pp.440-446. 
4. Gerdesmeyer, L., et al., 2008. Radial extracorporeal shock wave therapy for chronic tendinopathy: A systematic review of randomized controlled trials. The Journal of Musculoskeletal & Neuronal Interactions, 8(3), pp.271-280. 
5. Khan, K.M., Cook, J.L. & Bonar, F., 2002. Achilles tendinopathy: Some aspects of the pathology and treatment. Sports Medicine, 32(5), pp.291-306. 
6. Maffulli, N., et al., 2004. Chronic Achilles tendinopathy: An update on management. British Journal of Sports Medicine, 38(6), pp.541-546. 
7. Meyer, T., et al., 2001. Overuse injuries in sports: A review. Sports Medicine, 31(6), pp.407-421. 
8. Möller, M., et al., 2001. Eccentric calf muscle training in the management of chronic Achilles tendinopathy. Clinical Journal of Sport Medicine, 11(3), pp.139-144. 
9. Physiotutors. (n.d.). VISA-A Achilles Questionnaire | PDF & Online Calculator. [online] Available at: https://www.physiotutors.com/questionnaires/visa-a-achilles-questionnaire/. 
10. Rompe, J.D., et al., 2002. Shock wave therapy for chronic Achilles tendinopathy: Results of a prospective, randomized, double-blind, placebo-controlled trial. The Journal of Bone and Joint Surgery, 84(3), pp.335-341. 
11. Rompe, J.D., et al., 2010. Extracorporeal shock-wave therapy for chronic Achilles tendinopathy: A randomized controlled trial. British Journal of Sports Medicine, 44(4), pp.211-218. 
12. Rompe, J.D., et al., 2014. Extracorporeal shock wave therapy for chronic Achilles tendinopathy: A systematic review. British Journal of Sports Medicine, 48(7), pp.525-530. 
13. upani, S. (2024). Achilles Tendinopathy – Symptoms, Treatments, Recovery and more…. [online] CARESPACE Health+Wellness. Available at: https://carespace.health/post/achilles-tendinopathy/. 
14. Wong, M. and Kiel, J. (2018). Anatomy, Bony Pelvis and Lower Limb, Achilles Tendon. [online] Nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK499917/. 
15. Zhao, L.P., Kong, L.M. & Li, J., 2017. Effectiveness of extracorporeal shock wave therapy for chronic Achilles tendinopathy: A randomized controlled trial. American Journal of Sports Medicine, 45(10), pp.2334-2342.