Achilles Insertional Tendinopathy

A recent patient of mine presented with long standing Achillies tendinopathy. Having not done well with an eccentric loading programme, Shockwave therapy or rest with his fair share of anti-inflammatory medication, he opted for surgical review to try and settle his pain in the hope he could return to playing Soccer one day.

As part of my research on how to best meet the goals of this patient, I came across fascinating views on how to approach a patient who has tried many things and found no success. Here is some insight on the topic of how we treat an Achilles tendinopathy.

Achilles tendinopathy is an umbrella term for the various types of injury that can affect the Achilles tendon, this includes inflammation and degeneration, and is characterised by pain to the patient. A typical presentation of Achilles tendinopathy is pain felt in the initiation of loading or as you start to run for example. There are two types of tendinopathy – mid-portion and insertional. Both are differentiated by injury location. Mid-portion is in the thick of the tendon about 2-7 cm above the heel bone, while insertional is at the enthesis at the heel bone.

These two types of tendinopathy can be loosely differentiated by where you feel the pain and activities that bring on the pain. As Physio’s we explore your history on whether your pain is due to tensile load through the tendon which more favours a diagnosis of mid-portion, compared to the amount of compressive load which would be more associated with insertional tendinopathy.

Part of understanding a patient’s injury is to understand the patient as a whole, do they have any conditions that may influence their recovery, or are they generally well. And what are their expectations to their pain and their recovery. This helps guide how we can best meet their expectations. There are those with no other influencing factors and a positive outlook at one end of the spectrum and those who fear the thought of moving an old injury (as the pain sent them through the roof once) and they expect this to happen every time.

Equally as important is understanding how they tolerate load. This is simply by trying a movement. I would start with standing, then on one leg, then doing a heel raise, a single leg dip and progressively getting more complex from there. Load is good for tendons. Previously the focus was on eccentric loading as our best type of exercises, now there is great research pointing to isometric loading programs and isotonic programs having great success at rehabilitating a painful tendinopathy. The key is that we are loading a tendon. The specifics of how we load depends on how the patient tolerates these loads. It’s all about context. If you are extremely painful in a heel raise on one repetition for about a week, clearly this is not a great exercise. Likewise, if you do not respond well to an eccentric loading program, as this patient hasn’t, it is likely there is too much compressive load and would benefit more from another type of program.

For insertional tendinopathies I like to start with a wedge or a block under the heel to limit the compressive load, some authors suggest as high as 4.5cm initially, again it comes down to load tolerance on how high this needs to be. As they become more tolerant with loading we can progressively load further by adding weight, typically by putting on a backpack with weight in it, or using a smith machine or heel raise machine at the gym.

A steady progression of increased dorsiflexion through exercise then follows, decreasing the size of a wedge to getting a patient into more ankle bend. And then we progress into more dynamic movements that the overall goal demands, like returning to running for a soccer player.

Some researchers suggest that the focus lies more in how a patient copes with load, rather than how we can load to affect a traditional adaptation in the tendon structure. How a patient copes is different for everyone and time-frames are varying.

If you are finding a niggling Achilles holding you back come in and speak to one of our Bend + Mend Sports Physiotherapists and we can assess the right treatment to best suit your needs and fulfil your goals.

Campbell Hooker

About Campbell Hooker

Campbell Graduated from AUT University and has worked in private practice in both Australia and in London. Campbell has a keen interest in sporting injuries, office based injuries and the neck. He has worked at grassroots and elite levels of rugby union and league, and with surf lifesaving. He has recently taken to triathlon where he spends most of his spare time. Campbell has an interest in neurological conditions and has a Neuroanatomy degree out of Otago University. He utilises a number of methods when both analysing and treating patients, including dry needling and the Sarah Key Method.

12 Comments

  • Joel Nathe says:

    Hi
    I injured my right ankle about 2 months ago – either bowling or golf swinging at indoor range – not sure exactly. After about 2+ weeks of it not getting better I went to the Doc (it may have been aggravated when doing some stretches – pushing knee forward while foot flat). They Xrayed it with nothing noted. They also did an MRI. The report seemed to cover just about every thing and wasn’t explained very well to me (Tendinopathy, Bursitis, Bone spurs, Arthritis were noted but not necessarily where the real problem was). Part of the problem was normal movement by the doctor nor pressure in various places caused any real pain ( I probably could have done a better job prior to the appointment to figure out the pain source better, but part of it was just due to the inflammation). The doctor also wasn’t apparently very smart about loading it to create the pain.

    Per the doc, I went to PT. Some of these prescribed movements include things that you are saying aren’t good for Achilles insertional tendinopathy, are what were prescribed. Now that the swelling is gone and based on what you and some other reading say on the subject, I probably shouldn’t be stretching the achilles around the bone on ankle. The pain for me is when I load and push my knee forward and the pain is barely above the hard bone of my back heel(connection point).

    Seems you are recommending loading the achilles tendon, but not compressing it around the back heal bone. Right ? I am curious as this is exactly what my PT is doing, but it hasn’t improved over the last month +.

    I see you are aways away, but thought you would help answer this question. Not supposed to go to the doc right now with the Covid 19 issue. FYI I am a 56 yr old male.

    • Hi Joel,

      I’m sorry to hear about your right ankle pain. There are a number of things I would consider when prescribing exercises for your injury. Firstly the diagnosis is really important. It seems imaging hasn’t been helpful in narrowing down the pain source which is often the case. Your mechanism of injury is more important however.
      It would be interesting to assess some movements as you sound like you have some classic compressive pain. There’s a lot more to the picture than this though.
      If you would like a second opinion we have the option of an Online Telehealth consultation to talk through your injury, do a proper assessment, and look a little more closely at your biomechanics. This will help guide your exercise program required to resolve your pain long-term.

      Thanks for your question. The short answer is I would need a bit more information to help guide the actual exercises.
      I look forward to hearing from you.
      Campbell Hooker
      Physiotherapist

  • Travis says:

    I have had issues with my elbows for 9 years. I developed severe lateral epicondylitis in both arms when doing P90x training. About 4 years later, I discovered PRP. My lateral epicondyles are now pain-free, but I am left with nearly constant pain around the brachioradialis insertions. Nothing seems to help.

    Lately, I’ve also begun to develop medial epicondylitis in the R arm only. Stretching definitely makes things worse for me. Any recommendations? I am definitely hyper mobile at the elbows, which might increase likelihood of soft tissue injury.

    • Hi Travis,
      Thanks for reaching out. I can’t imagine how difficult 4 years of pain would be! You sound like you have a solid understanding of your injury as a result.
      It is really interesting noting your P90x classes and I am curious about how you exercised prior to this. As I have mentioned in many of my tendinopathy blog posts a sudden change is often associated with painful tendons.
      Also interesting about your positive experience with PRP.
      As always a definitive diagnosis is critical in injury management and this is especially important in your case as it helps dictate which treatment option is best. Diagnosis can be difficult with medial and lateral epicondylalgia as there are other areas of the body which can refer pain to the elbow which need to be ruled out. The diagnosis will also direct more accurate treatment decisions. Stretching in a lot of cases doesn’t help unfortunately, and in some cases can make the pain worse.
      I am also curious about your exercise since and your experience with these exercises as this has a major role to play in management. After a period of time the elbow will need re-loading with exercise again but in a controlled manner. It would be great to assess you in clinic and get the full story if possible.
      If you are in Sydney we would be more than happy to assess and help guide your injury management in clinic, otherwise we are available by remote Telehealth consult and I would be happy to see you online if this works for you.
      Thanks again.

      Campbell

  • Rachel says:

    I have tendonitis in my Achilles’ tendon as the result of side effects from levofloxacin. How do I treat this. It’s in both legs. I was sick so haven’t worked out in a couple weeks. I hope this is not permanent. I am over 65.

    • Hello Rachel,
      Thank you for your comment, I understand it must be frustrating to recuperate one ailment only to develop another. Firstly after reviewing literature by highly respected tendon researchers this is not an abnormal side effect. There are many studies that show causative links of your type of medication (Levofloxacin included) and tendon degeneration and pain. The medication is part of a larger family of medicines known as Fluoroquinolones. These seem to target the Achilles tendon more commonly. You are not alone!

      You also mentioned you have pain on both sides. It’s worth mentioning that bilateral pain may be attributed to a different diagnosis, such as referral from the lumbar spine. So it’s a good idea to make sure this has been ruled out first.

      The exact mechanism of how these medications cause Achilles pain isn’t entirely known. It is thought that they disrupt the constant building and breakdown of normal tendon structure (collagen fibres). This may be via starving the cells that rebuild collagen, directly targeting and disrupting the collagen fibres or by changing the way the cells in the tendon behave.

      Pain usually is the first sign, and if exercise persists there is a risk of tendon rupture.
      How long this goes on for is poorly understood too, pain and increased risk of rupture can last for up to 6 months. Fortunately the pain does settle and you can go on with exercise at some point in time.
      My advise would be to avoid taking anti-inflammatories if possible, these will also alter tendon cell function. Secondly find some suitable ankle braces to help reduce your pain if applicable. And then gentle loading exercises as directed by an experienced clinician will help to restore your normal function. Try and avoid what we call eccentric exercises in the commencement of your exercising.

      If you would like any guidance with your rehabilitation we offer Telehealth consultations for patients outside of Sydney. Alternatively come in and see us at one of our four City clinics.

      For more information please also look up a literature review by Trevor Lewis and Jill Cook from 2014 (Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature).

      Thanks again for your question!
      Kind regards,
      Campbell

  • Chelsea Wallace says:

    Hi my name is Chelsea and I believe I have tendinitis in my right elbow. As I am right handed it causes me extreme pain, I enjoy doing yoga and walking my shepherd. Are these kind of exercises allowed with tendinitis?

    • Hello Chelsea,
      Elbow tendinopathy is an interesting area of current research. There are many articles continuously reviewing the pain management from tendons in this region. It is an exciting area of expertise!
      Like all pain I would advise correct diagnosis of the source of the pain. You could have this pain from many different sources so finding the correct one is important when we consider rehabilitation exercises. If you are confident in your diagnosis I would also recommend looking at how much tolerance your elbow has toward certain yoga poses and walking the dog. This is tricky as tendinopathies usually warm up well and then when they cool down the pain can be higher.
      I am happy to discuss your management further if you like. We have 4 convenient city clinics, alternatively we offer Telehealth video link consults which may benefit if you are outside of Sydney Chelsea?
      Please reach out and let us know how we can help further!
      Kind regards,
      Campbell

  • Jeremy L Wall says:

    Hello, I am experiencing localized pain in my right ankle. I have suffered a full Achilles rupture in my left which was surgically repaired. The rupture was a loading injury while working, a Z formation ruptured it just above the bone attachment. Now my left Achilles will hurt right on the bersa sack location and radiate mostly in my heal about 3 inches in diameter from that point. Its becoming more often, the attacks, before it was once a year, now it’s once every 2 months. It lasts 6 to 8 days with rest, ice, elevation, topical ointments, and naproxen, with complete rest and no more movement than needed. I have also tried stretching I used for my recovery rehab, an 8 month rehab 3 years prior, from my first rupture. I am concerned because the first rupture never hurt or had a chance to show warning signs, it was an immediate injury. My question is, do I continue to stretch and rehab with loading and compression exercises or do I stay away completely and rest it? This pain will not allow me to walk. I feel my gate has caused this due to the left rupture which took almost 2 years to recover completely. Heel lifts are painful, very., but it doesn’t feel weak. Stretching the toes back with a towel hurts but very possible and actually helps some but it eventually returns. No part of my tendon hurts from the bersa sack location upwards into my calf, none at all. I haven’t done anything but rest and be very careful in between both flare ups, that’s what’s concerning me, no over use or the slightest indication of onset symptoms. I am a truck driver, my weight is above what it should be but nothing extreme for my frame. This results in lose of motion in the ankle, stiffness, and some heat and swelling in the exact spot, no major swelling at all. My wrist has been compromised for almost 6 months with lose of motion in all directions, weakness in my grip, pain in the top middle of my hand and pinky side of my wrist. It pops and cracks constantly when I grip or move it. In have also iced it and cared for it over thr 5 month duration with no real results or improvement. I have it in a stable splint most the day, still no improvement. It wrist injury is likely an overuse injury due to shifting. My question is the same, should I push the stretching and rehabilitation exercises? I have many appointments scheduled to find answers. I should have before now but I never get sick or need treatment. I went 30 years with no medications or treatment, other than comment colds, before my rupture and 3 years to date, without any problems. I guess this is my explanation for ignoring a doctor’s visit. Any information would be helpful.

  • Anne says:

    This is old, but I have a general question.
    How often do you see this sort of tendonopathy associated with psoriatic arthritis?
    For these patients, is treatment the same?

    Thank you

  • Stuart M Tomlinson says:

    Hi Campbell
    I’ve read with interest your articles on achilles tendons pain and exercising.
    I’m a 63 year old guy in the UK who has been relatively fir for my whole life. I have hypermobility issues, mainly in my back and wrists but am able to manage these. I regularly walk between 1500 -2000 miles a year with about a third of these in mountains up to about 3000 feet high. This year I did a couple of wild camps in the mountains and shortly afterwards about 4 months ago my achilles tendon started to give me trouble. I get a pain that seems to move position when I try to walk any distance but focuses between the mid to top of the tendon in the main, though occasionally near the heel. I also get what I describe as a crunching sort of pain under the outside of my ankle bone and over the top of my instep which doesn’t make sense to me.
    I’ve tried the usual rest and ice with anti inflammatories. I’ve had some sports physio and they think it may also be related to an old calf muscle tear. I’ve done some exercises including wobble cushions and bosu balls to try and strengthen the muscles around the tendon but am very careful of what I try because of my hypermobility. I’m currently awaiting an ultrasound scan but feel at the moment as if I’m getting nowhere. Everybody I’ve spoken to say that I’m doing all the right things and that it will just take time but as you seem to specialise in this I thought I would ask your advice please.

    • Hi Stuart,
      Thank you for getting in touch, I am pleased to hear you follow my blogs, thank you!
      It sounds like an interesting issue. I have to ask what exercises you have been doing? The way you describe the pain location is interesting, I think we need more information however. I am interested in type of pain, pain pattern over the course of a day, and since onset. And what provokes your pain other than walking.

      Most heel pain I attribute to a few things based on the points previous. These include Achilles insertional tendinopathy, mid-portion Achilles tendinopathy, enthesopathy, bone issues, referred pain and nerve issues, (not to mention inflammatory conditions like gout etc). The treatment varies for these diagnosis and can be as simple as rest, or as complex as a progressive loading program, or outside the realm of physiotherapy completely.
      I think you have made a good start by seeing a sports physio, they should be able to rule out other diagnosis, like what I mentioned above. If you are happy with your diagnosis you can focus on getting the right exercises at the right loads to help you both manage pain, and increase the load tolerance of the tissue (restore function). If you are not completely convinced of the diagnosis then a second opinion may be warranted. If you are convinced with the diagnosis then there are many cases I have seen which require patience and persistence.
      The ultrasound is a nice way to confirm a diagnosis, I wouldn’t send for a scan without having a fair idea of what I am scanning for however, a 63 year old tendon with some mileage will likely show some irregularities on a scan whether or not this is the cause of your symptoms, so keep this in the back of your mind.
      I hope this is a helpful response, apologies but it is always hard to give solid advice without making assumptions via forums, please keep me updated Steve!
      Once again thank you for your time to write to me, I look forward to hearing an update.
      Kind regards,
      Campbell Hooker

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