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.

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