The Truth Behind Achilles Tendinitis

by Dr. Christopher on December 10, 2013

Achilles Tendon ScarDoes your Achilles tendon hurt?

Then you may have achilles tendonosis.

**Note: 97% of achilles tendon tears had a non-symptomatic achilles tendonosis present.  If you don’t want to end up like the person presented to the right, read on.

Why It’s Not “Achilles Tendinitis

The “-itis” ending in tendonitis or fasciitis implies “inflammation.”

Inflammation is the natural bodily process of attempting to heal.  It normal and healthy in musculoskeletal conditions such as a bruise on the arm or a torn hamstring.

It isn’t normal when the body is in a hyper-inflammatory (“hyper”= too much), usually through a diet consisting of grains (that include gluten), processed dairy, and lots of sugar.

The hallmark signs of inflammation are:

  • rubor – redness
  • tumor – swelling
  • calor – heat
  • dolor – pain

In tendon issues, the only hallmark sign that is present is pain.  None of the others show.

Contrary to popular belief, most tendon or fascia issues are not “-itis”or inflammatory issues but “-osis” or degeneration issues.  When technicians open up the fascia in anatomical studies or biopsies, inflammatory cells are not found.

Degeneration occurs when a tendon is either overloaded (too much work) or underloaded (not enough work) over time.

Observe the window of a box of spaghetti.  Notice all of the spaghetti are lined parallel to eachother, straight up and down.

Tendon fibers align parallel to each other when healthy

This is how the fibers are oriented in a normal, healthy tendon.  One that can handle the load you put on it.

Now take the box of spaghetti and cook it or worse, throw it on the ground (and waste it).  After either event, the spaghetti will no longer be parallel, but going in every which way direction.

Tendon fibers arrange in a haphazard fasion when unhealthy.

This is how the fibers are oriented in a degenerated tendon.  One that can’t handle the load you put on it (and lets you know with the fire alarm that is “pain”).

Conventional Management of Achilles Tendonosis

As mentioned above, degeneration in the achilles tendon occurs by doing too much or too little work.

It can develop in a runner who does fifty miles a day or in a tv-watcher who watches fifty tv shows a day.

Achilles Tendonosis is usually diagnosed under 4 conditions:

  1. Location – Achilles tendon.
  2. Palpation – The achilles tendon, 1″ above the insertion into the calcaneus, will thicken when degenerated.
  3. Range of Motion – Normal ankle dorsiflexion range of motion is 5-7″.  Someone with AT will usually present with a much decreased range due to adhesion in the deep calf structures listed below.
  4. Symptoms specific to the timing of load – Nirschl Tendinosis Pain Phases.

Nirsch’s Pain Phases are symptoms letting you know how far your tendon has broken down.  The cool part of this is as symptoms progress and an individual wants to simply continue working (and putting load on their body), then we can say objectively “Your body is breaking down.  You’re on a path towards greater damage.  How far do you want to take this?”

  • Phase 1: Mild pain after exercise, resolves within 24 hours.
  • Phase 2: Pain after exercise, exceeds 48 hours, resolves with warm-up.
  • Phase 3: Pain with exercise that does not alter activity.
  • Phase 4: Pain with exercise that does alter activity.
  • Phase 5: Pain caused by heavy activities of daily living.
  • Phase 6: Intermittent pain at rest that does not disturb sleep, and pain caused by light activities of daily living.
  • Phase 7: Contsant rest pain and pain that disturbs sleep.

Pain phases 5, 6, and 7 indicate increasing percentages of permanent tendon damage.

With a diagnosis, Wikipedia’s list of treatments for “Achilles tendonitis”: (notice the likely wrong diagnosis) includes:

  • ice
  • cold
  • compression therapy
  • wearing heel pads to reduce the strain on the tendon
  • eccentric Achilles tendon strengthening
  • NSAIDs
  • ultrasound therapy
  • manual therapy techniques
  • rehabilitation exercises
  • plaster cast application
  • steroid injection
  • autologous blood injections
  • prolotherapy
  • extracorporeal shockwave therapy

The four conditions listed above are enough to diagnose Achilles tendonosis.  The issue with this list of treatments is that it does not address the cause of the problem, only providing a plethora of random solutions.

Let’s look at the list again.

  • ice – implies “inflammation” is a problem and that the body doesn’t know what it’s doing in bringing immune system cells to the area of damage.
  • cold – implies “inflammation” is a problem.  But we’ve already clarified how achilles tendon-ITIS is not caused by inflammation, because the correct diagnosis is achilles tendon-OSIS caused by degeneration.
  • compression therapy – implies “a lack in pressure”.  Compression through the form of sleeves can help reduce symptoms by improving the elastic ability of muscles to stretch or contract.  Again, this is not addressing the cause of the problem though.
  • wearing heel pads to reduce the strain on the tendon – implies that “tightness” is a problem, which is often very true with ankle dorsiflexion.  While this treatment tool can reduce symptoms, it’s not getting rid of any pathology.
  • eccentric Achilles tendon strengthening – implies “weakness” of the tendon is an issue.  Actually, eccentric exercises greatly increase the effectiveness of treatment.  I like to recommend 2 sets of 15 reps of this exercise.  A 1-3 on the 10 point pain scale (with 10 being the worst possible pain) is ok and helpful in this case.  When no symptoms are experienced, you can increase the load with a backpack full of weights.
  • NSAIDs – implies “inflammation”.  These medications are not worth it.  Google “NSAIDS and gut health” and you’ll see why.
  • ultrasound therapy – I learned all about ultrasound in chiropractic school.  I don’t even bother with it.
  • manual therapy techniques – implies that “soft tissue” is a problem.  Now, we’re getting somewhere.  Do be weary of regular massage.  Stick to ART for the calf and ART/Graston for the achilles tendon and plantar foot.
  • rehabilitation exercises – implies that “weakness” is a problem.  Weakness can be involved, but not often.
  • plaster cast application
  • steroid injection – Skip it!  Studies show that they result in decreased tendon strength and only make the tendon worse!
  • autologous blood injections – A procedure where they inject your blood into the symptomatic area.  Results are variable as this is a fairly new procedure.
  • prolotherapy – Another fairly new procedure that appears to have some positive results.
  • extracorporeal shockwave therapy – A last new procedure that may prove effective as well.

How To Successfully Treat Achilles Tendonsis (Almost) Every Time

If these interventions were working, patients wouldn’t go from podiatrist to podiatrist, year after year, looking for answers as one of my patients did.

The NUMBER 1 problem in achilles tendonosis is that the tendon has started to degenerate and its fibers orient in a haphazard fashion due to scar tissue in the plantar fascia and deep calf stabilizing muscles.

Legitimate secondary problems are non-optimal bone alignment, scar tissue in the calf structures (tibialis posterior, flexor hallucis longus, flexor digitorum longus, flexor hallucis brevis), and risky activities of daily living.

Knowing what all of these problems are, a sweet spot solution needs to be delivered for each problem.

  • The NUMBER 1 solution for achilles tendonosis: Active Release Technique or Manual Adhesion Release – the best technique to remove scar tissue from the body.  The achilles tendon is a location where instruments such as Graston work very well, but the tools can only be used on superficial tissue (within one inch of the skin).  Graston would not work well on the deep calf structures mentioned above.
  • Load Management (Orthotics) – to correct bone aligment between the second metatarsal and the tibia.  As much as I used to believe that everyone should be walking around barefoot, faulty bone structure proves this belief wrong.  I learned this the hard way through destroying my own ankle with barefoot running.  I use Sole Supports in practice.
  • Load Management (Modification of Activities of Daily Living) –the body needs to be loaded just the right amount to be healthy.  Overload (running too much without sufficient time for recovery) or underload (sitting for eight hours a day) won’t keep the spaghetti lined up nicely in the box.  Only in introducing movements such as squats and lunges into an exercise program, taking breaks from sitting, managing the amount of running one days we can prevent this problem from developing in the future.
  • Increase Capacity (eccentric Achilles tendon strengthening) – Tendonosis is one condition that responds very well to eccentric exercises. I like to recommend 2 sets of 15 reps of this exercise.  A 1-3 on the 10 point pain scale (with 10 being the worst possible pain) is ok and helpful in this case.  When no symptoms are experienced, you can increase the load with a backpack full of weights.

Here’s the big picture: if you have achilles tendonosis and you’re not getting the scar tissue addressed through manual therapy, you’re not addressing the main problem.  Your symptoms may go away with Wikipedia’s interventions, but I’m confident in saying they will return.

You can find providers near you by clicking on the appropriate link: Active Release Technique, Graston Technique, and Sole Supports.

Any questions about this condition, feel free to ask.

Dr. Christopher Stepien is a chiropractor, chronic pain specialist, A.R.T. provider, and clinic director of the Barefoot Rehabilitation Clinic.  He practices out of Heroes Journey Crossfit in Parsippany, NJ.

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