What is the Achilles tendon?

The Achilles tendon attaches the gastrocnemius and soleus, commonly known as the calf muscles, to the calcaneus or heel. It functions in a similar way to most other tendons, in that it effectively acts to transmit force from the muscle to the bone. The achilles tendon also acts to absorb ground reaction forces such as with walking, running or jumping. Typically the tendons are able to withstand forces which cause deformation of the elastic fibres up to about 4%. More than 8% and there is enough stretch to cause trauma to the tendon fascicles. The amount of load a tendon is able to withstand is proportional to the thickness of the tendon. A normal running gait will meant the achilles tendon is loaded by up to 12 times one’s body weight.

What is Achilles tendinopathy, tendonitis and tendinitis?

The terms tendinosis, tendinopathy, tendinitis and tendonitis are often confused, which makes it difficult when trying to research the terms. The term tendinopathy is generally accepted to be an overall summary of the pathology at play, encompassing tendonitis, tendinitis and tendinosis. Largely a more specific description can be applied after histopathological examination; this should highlight the degree of degeneration (tendinosis) or inflammation (tendinopathy) which is resulting in the patient’s heel pain.

In recent years the occurrence of Achilles tendinopathy has risen – largely due to the increased incidence of people taking part in recreational activities and competitive sports. Although common in other sports (such as football, athletics and racquet sports), Achilles tendinopathy is roughly 10 times more likely in runners vs age matched controls. The condition may also affect people who do not take part in intense sporting activity, so the sedentary population are also at risk.

Symptoms include pain in the achilles tendon, often at the beginning or end of the training session. A nodule may often be present and may signify an element of degeneration according to some clinicians. Confirmation of achilles tendinopathy can be largely clinical but often radiological investigation is needed to quantify the level of deterioration of the achilles tendon.

What other treatments are available for Achilles tendinopathy?

Largely in the early phases, achilles tendinopathy can be managed conservatively by looking at various factors such as foot mal-alignments, poor ergonicmics and muscles imbalances. Modifying activities of daily living can make a significant difference in the early management of achilles tendinopathy.

Reducing activities that are known to aggravate symptoms may be all that is needed in the early stages of the condition. However, complete rest of an injured tendon can be detrimental due to the activation of tenocytes which lead to the release of matrix metallo proteinase (MMP) causing further degradation and permeability of the paratendon to permeating blood vessels.

Cold therapy has a benefit in the early stages as it slows down the inflammatory reaction in the tendon as well as having an analgesic effect on the afferent nerve fibres/receptors/endings. Ultrasound can be used in the acute phase to help reduce swelling and improve healing.
Laser has also been shown to be beneficial for management of acute and chronic tendinopathy. Deep frictions massage and stretching can be used in more chronic cases to help increase blood flow and reorganisation of collagen fibres.

Commonly eccentric muscle training is used to reduce pain in chronic achilles tendinopathy, as well as increase the tensile strength of the musculo-tendinous complex. Heel lifts are commonly used for the ‘off-loading’ of the achilles tendon during acute phases.

Several studies have looked at the role of drugs and injection therapy and concluded there is little evidence for the use of pertendinous and intratendinous corticosteroid injection therapy. Surgery is an option for more severe cases but the long-term complications and outcome measures are still in question. Shockwave therapy provides an alternative to surgery and, in most cases of tendinopathy, will result in a satisfactory outcome.

How is shockwave therapy applied to the area?

Shockwave therapy for Achilles tendinopathy is applied following a set protocol. The practitioner will review your history history, and do some orthopaedic testing to better understand the clinical history behind the condition. It is important to make sure that the condition being treated is actually an Achilles tendinopathy and is treatable with shockwave therapy. During the assessment, a tender point where the pain is maximal will be located, upon which an ultrasound gel will be applied. This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your Achilles tendinopathy will begin. There is typically some pain experienced, so the clinician will ensure the discomfort is minimal by adjusting the treatment settings to your comfort or tolerance level. Fortunately, shockwave therapy has a natural analgesic effect, so any discomfort diminishes as the treatment progresses. After treatment you should feel very little pain and this may last for a few days. After then an aching sensation can occur. After subsequent treatments there will be a definite improvement in symptoms leading to reduction in the original pain felt.

How many treatments are typically required?

Treatment of Achilles Tendonitis with Shockwave Therapy generally required 3-5 treatments of about 20 minutes each. This can depend on the exact presentation of symptoms and the patients level of tolerance for receiving the treatment. For example, if the first couple treatments need to be at a significantly lower intensity due to pain, then addition treatments may be required. Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.

It is vital that you continue to work with your therapist to maintain the exercise routine you should already be doing for achilles tendonitis. There is likely a biomechanical dysfunction that caused over loading of the tendon in the first place, which need to be addressed. If the underlying cause is not addressed, it is more likely that the pain and dysfunction could return in time.

What is the evidence for shockwave therapy and achilles tendon pain/achilles tendinopathy?

There is growing evidence for the use of shockwave therapy in the management of achilles tendinopathy. Largely the area of non-operative management of achilles tendinopathy has been poorly studied. One area that is of increasing interest is the use of shockwave therapy for the conservative management of achilles tendinopathy.
A recent paper has highlighted the previously gold standard eccentric loading programmes having inferior results to shockwave therapy at 4 months follow up. It is very promising that there are alternatives available which are proving better than what we have been prescribing previously (Rompe 2008).

How long will the effects of treatment last?

If everything goes to plan with your shockwave therapy for Achilles tendinopathy then the treatment should make a significant contribution to reducing the pain and improving the function of your Achilles tendinopathy. In most cases the shockwave will get rid of the tendinitis.
With some tendon surgery there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result. Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.

Conclusions: Shockwave therapy has proven to be better than surgery and better than the current non-operative measures used for management of resistant achilles tendinopathy.