How to treat Achilles tendon pain

There is no miracle method to overcome the pain in the Achilles tendon. Several methods are used. Our sports doctor, Yannick Guillodo, reviews them.

As explained in the article on calcaneal or Achilles tendinopathies , not all Achilles tendon pain is tendinopathy.
The decision to treat achilles pain in an athlete must therefore be preceded by a clinical examination and a precise ultrasound examination to determine whether or not it is tendinopathy.

Among the achilles pains of the sportsman which are not tendinopathies, let us quote:

Peritendinitis : the treatment of this inflammation of the peritendon is centered, obviously since it is an inflammation, on anti-inflammatory drugs: local treatment (ice, anti-inflammatory gel, tissue or dressing with anti-inflammatory drugs, etc. ), general treatment (i.e. anti-inflammatory by mouth) and sports rest for a few days. Generally, these peritendinitis have a short course and a cure is obtained quite easily. It is Achilles pain "the most sympathetic" for an athlete.

Enthesopathies: the treatment is more often centered on an infiltration of the pre tendinous bursitis. Indeed, in this disease of the junction between the tendon (Achilles) and the bone (calcaneus), there is often a local inflammation which is manifested by a liquid pocket which is called bursitis. When this bursitis exists, with the help of ultrasound guidance, it must be punctured and infiltrated. Generally, the results are good and do not hesitate to repeat this treatment, 1 to 2 times a year. But sometimes, this conflict between the bone and the tendon is chronic and there is a failure to this local treatment by infiltration. Surgery will then be used in some cases. This surgery aims to make the bone less aggressive on the tendon,

But, in around 60 to 70% of cases, the Achilles tendon pain in athletes is due to tendinopathy: disease of the body of the tendon. Many treatments have been and are still offered in the context of these pains. As always in medicine, if several treatments are proposed, it is that there is not a treatment, really effective, which is essential. We must therefore be careful and very critical of the statements that can be made about this or that therapeutic process.

What are these different treatments?

• Sports rest?

Certainly stopping physical and sports activity always leads to sedation of pain. But does it cure the disease? This is debatable because the same causes often produce the same effects. Why impose a rest of two months a sportsman if he reproduces the same pain upon the resumption of the sport is to say, the 61 th or 62 th day? It is not uncommon to encounter this case. We must therefore wonder about this strict rest for a period which is not really determined on objective criteria.

It is better to speak of adaptation of the sporting practice and to decrease, quantitatively and qualitatively, the training according to the pains of rust removal, in the morning, on waking. These pains, during the first steps, in the morning, are the real "thermometer", measuring tool, of Achilles tendinopathy. Indeed, if a training does not lead to an increase in pain, the next day upon waking, we can validate and authorize this training. Conversely, if a workout triggers the next morning a significantly greater pain and longer than a normal morning, this type of session should not be done. This adaptation of the training seems the best solution in the face of tendinopathy of the Achilles tendon body, especially when the ultrasound does not show a partial rupture.

• Medication ?

The often prescribed anti-inflammatory drugs have not really shown great efficacy in pure tendon disease. The ice , by cons, should always be applied after a workout. Remember  : it is never a mistake to apply ice to a painful area , provided you protect the skin (cloth between the ice bladder and the tendon) to avoid skin burns.

Corticosteroid (cortisone) infiltrations into the tendon are absolutely contraindicated .

• Dietary hygiene recommendations?

Apart from abundant hydration (drinking often in small quantities), there is no real evidence that diet plays a role in mechanical tendon pathology. Many articles are written on acidic foods, among others, which would have a share of responsibility in the cause or the chronicity of tendinopathies ... but without scientific element of good level . Drink abundantly, yes, modify your diet completely, no .

Similarly, in the sports world, we still cite this old medical hypothesis which dates back more than 30 years: tooth decay is responsible for tendon problems. Again, this hypothesis has never been proven. Obviously, athletes, like anyone else, must have perfect dental hygiene and regular follow-up with a dentist, but there are many runners who have dental cavities and who do not suffer from Achilles tendon, like many runners. who have perfect teeth and who suffer from tendinopathy. Too bad, but it is so, scientific evidence and beliefs in the field are sometimes contradictory!

• Re-education ?

The stretches and in particular the eccentric work of the sural triceps (calf) showed a certain effectiveness on the corporal tendinopathies of the Achilles tendon (nodule in the body of the tendon). You must therefore get into the habit of always ending a session with a specific stretch (eccentric work) of the triceps and Achilles tendon : put the front of the foot on a sidewalk or a stair step and descend the back of the foot in the air, always controlling this tensioning.

The other physiotherapy-type treatments (ultrasound, ionization, etc.) are certainly good adjuvants but with no real effectiveness shown.

On the other hand, in recent years, shock waves have appeared . They are in fact “small jackhammers” which strike the painful tendon. This treatment, generally done by physiotherapists who are equipped, seems really adapted to the nodule of the Achilles tendon. It takes between 8 to 12 sessions . If the results are zero, there is no point in continuing and conversely we can continue beyond 12 sessions if progress exists.

So overall, the physiotherapist , by teaching stretching (eccentric work of the sural triceps) and shock wave treatment, is the essential partner of an athlete who suffers from an Achilles tendon nodule .

• Intra tendon injections?

We have already said that intra tendon infiltrations of corticosteroids are contraindicated because the risk of rupture of the tendon, following these procedures, is not zero.

Some have proposed injections of Polidocanol. What is it about ? In fact, when we do an ultrasound, coupled to the Doppler, of a achilles tendon, there is sometimes a vascularization of this tendon. Indeed, thanks to the current power doppler technique, we can highlight small vessels in the tendon (in a normal tendon, we do not demonstrate vascularization). These vessels are therefore abnormal, but it is not yet clear whether this is an attempt to heal (the body reacts by creating new vessels) or the cause of the disease (it is these vessels which cause pain. because they are accompanied by nerves responsible for pain).
This recent notion, of vascularization of a tendon which suffers, is however capital and must allow in the future to better understand the tendon pathology and its evolution.
For some doctors, this vascularization is really pathological and must be "made to disappear". For this, as for varicose veins, they inject a product (Polidocanol) into the tendon to sclerose (close) these vessels. This therapeutic solution is truly experimental and has yet to prove itself. So be careful.

very popular, for several months now, PRP injections have also been offered in chronic tendinopathies. What is it about ? The goal is to inject growth factors, in larger quantities than naturally, to help the body treat the disease. These growth factors are normally present in our body and especially in the blood. Blood is therefore taken from the patient (conventional blood test) and centrifugation is carried out (blood tube placed in a centrifuge) to separate the different elements. We then extract a fraction, PRP (Platelet Rich Plasma) which is very rich in growth factor. This PRP (growth factors) is then injected into the tendon to try to speed up healing.
Although the process is appealing, intellectually speaking , studies show little or no net benefit at the moment . But it is certain that many sports trauma teams are working on this method and we will know in a few months if it is a real drug, effective for the patient who suffers from chronic tendinopathy or ... in a fashion " push ”by the laboratories that market this technique.
Here again, you have to know how to be critical and careful, especially since all the "manipulations" of the blood must be done under very strict conditions of asepsis and safety.

The other therapeutic procedures such as acupuncture and mesotherapy have a possible positive action, in particular on pain, but without frank scientific evidence. However, as simple therapeutic adjuvants, they can be included in the overall management of chronic tendinopathy.

• Finally the famous shoes and the adaptation to the ground?

For the soil, the change in surface can be a triggering factor (among many others) for Achilles tendinopathy. The organization does not like changes! Running on the sand or on the road is not the same thing. It is the change between these two surfaces, for example, that can be bad for an Achilles tendon.
Because, contrary to conventional beliefs in the sporting world, with good equipment, the road is no more deleterious than coastal or mountain paths .
On the other hand, the downhill raceis, biomechanically speaking, bad for the lower limbs. The load is increased by 2 to 3 times compared to the weight of the body (for example, a runner of 60 kg obliges his lower limbs to cushion 120 to 180 kg additional with each stride, downhill ... it's huge).

Here again, we must therefore be careful and critical of such and such statements that circulate in the middle of running.

Keep the best for later: the famous shoes and the orthopedic sole !
How many times have I not heard a patient tell me to have started or inversely cured his Achilles tendinopathy by new shoes or by wearing a plantar orthosis? For more information on this point, read the article "Tendinopathy, shoes and soles, what are the links?" »(LINK!).

Conclusion

The treatment of Achilles tendinopathy is a set of therapeutic procedures.

It is always necessary :

• Adapting your training (it's essential)
• Drink plenty
• Make stretching every night and end of sessions (learning a physiotherapist, eventually)
• Always apply ice after a sports session

Sometimes it takes:

• Make shock waves (and possibly add other physiotherapy techniques) to a physiotherapist equipped with this machine.

It is also necessary (why not?):

• Introduce other small means that we have mentioned (and others that we have not mentioned…) if the runner feels improved by one of these procedures.

Finally, you must:

• Wait for the progress of science to really understand this pathology where the vascular element is important