Achilles Tendinopathy is characterized by pain, swelling, and impaired function of the Achilles tendon, which connects the calf muscles to the heel bone. As individuals of various activity levels and ages can be affected, it is crucial to approach its management with a holistic perspective.

If you want to learn more about this topic, you can watch Dr Peter Malliaras' lecture here:

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So what are the 3 important components of managing Achilles tendinopathy?

1. Education and load tolerance 

The first thing to educate a person with Achilles tendinopathy is talking about individual risk factors. So what are the factors that have led to this problem for that particular individual? It might be that it's load, change in load or change in activity. It might also be metabolic factors, hormonal factors or biomechanical factors.

The other thing that's important is to explain the pathology. So we know from our qualitative work that patients really value when someone explains that, this is what's happening to their body from a tissue level. And we know as clinicians that the tissue is not always the driver of our management. Often it's not. But it is important to provide this information.

As part of that, we also can start to talk about the mismatch between pathology and pain. So we know pathology can be present in people that don't always have pain, and starting to share that knowledge with patients is important to provide them with a full understanding of their problem.

Another aspect of education is explaining pain and what the likely mechanisms of pain are. Like in case of tendinopathy we know that it's most likely a local, nociceptive pain because of a tissue peripheral sensitization. But there are other factors also like biopsychosocial factors such as stress and attention and fear, kinesiophobia or expectations, that obviously can influence as well. 
Apart from this we also need to educate them about what we can do for their problem, the risks, benefits and why we are using any particular therapy.

2. Exercise 

When we talk about exercise for Achilles tendinopathy we use a graded progressive approach, where you're trying to progressively increase the loading of the tendon and do progressive activities that the patient finds painful or fears doing.  It could be things like running or jumping or specific sports type activities, or it could just be things like walking and walking up hills and doing various other things that are not typically thought of as things that really stress a tendon. 

For the progressive approach, isometrics is a good starting point because it's often less
painful and less provocative than anything else. We then move on to isotonic exercises followed by stretch-shorten cycle. 

To know more about exercises for Achilles tendinopathy watch this clip taken from the lecture ‘Achilles Tendinopathy: Management and Rehabilitation’ by Dr Peter Malliaras.

3. Adjuncts

NSAIDs : In terms of medication, anti inflammatories may be useful in short term like in an acute flare up. 

Heel wedges: A trial published in the British journal of Sports medicine stated that it is possibly more effective than exercise for some outcomes. Thus, heel wedges can be incorporated in our management as an adjunct.

Some other adjuncts which can be used are manual therapy, shock wave therapy and dry needling which have mixed evidence.

If you want to learn more about this topic, you can watch Dr Peter Malliaras' lecture here:

Click here

Sources:
1. Lecture ‘Achilles Tendinopathy: Management and Rehabilitation’ by Dr Peter Malliaras.