Heel pain at the lower achilles tendon insertion

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Heel pain at the lower achilles tendon insertion – a combination of cam and insertional tendinopathy – an example of comprehensive sports medicine management.
(Information for referring practitioners and informed patients)

Pain is activity related often particularly with push off especially running, ascending stairs, walking hills or on uneven surfaces. Pain may

Lower Achilles heel pain in an excessively pronated foot
Lower Achilles heel pain in an excessively pronated foot

persist for some time after the activity and is normally well localised to the back of the heel. There may be limited calf muscle flexibility (tightness). There is normally tenderness over the retrocalcaneal bursa between the upper back angle of the heel bone (calcaneus) (Haglund’s bump) and the front part of the Achilles tendon.
There is tenderness always at the actual bone attachment of the Achilles part way down the back of the calcaneus.
This is a combined overuse failure of the Achilles tendon.  Normally in dorsiflexion (pulling the foot up towards the shin) the lower part of the Achilles just above the insertion wraps around the upper back angle of the calcaneus.  The idea is to substitute some pulling (tensile) load that would otherwise be placed on the actual bony attachment of the Achilles tendon with a compressive load as the tendon wraps around the upper part of the bone.  This is a normal mechanism but sometimes if overused, particularly in squash or running on hills or uneven surfaces, the tendon can fail as a combination of tensile loading at the insertion and compressive loading as it wraps around the cam somewhat proximal.  Often the retrocalcaneal bursa is an innocent victim of this as it attempts to decrease friction with the cam action of the Achilles.
There are a number of evidence based interventions which have been shown to be effective in various stages of tendinopathy, in this case chronic degenerative tendinopathy associated with retrocalcaneal bursitis. This may be acute reactive tendinopathy but it is not inflammatory.

Plan of management:

  1. Direct local use of Nitro-Dur patches which release nitric oxide which can work against the promotors of the degenerative tendinopathy, particularly tumour necrosis factor alpha and the matrix metalloproteinases which are causing the degeneration through programmed cell death of the tenocytes (the cells that maintain the microstructure of the tendon) due to over-stimulation.
  2. Use of Ibuprofen which is better than most of the other anti-inflammatories and this can be used orally and again this has a similar action in reducing the degenerative tendinopathy but this also has a secondary effect on reducing the inflammation in the retrocalcaneal bursa.
  3. The use of Ketoprofen 20% cream locally which can have a dual effect of reducing the tendinopathy and also settling down the inflammation in the retrocalcaneal bursa.
  4. Avoiding activities as much as possible which involve placing the ankle into dorsiflexion under load such as walking up stairs with the toes on the edge of the step as mentioned above, and playing squash.
  5. Green tea extract, the equivalent of 6 cups of green tea a day has also shown to have an anti-degenerative tendinopathy effect.
  6. Fish oil capsules have a similar effect and these can be taken aiming at 1500mg of EPA per day (eg  3 Blackmores Omega Triple capsules per day), and this should be taken every day on a regular basis.
  7. The oral Ibuprofen (eg Nurofen) should generally be taken for a limited time or intermittently and this can be taken prior and sometimes immediately after, or sometimes with a meal after physical activities likely to flare up symptoms.
  8. Radial shockwave therapy has also been shown to be effective in tendinopathy. We have used this successfully at our clinic for some years now and this is normally given in three treatments one week apart, 2000-2500 shocks at 10Hz at variable pressure according to symptoms. There is good research evidence to support its efficacy and this is more likely to be effective than other more expensive treatments including PRP injections and certainly stem cell injections which are very expensive and not validated.
  9. Graded exercises including isometric exercises, 20 seconds at 70% of maximum voluntary contraction of the Achilles tendon muscles 5-10 times a day.  This can be done before and after symptom-producing activity as a means of reducing pain.
  10. Strength work done twice a week for the calf muscles doing heel raises, standing against a wall, doing 3 sets of 15 on the affected side. The number of sets of repetitions can be increased as symptoms allow (this may be more effective if physio supervised).

Treatment may take several weeks or months to resolve this condition depending on severity, compliance with activity modification and exercises and response to individual treatment components.

Dr Stuart Watson, Sports and Exercise Physician
January 2015