What is Achilles tendinopathy?

The Achilles tendon is the large tendon at the back of the ankle. It connects the large calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus) and provides power during the push-off phase of walking and running. Children with Achilles tendinopathy often also have pain in their plantar fascia. It is a very common overuse injury, especially in growing children and teenagers.

Very severe cases of Achilles tendonitis can cause a rupture of the tendon. This can take months to heal and may remain an area of pain and irritation in the future. This is very rare in children.

What are the symptoms?

Pain is usually felt at the back of the ankle and is often aggravated by activity and sport, especially walking uphill, running or climbing stairs. Symptoms are usually relieved by rest but may return when standing after resting or when first getting up in the morning. The back of the heel, or the middle of the tendon a few centimetres above the heel, may be tender to touch, swollen, lumpy or thicker than usual.

Treatment

Most cases are easily treated and heal quickly. The longer symptoms continue without treatment, the longer recovery may take. Returning to normal activities too soon or too suddenly can delay the healing process and make the condition more difficult to treat.

Failure to rehabilitate the tendon properly after recovery increases the chance of symptoms returning.

1. Home exercise programme (see below). This is usually what fixes the problem and is the cornerstone of treatment. It consists of stretching and strengthening exercises. Results can often be seen within four to six weeks if completed as advised. Severe cases may take longer.
2. Taping by your physiotherapist or podiatrist may provide relief.
3. A heel cushion may reduce pressure on the tendon. If used for more than three weeks, it may worsen the condition.
4. Plaster casting may be required if symptoms are very severe.

If symptoms remain after the muscle imbalance has been corrected by the exercise programme, foot orthotics may be necessary to reduce stress on the Achilles tendon. Changes to training schedules or techniques may also help.

Things you can do at home

• Ice: after your main activity for the day has finished, for example school or sport. Apply for 15 minutes to each area. You can reapply ice, but leave 10 minutes before repeating. You can use an ice pack or frozen peas, which mould well around the foot
• Anti-inflammatory medication: such as Ibuprofen. Follow the directions on the packet. If you are taking other medications, check with your GP or pharmacist first
• Rest: avoid activities that aggravate your condition. Do as much as you can comfortably
• Footwear: firm, supportive footwear is important to support your feet and body. If you take part in lots of sport, make sure you have the correct footwear for your foot type and activity.

Home exercise programme

Part one – stretches

You are doing the stretches correctly when you can feel a good, strong pull in the muscle. There may be some discomfort initially, but no tears in the eyes.

If possible, try completing some stretches before school as a good start to the day. This should only take five to 10 minutes of your day in total.

• hold the position for 30 to 60 seconds
• relax
• keep breathing
• complete five stretches per leg per day, five days a week as a minimum.

Calf stretch

• stand with only the ball of your foot on the edge of a bottom step
• keep your feet pointing straight ahead and your body upright
• gently drop your heel until you feel a strong pull at the back of the leg
• hold on to a banister for balance, but do not bend.

Hold: 30 to 60 seconds, five stretches per day, five days a week.

Hamstring stretch

• stand facing a bed, chair or sofa and use your hands to steady yourself
• place your heel on the bed or chair, bend your knee and place your chin on your knee
• then gently straighten your knee until you feel a strong pull at the back of the thigh.

Hold: 30 to 60 seconds on each side, five stretches per leg per day, five days a week.

Part two – strengthening

It is normal for a muscle to ache when it is being worked hard. This usually means you are doing a good job.

Stop when you feel like you cannot do any more, but try to complete one more repetition than you did the day before.

• do as many repetitions as you can each day, gradually building up to 35 on each leg
• only count good-quality repetitions
• it does not matter how few you start with. Doing more each day is the key
• use slow and controlled movements
• quality is more important than quantity. It is better to do five good repetitions than 10 poor ones.

Calf strengthening

• stand close to a wall with your hands against the wall for support
• stand on one leg, keeping the knee straight, and rise up onto your tiptoes. It is important to go all the way up
• gently lower back down in one controlled movement
• do not let the other foot touch the ground
• do not bend your knees.

Goal: gradually build up to 35 repetitions. If this is too difficult, begin by rising onto tiptoes using both feet. Once you can complete 20 repetitions comfortably, start practising on one leg.