In this first edition of “How to treat your injury” we focus on the Achilles. A quick look at the online traininglog Attackpoint shows that over 200 orienteers suffer presently from Achilles related injuries.
In orienteering and other sports where running, jumping and other impact-loads are common the Achilles tendon is sufficiently important. Achilles tendon injuries can vary in origin, acute versus overload, and localization. By chronic overload of the Achilles tendon an Achilles tendinopathy can arise. This overload injury of the Achilles tendon is quite common. In running 6-18% of the injuries exist of an Achilles tendinopathy. [1,2]
The Achilles tendon connects the calf muscles (m. triceps surae) with the heel bone (calcaneus). The calf muscles consist of the m. gastrocnemius and the m. soleus. Together they form the Achilles tendon in the direction of the heel bone, where it is attached. Near the Achilles tendon there are two bursae. In between the heel bone and the Achilles tendon and the other one is situated in between the Achilles tendon and the skin. [1,3,4]
With complaints in the Achilles tendon region you can think of multiple diagnosis:
- Overload of the Achilles tendon or an inflammation (Achilles tendinopathy / tendonitis)
- Partial rupture of the Achilles tendon
- Inflammation of the gel-like skin around the Achilles tendon (peritendinitis / tendovaginitis)
- Irritation of a bursa (bursitis superficialis / retrocalcanea)
- Combination of a bursitis and Achilles tendinopathy / tendonitis (Haglund’s syndrome)
- Impingement on the back of the upper ankle joint (os trigonum-syndrom / Posterior impingement syndrome) [2,4,5,6]
An Achilles tendinopathy can be diagnosed correctly based on the story and the physical examination by the General Practitioner or a Sports doctor. The doctor is interested in risk factors for an Achilles tendinopathy that can be changed like overweight, overall health, postural abnormalities, ankle instability, training surface and bad shoes. The training load is often increased, or there is not enough rest in the training plan (too much, too soon, too little rest). There is a classification in five stages with different symptoms of Achilles tendinopathy. Morning stiffness is a common symptom, but not mentioned below. [2,7]
Stages of Achilles tendinopathy
Stage 1: pain, stiffness and local tiredness after sports, wich disappears after a few hours
Stage 2: pain during the warming-up, wich disappears after a few minutes and returns after the training. After exercising more pain compared to stage 1
Stage 3: pain during sports, pain during daily activities and during the night. Pain only resolves after a period of rest
Stage 4: dito stage 3, but with decreased ability to perform
Stage 5: continuously pain which does not disappears after a long period of rest 
In the treatment of Achilles tendinopathy a lot of different therapies are used. Anti-inflammatory drugs, heel lifts in shoes, massage, tape, steroid injections and surgery are all used to a greater or lesser extent. However steroid injections near the Achilles tendon are almost not used anymore. This is because the chance of an Achilles tendon rupture due to softened tendon tissue. Basically there is no evidence for any of the different treatments for Achilles tendinopathy. Still a conservative treatment with – Alfredson’s – eccentric exercises is used more often, because multiple studies show positive results. [7,8,9] The eccentric exercises provide for example a greater reduction of the Achilles tendon thickness compared to concentric exercises. After the complete therapy there are also less complaints and the longterm results are better with eccentric therapy than with the concentric variant. [6,9,10] However, the level of evidence in the different investigations is limited and there is need for additional studies with more optimal study designs. 
We know you can not wait untill those researches are done. When you are suffering from an Achilles tendinopathy you can try to improve the present risk factors. For example to train your active ankle stability, replacing bad shoes and avoiding training mistakes like we wrote before. You can improve the condition of the Achilles tendon do to the – Alfredson’s – eccentric exercise therapy.
The eccentric exercise therapy of Alfredson consists of three sets, starting in toe stand, of fifteen repetitions of eccentric calf exercises with straight and flexed legs. To come to the toe stand both legs are used. The three sets of fifteen calf exercises with straight and flexed legs has to be done twice a day. The program needs to be followed twelve weeks, where the training should not to be stopped if there is a painful sensation. When the exercises are pain free you need to add weight till the exercise is painful again in the Achilles tendon. You can add weight for example to use a backpack with weights, books or bottles of water. 
Handout Alfredson’s – eccentric exercise therapy
We created a personal handout for you with Alfredson’s – eccentric exercise therapy and a table which you can use to count down the amount of exercises left.
This article is written by W. Foppen, BSc in Medicine still in education.
- Chang JH, Glass RM. Achilles Teninopathy. JAMA 2010; 303: 188
- Mosterd WL, Sitsen JMA, et al. Het sport-medisch formularium, een praktische leidraad. Bohn Safleu van Loghum, Houten 2005. Derde editie
- Ptuz R, Pabst R. Sobotta, Atlas van de menselijke anatomie. Bohn Stafleu van Loghum, Houten 2006. Derde, herziene druk
- Moore KL, Dalley AF. Clinically Oriented Anatomy. Lippincott Williams & Wilkins, 2006. Fifth edition
- Jongh TOH de, Vries H de, et al. Diagnostiek van alledaagse klachten. Bohn Stafleu van Loghum, Houten 2005. Tweede, herziene druk
- Verhaar JAN, Linden AJ van der. Orthopedie. Bohn Stafleu van Loghum, Houten 2007. Vijfde oplage
- Linschoten R van, Bom LPA, et al. Richtlijn Chronische achilles tendinopathie, in het bijzonder de tendinosis, bij sporters. Vereniging voor Sportgeneeskunde, Bilthoven 2007
- Alfredson H, Pietilä T, Jonsson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26(3): 360-6
- Mafi N, Lorentzon R, Alfredson H: Superior short term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrose 200; 9: 42-7
- Grigg NL, Wearing SC, et al. Eccentric calf muscle exercise produces a greater acute reduction in Achilles tendon thickness than concentric exercise. Br J Sports Med 2009; 43: 280-3
- Woodley BL, Newsham-West RJ, et al. Chronic tendinopathy: effectiveness of eccentric exercise Br J Sports Med 2007; 41: 188-98
The purpose of this article is to provide information regarding common injuries, however the information provided through this site has been provided primarily as a support system, and in no way as a replacement to health care providers. We advice our readers to consult a specialist in order to diagnose the injury.