Achilles Tendinopathy Steroid Injections

Achilles tendinopathy is a common overuse injury caused by repetitive loading over time or a sudden increase of load to the Achilles tendon.

Achilles tendinopathy can be divided into two categories –
Midportion Achilles tendinopathy – where the injury is located in the middle part of the tendon.
Insertional Achilles tendinopathy – where the injury is located in the heel where the tendon inserts into the heel bone.

Symptoms of Achilles Tendinopathy

Common symptoms of Achilles tendinopathy include:

• Pain in the tendon or heel – this can be an ache or a sharp pain, which may get worse after increased activity, such as walking and running.
• Stiffness of the tendon which is felt first thing in the morning or after a period of inactivity.
• Thickening of the Achilles tendon or swelling at the back of the heel.
• Creaking feeling when moving your ankle.
• Tenderness to touch the Achilles tendon or heel.

Causes of Achilles Tendinopathy

Achilles tendinopathy is usually caused by repetitive stress to the tendon caused by a rapid increase of load. It is a very common condition found in runners, one in twenty runners will develop Achilles tendinopathy (Lagas et al, 2019).

This may be caused by a sudden increase of mileage or frequency, wearing unsupportive shoes with poor shock absorption or excessive hill training (Li et al, 2016).

Risk Factors that can increase your risk of developing Achilles tendinopathy include (Vlist et al, 2019) (Li et al, 2016):

• Weakness within your feet and lower leg.
• Training during cold weather without wearing appropriate clothes.
• Prolonged use of oral corticosteroids or certain antibiotics – such as fluoroquinalone.
• Inflammatory conditions such as rheumatoid arthritis or gout.
• Obesity.
• Diabetes.
• Older age.

Anatomy

The Achilles tendon (also known as tendon calcaneus) is the strongest and biggest tendon in the body. It attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). The blood supply to the Achilles is low and therefore has a slower healing rate following an injury.

How to diagnose

Your physiotherapist will take your history and ask a number of questions about your symptoms. They will then examine and assess the area – looking at your range of movement, strength and biomechanics. The physiotherapist will then advise on the diagnosis and explain the cause of your injury.

An ultrasound scan can also be performed in our clinic to confirm the diagnosis.

Physiotherapy Treatment

The majority of Achilles tendinopathy injuries will resolve with physiotherapy. The key for recovery is load management and following a progressive heavy resistance loading program. This will decrease pain, promote tissue remodelling and improve calf strength and endurance.

Our physiotherapists can guide you and provide a plan to ensure you safely return to exercise or sports, whilst minimising your risk for re-injury.

You may want to use a heel raise insert in your shoe to reduce the strain on the tendon and reduce pain whilst walking (Wulf et al, 2016).

If your pain is located towards your heel, it is important to avoid stretching the calf – for example hanging your heel off the edge of a step, as this can aggravate your symptoms.

Extracorporeal Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) is a non-invasive treatment which sends acoustic waves into the injured tissue which then stimulates the healing process. It also provides a temporary reduction of pain.

ESWT has been found to significantly reduce pain and improve function in those who have been diagnosed with Achilles tendinopathy (Santamato et al, 2019).

We can perform Shockwave therapy for your achilles tendinopathy in clinic if you would prefer to try conservative treatment prior to progressing to an injection procedure. Treatment usually requires 4-6 treatments over consecutive weeks and more information can be found about this treatment here:

Injection Therapy for Achilles Tendinopathy

For cases that do not improve with physiotherapy and ESWT, there are several injection techniques that can be used alongside your physiotherapy treatment.

Ultrasound guided Hyaluronic Acid Injection

Ultrasound guided Hyaluronic Acid Injections can be an effective treatment for mid-portion or insertional Achilles tendinopathy.  A small amount of hyaluronic acid is injected into the soft tissue surrounding the Achilles tendon and can provide a reduction in pain and improve gliding of the tendon by removing adhesions.

Research has found that this is a safe and an effective treatment option for those who have failed conservative treatment. A study by Ferraz et al (2021) found that after one injection for insertional Achilles tendinopathy there was an improvement in function and pain for at least 6 months.

Another study by Fogli et al (2017) found that an ultrasound guided injection of Hyaluronic Acid resulted in a significant improvement of pain and reduced tendon thickness. The same study also found no serious adverse effects.