Heel Pain: Achilles Tendonitis, Tenosynovitis, and Tendinosis

Heel pain felt on the back of the heel instead of on the bottom where you would feel plantar fasciitis, could be Achilles Tendonitis, Tenosynovitis, or Tendinosis. This pain is usually described as stiffness and soreness that comes on gradually then continues to worsen till treated. Frequently the mechanism of injury is due to the tendon being overloaded with excessive tensile stress. This occurs during activities such as running and jumping especially while performing sports and recreational activity.

Many times, the injury occurs when someone begins a repetitive weight-bearing activity such as running during preseason workouts or beginning a new exercise routine. Commonly these activities are conducted with a progressive increase in duration and intensity that are increased too quickly without an adequate recovery period. In addition, poor gastrocnemius and soleus muscle length can also contribute to the onset of symptoms.

The vast majority of Achilles pain could technically be called a tendinosis. Typically, if a client has a long history of injury to the Achilles area, then it is usually not evaluated to have a large amount of inflammation. Instead it is considered to have a loss of normal appearance, disorganized collagen fibers, as well as a fair amount of scarring and degenerative properties that present upon evaluation with a ropey feel and coarseness to touch. However, if the injury is more acute then the tendon may be warm and painful to touch as well as thickened, which more correctly would be called a tendonitis. In general, injury to the Achilles may be resistant to fast recovery because of the poor vascularization of tendinous tissue when compared to other tissues like muscle tissue.

The difference between the Achilles tendonitis, tenosynovitis, and tendinosis is subtle. Knowing the difference among them can make a huge impact as it relates to treatment and how quickly it resolves. For example, a tendonitis is an acute inflammation of the tendon. When the tendon sheath is involved we would use the term tenosynovitis and when the tendon has become more degenerative and less inflamed we would use the term tendinosis. When a therapist suspects a more degenerative tendon verse a more inflamed tendon, then treatment may be more geared towards returning the tensile strength to the tendon via gradual strengthening. Additionally, the use of modalities can increase blood flow and circulation. In contrast, if the Achilles seems more inflamed, then treatment would include immobilization, rest and modalities to decreased blood flow and soft-tissue edema. If a therapist suspects the tendon sheath is involved, thus more scarring and that fibrous tissue formation is limiting the tendon motion within the sheath, then more progressive techniques such as cross friction massage and dry needling might be indicated.

Treatment for the Achilles area varies from person to person and injury to injury as well as the length of time someone has been dealing with the injury. Depending on symptoms and history of pain your treatment plan will be different. For this reason, it is important to consult a skilled Physical Therapist. At your visit, the Physical Therapist will evaluate your unique situation and determine the best treatment options for you which may include manual therapy, ultrasound, dry needling, taping, and/or therapeutic exercises. If you are tired of living with heel pain, you should consult a knowledgeable Physical Therapist to help you get back on your feet and enjoying the activities that you love.