Written By Chris Dohrmann, DPT
Posterior ankle pain is a common experience amongst active individuals. In a young and active population, achilles tendinopathy tends to be the most common cause of posterior ankle pain. However, not all posterior ankle pain is necessarily tendinopathy…and not all tendinopathies are treated the same.
A formal evaluation is often required to truly identify the correct diagnosis, or also to see if there are comorbid issues contributing to the problem. The good news is once this is identified, most of the causes of posterior ankle pain are very treatable using conservative care. In fact for a tendinopathy, conservative care in the form of mechanical loading (i.e. exercise), is the only grade A evidence and is often combined with other medical interventions when treating tendinopathies throughout the body such as rotator cuff, gluteal, and patellar tendon.
A tendinopathy by definition is a tendon that has been under excessive mechanical stressors, and has gone through a change in its make up. The term “opathy” alludes to this as a gradual process, because early characteristics of these changes manifest not as pain frequently, or pain enough to stop most individuals from activity participation. Some early characteristics can be stiffness notably around periods of increased training or loading. This process may ebb and flow for a while before symptoms begin to limit activity. This is often when these mechanical stressors have reduced the tendons capacity to act as a medium to transfer energy and also has effects on strength of that musculotendinous complex.
Characteristics of Achilles tendinopathy generally include a gradual onset of symptoms, pain and stiffness after periods of prolonged sitting or in the morning, tenderness at the achilles tendon, and pain with activities like running, jumping, and cutting. Characteristics that are not typical with tendinopathy include:
Symptoms that develop acutely (generally more consistent with an acute inflammatory process and can be comorbid with an already present tendinopathy)
Numbness, tingling, or burning sensations
Pain that worsens as activity continues. Generally speaking, at the beginning of activity, tendinopathies tend to feel stiff and sore and warm up as activity continues.
During a formal evaluation, the diagnosis is crucial to help determine the prognosis. In many cases, the prognosis for tendinopathy tends to be long, therefore early identification is crucial. The long prognosis is for a few reasons. First, if symptoms have been present for a while (see back to the paragraph defining tendinopathy), these mechanical changes in the tendon are not an inflammatory process that needs to heal. These changes need to be remodeled. The process of remodeling is implying a stimulus is required to promote a change in those tissues, and this process can take a long time. Second, the length of time until a diagnosis is made can have an impact on secondary effects like lower limb strength or flexibility, which may need to be addressed. While these effects generally don’t take as long to remedy, they can have an impact on the trajectory of the plan of care.
The good news is that throughout this process, symptoms like pain can improve pretty rapidly and manage throughout and activity tolerance can improve as well. A loading program will be implemented to help with this remodeling and is progressively increased throughout. With the right guidance and coaching, the program can be adjusted similar to how a strength training program should be adjusted every few weeks to avoid plateauing. Guidance and coaching will also be necessary to help balance a loading program with recreational activities.
We find that this guidance is invaluable, because it’s human nature to have doubts of whether this plan is putting you on the right path when there’s inevitable flare ups. However, there’s a lot of research now supporting that an active approach to recovery (i.e. performing activities that are less than or equal to 5/10 on a 1-10 pain scale) is at worst the same as an inactive approach. We would argue that this active approach is even better, as you’re not allowing the secondary effects of deconditioning to set in. Aside from deconditioning, we just know how important an active lifestyle is to overall health and wellness, sleep quality, and mental health, that to us remaining active is almost non negotiable.
Therefore, an early diagnosis allows for early differential diagnosis, allows for reduced secondary effects, and most importantly helps reassure and guide you to maintain the lifestyle that you want to lead all while knowing that you're moving in the right direction to addressing all too common, achilles tendinopathy.
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