Chronic Achilles tendonitis treatment – understanding the nature of pain

Pain is useful – our brains create it to protect us from danger and to help us heal from injuries such as Achilles tendonitis. But if pain lasts for too long, it becomes learned and can continue long after the danger has passed. This article explains how chronic Achilles pain can be “unlearnt” by understanding the nature of pain and by adapting your subconscious brain away from the perceived danger it is reacting to. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

In this article:

1. Why do we have pain?

2. Why and how does the brain react to pain?

3. Pain doesn’t relate to the severity of your injury

4. How chronic pain develops

5. How to deal with chronic Achilles pain – step-by-step

6. Where to get help

This article is based on an interview that I did with Caroline Marlow PhD, a Chartered Sport and Exercise Psychologist who specialises in injury and pain, whose details can be found here. And here is a video of the interview:

Why do we have pain?

The purpose of pain is to protect us from danger – current and future – and also to help us to heal. However, if you're in pain, it's really difficult to appreciate that it’s actually there to keep us safe.

Science leaves us in absolutely no doubt that pain originates in our brains; there is nothing in our bodies that can “detect” pain (Butler and Moseley, 2013).

What we do have are sensors all over and inside our bodies. But these can only detect changes in mechanical forces, like pressure and movement, temperature, and chemicals, such as acids. These sensors continuously send information about what they detect to our brains, but most of the time our brains ignore these.

For example, if you’re holding a computer mouse or a phone while reading this article, information about the pressure on your fingers is being sent to your brain. Because this is “normal”, your brain has ignored it … until this article alerted you to it. But still, you feel no pain, because the brain does not interpret those signals to mean that you’re in danger.

Now, if you were to hammer a nail into a wall and you accidentally whack your thumb, the signals about that kind of pressure will definitely cause your brain to swing into action and to create pain to warn you that what you’re doing is dangerous. Pain makes us change what we do. It makes us stop, it makes us move differently, and it makes us shield ourselves from harm – all the things that we need to do to help us heal and protect us from harm in the future.

Why and how does the brain react to pain?

So, what makes our brains take notice of certain signals and create pain in reaction to it? It uses other information from across the brain – much of it in our subconscious – and this differs from person to person, and for every person from time to time. This could be anything that makes us feel in danger, threatened, or worried.

Our beliefs play a crucial role in this; for example, the belief that the amount of damage that an Achilles injury has caused to your tendon is equal to the amount of pain you feel (it’s not – see below). Or that moving will be painful or hurt you - leading to a fear of movement.

We often hear about pain catastrophising; that's when people really over-emphasise the pain and the problems this is bringing them. So, it might be worrying that you won't be able to run again, or that the pain will never go away or even that you can't work again.

Your thoughts and fears can cause your brain to think you are under increased threat.

Alternatively, it could be your memories, such as thinking about doing something that's caused your Achilles pain before or going somewhere where it has hurt before; it could be absolutely anything either to do with your Achilles or not – anything that makes you feel you're in danger. So it could be a smell. It could be the sound of someone's voice or watching someone move. Even thinking of the word “Achilles”.

So, the brain thinks we're in danger. What does it do? It instructs the body to act to protect us or to help us heal. It increases our flight-or-fight chemicals, it might increase inflammation, it might lead to the increase in the number of the sensors in the body area, it might cause you not to move. But all of these will, in the short and potentially in the long term, increase pain to protect you.

Pain doesn’t relate to the severity of your injury

Research has shown that the amount of damage that an injury has caused to your body does not equate to the amount of pain you experience. (As it happens, the study was done on people with Achilles tendonitis, and I made a video about Achilles pain vs. Achilles scan results.)

The amount of pain all depends on whether your subconscious thinks you need protecting and how best it can do it.

For example (and there are many examples of this in people like soldiers or those who work in the emergency services), someone could have a severe injury but also be in a very dangerous situation. They might not even notice the injury while they focus on getting themselves to safety.

Alternatively, there are many people whose injuries have caused them little or no physical damage, but they have beliefs, thoughts, and triggers that can lead their subconscious to think that they're in danger and therefore it needs to protect them. So, it sets off the body’s systems that lead to pain.

Back to the example of whacking your thumb with a hammer. If, shortly afterwards, you were to hold your mouse or phone like before, you will probably feel additional pain in your thumb, even though holding the mouse or phone isn’t dangerous to you and not causing further damage. That’s because your subconscious is now on high alert for danger to your thumb.

How chronic pain develops

When we have an injury for an extended period of time, our brain and body make physical changes to ensure that we are better able to detect and protect ourselves from danger. And if the pain persists for more than three months, changes in the brain lead to pain becoming learnt. In the same way that repetition helps us to learn a language or a skill, if we constantly repeat the same beliefs, thoughts, memories, etc., that can lead to pain, the subconscious brain creates pain more effectively to protect us.

In a sense, the brain’s danger alarm system goes awry. It gets oversensitive, and it becomes like that light sensor in your driveway that’s far too sensitive and gets triggered by every leaf blowing by.

And then, it makes us do more and more of the things that we initially needed to keep us safe, like making fight or flight chemicals or moving differently, and unfortunately, people get caught in this awful cycle of pain.

How to deal with chronic Achilles pain – step-by-step

The great news, however, is that we can unlearn pain. This is not a case of “mind over matter” or “ignoring the pain”; it’s about making your subconscious feel safe again about your Achilles tendon.

Just as our brain and body can adapt so that we become better at making protective pain, likewise it can adapt – often slowly, admittedly – to bring us away from pain. And we can do this by understanding and reducing the beliefs, thoughts, and triggers that caused our pain in the first place.

This is good news for people who have been through an entire system of medical professionals who have not been able to find a physical cause of their pain and for people with chronic Achilles pain whose scans show little or no damage to their Achilles tendons.

Remember, chronic pain is there because your subconscious believes you’re in danger. So, you need to find out what will make it feel safer.

So, to take control of making your brain feel safer, it’s useful to understand pain and your own pain triggers, and to use some helpful psychological strategies. For example, if you have a fear of movement, knowing and doing the following is a good place to start.

When exercising before you developed your Achilles tendonitis, you had an idea of how much further you could push your body without acutely damaging your tendon. This includes even after you’ve started getting warning signs that you’re pushing your body hard.

Now that your brain has got used to worrying that you might reinjure your Achilles tendon, even the thought of movement might trigger increased pain: Your warning signs will come on earlier. But, as before, there’s still a difference between when the warning sensations come on and actual damage to your tendon. In fact, when you have chronic pain, the difference between the warning signs and the point at which you damage your tendon is bigger – so you have a bigger window in which to work.

With this in mind, have an honest conversation with yourself about what amount of exercise you can safely do without fear of flaring your tendon up (say, x amount of exercise); a flare-up being that sudden increase in pain that means you can’t move for hours or that you reach for the pain meds. Remember, there will be warning sensations before the flare-up point, but that you can move through these for a bit more without causing damage.

Then, do x amount of exercise, and only this amount. If you’ve got it right, then plan a very gradual increase and stick to the plan.

So, if you believe you can walk for 2 minutes on the flat without flaring your Achilles up, start with 2 minutes on the flat. Your subconscious should soon realise that this level of activity is, in fact, not dangerous, and it should dial down the pain sensitivity somewhat.

Then, increase your walk time by, say, 30 seconds a day, and your subconscious should follow suit.

If you do flare up your tendon, stay calm. Don’t worry. Don't get annoyed with yourself. Remember, worrying will only increase your sensitivity again. So, stay positive and do what you can to make yourself feel safe.

Also, don’t give up if you get it wrong. Let it settle down and learn from it. And then, again, start doing what you feel you can do without flaring up your Achilles tendon.

Where to get help

At Treat My Achilles, we can help you with an assessment of your Achilles injury and a personalised rehab plan to get your tendon physically back into shape. But because we’re aware of the psychological nature of pain, we often work with people like Caroline Marlow, PhD. C.Psychol, who can help our patients to deal with that aspect of their recovery. Caroline can help you understand what factors may be contributing to making your subconscious feel that you’re in danger and find ways to address them. These are usually not things that you’re aware of.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References:

1. Butler, D. and Mosely, L. (2013). Explain Pain. Noigroup Publications: Adelaide, South Australia.

2. Hanlon SL, Pohlig RT, Silbernagel KG. Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy. J Orthop Sports Phys Ther. 2021 Sep;51(9):440-448