Achilles Tendinopathy
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Achilles Tendinopathy
Achilles injuries are one of the most common injuries faced by runners. In the clinic, I see runners of all levels of experience from the most experienced marathon runners to those just starting their running journey and everyone in between. Whichever camp you fall into you will know someone who has been affected by this condition and if you are reading this blog that is likely you! Unfortunately, this is because approximately half of all runners will experience an Achilles Tendinopathy / Achilles tendon injury across their lifetime.
The good news is most Achilles injuries recover without surgical intervention. The tough news is there is no hard and fast way for them to recover. The Achilles tendon is a robust tissue structure that can tolerate forces of almost 8x your body weight! For it to get damaged means it has been loaded beyond this and returning to 100% is going to take some work.
What causes an Achilles Tendinopathy?
Irrespective of the Achilles’ size or strength, like any other tendon in the body it is susceptible to wear and tear. Regardless of the source, damage to the fibres of the tendon will result in weakness and pain until they are repaired. Common causes of Achilles tendon damage include:
- Direct trauma
- Sudden increases to exercises or load
- Changes in sporting activity or training pattern
- New or inappropriate footwear
- Progressive weakness or tightness in the calf
- Bad lower limb biomechanics
This list ranges from sudden trauma to damage accrued gradually over time, but all sources share the result of deterioration of the tendon. The most common cause of damage however is repetitive micro trauma to the tendon associated with overuse. Constant overload to the tendon slowly breaks down the tissues either in the middle portion or at the at the base of the heel bone where it attaches.
Achilles Tendinopathy Exercises
Tendons attach muscles to bones. They effectively act as springs to store and release energy during movement. When tendon fibres are damaged, they become unable to perform this task effectively. Therefore, the goal of rehab is to improve their tolerance to force. During rehab, exercises need to progress gradually otherwise excessive forces may further damage the tendon. To manage this vulnerability to load, the type of exercises gradually become more challenging as the tendon becomes more capable and these exercises fall into 3 main categories.
Isometrics Exercises
Early in rehab managing pain is the primary goal. Thanks to research by Cook and Purdam we know that isometric loading exercises have pain-relieving effects on sore tendons. Isometrics, sometimes referred to as ‘holds’, involved loading the injured tendon and its muscles in a static position i.e. for the Achilles this may involve standing on tip toes or hovering off the edge of a step. By holding a static position, the injured area can be worked without stretch or contractions of the structures thus reducing pain and maintaining strength in the area as it settles.
Duration of the holds is determined by severity of the injury. Highly irritable Achilles may require double leg holds for shorter durations, while tendons that are starting to settle can progress to single leg holds lasting longer with multiple repetitions.
Isotonic exercises
Once pain has started to decrease and the tendon is becoming more tolerant of load it is time to progress exercises to be more demanding. The goal here is to strengthen the tendon and its associated muscles. Loading these structures through range stimulates their growth. We recommend starting with exercises like calf raises at mid-range resisting body weight gradually becoming heavier and working into further range. Loads heavier than just running here are integral to recovery as walking and running does not stimulate the tendon matrix enough to promote growth. Its important to remember that muscle growth take time, it may be 6-8 weeks for strength changes to occur and up to 12 weeks for changes in muscle fibre size.
Plyometric Exercises
As pain remains low and strength has returned, the next step is to reapproach the energy storage role of the Achilles tendon. Exercises in this phase revolve around impact and propulsion through jumping and hopping. Naturally impact forces like this, load the tendon significantly heavier than just calf raises, walking or running. These exercises are reserved for when pain and stiffness is minimal and light running is tolerated well. Starting slow with plenty of rest between exercises, they are gradually preformed faster and for longer to better simulated running until the Achilles is not only pain free but strong, flexible, and tolerating all forces applied to it.
When to seek assistance?
Achilles injury are difficult by their very nature. Even with these guidelines these injuries can be slow and most patient have a flare up during their recovery. We recommend that anyone experiencing Achilles pain seek assistance from a physiotherapist to get the best guidance through rehabbing their injury and navigating their recovery phase by phase.
Matthew Hagerty
