Achilles Tendinopathy

Achilles Tendinopathies

Achilles tendon injuries are one of the most common running injuries we see in clinic.

Common tendon injuries we see include:

• Insertional 
• Mid Portion 
• Partial Thickness Tears 

For tendon injuries and this blog lets focus in on insertional and mid portion. 

Insertional tendon injuries occur when the achilles tendon inserts onto the bone at the back of the heel (The calcaneus). If we really want to get technical it’s an enthesopathy because it is the region where the fibres of the tendon “blend” with bone cells. 

Mid portion is where you get tendon pain on the inside or outside of the tendon, it can be one sided or over the main part of the tendon. 

How do we Manage Achilles Tendon Injuries? 

Does the diagnosis of Mid portion and insertional really matter? 

Yes, there are differences in the management however in the early stages of rehab there is a lot of overlap.

Rehabilitation exercises are a key for management of Achilles tendon injuries but it is not the only thing that will help you improve. We look at numerous treatments these include: 

• Soft tissue work 
• Dry needling 
• Your running programs
• Overload 
• Appropriate footwear 
• General lower limb strength and 
• Overall conditioning 

To keep things simple for this blog the key aim in tendon management is to improve the energy storage capacity of the tendon, so if you think of a Kangaroo, the tendons act like a spring in storing then releasing energy. 

3 Key Stages 

1. Isometric

Isometric means holds. There is good research and more importantly clinical application to show that isometric holds provide pain relief to tendons while assisting in developing low level strength in the tendon. 

We often use isometric exercises as a “pain relief method” for reactive tendons. Initially we will start with double leg holds then progress to single leg. 

Tendon management is also all about load management and reducing irritability so initially we start with short duration holds, less reps then we progress the range of motion, length of time and reps. 

E.g. 

• Lift heels hold for 30 second.
• 30 second rest
• Complete 5 reps 
• These can be done 2-3 times per day, and in reactive tendons they can be done hourly as I mentioned for pain relief.

2. Isotonic

These exercises are completed when the achilles pain is under control, we use a pain scale to assist in adding in isotonic exercises, we typically want pain to be under 6/10. A great example of an isotonic exercise we use for achilles pain is a calf raise. We use calf raises ti increase the strength of the muscle and the tendon of the calf. 

These exercises can be commenced once a runner’s pain level and the tendon’s irritability has reduced. There are no ‘hard and fast’ rules for when to start a runner on isotonic loading for the rehabilitation of Achilles tendinopathy. 

Now if you didn’t know this there are 2 key muscles that make up the achilles, the gastrocnemius and the soleus. In this case we use various forms of calf raises but not limited to calf raises to improve the overall strength of the lower limb. 

These exercises aren’t all prescribed at once and they aren’t all used for every client but here are some examples of exercises we use: 

• Double leg calf raises 
• Single leg calf raises
• Runners’ calf raises 
• Bent knee calf raises 
• Creeper walks 
• Sled pushes and sled drags

In a well programmed rehab session, you will increase your work and work capacity to induce adaptation in the tendon matrix. Running alone does not help with this!

And just remember you will not be better “instantly” it takes 6-8 weeks to build strength – patience is required, if you are like most runners you’ll just want to run but a good practitioner will find other ways to give you your fix and you can get your “hit” from other exercises and different training methods. 

3. Energy Storage

The last stage is the most important and this is where we see most people “fall of the band wagon” and fail to compete their rehab which results in a reoccurrence. 

Plyometric exercises help the tendon regain its ability to absorb and then release energy via the stretch shorten cycle, this is particularly important in runners because it relates to landing and toe off. 

There is no hard and fast rule with plyometric exercises, however Peter Malliaris has developed several protocols which can be used. This is a key and critical stage of rehab, exercises may include: 

• Pogo hops
• Single leg hops 
• Zig zag jumps 

4. Recovery 

Tendon injuries are not straight forward and they often have some ups and downs, patients become irritated and frustrated by the slow progress, but under the guide of a experienced/ knowledgeable practitioner the process is simplified and you will see results. It takes time for the tendon to adapt and this includes allowing enough recovery between exercise sessions to allow for adaptation. The diagram below shows we need 48hrs rest between to allow for the tendon to “build” and not breakdown. 

Reproduced from Magnusson et al. (2010).