Achilles Tendon Pain

Achilles Tendon Pain

The Achilles tendon is the largest tendon of the body for a good reason, it takes much of the load when we are running, ย jumping, or even walking! This tendon connects the calf muscles to the heel assisting with force transmission and acts like a spring when you push your foot off the floor. Achilles Tendinopathy is when the Achilles tendon is irritated or painful. ย The majority of individuals that suffer from Achilles Tendinopathy are active individuals, from the weekend warrior to the high-level athlete. Achilles Tendinopathy seems to be as high as 7-30% in runners, 2.1-5.1% in soccer players, and 12.5% in rock climbers. This article will show you an evidence-based approach on how you can address you Achilles Tendon Pain.

Achilles Tendinopathy

Achilles Tendinopathy

Achilles Tendinopathy can occur after a single mechanism or due to repetitive microtrauma, the latter is more often the case. This condition is characterized by focal pain behind the heel, swelling behind the ankle, calf stiffness (often worst in the morning), and limitations with walking, running, & ย jumping. This article will be referring specifically to midportion Achilles Tendinopathy, which represents a majority of the dysfunction to this tendon (55-60%). To be classified as mid-portion Achilles Tendinopathy the lesion must be 2-6 Centimeters from where the Achilles tendon inserts onto the bone (calcaneus-tendon junction). ย Insertional Achilles (accounting for 20-25% of Achilles tendinopathies) and proximal tendinopathy (accounting for 9-20%) would be treated slightly different than mid-portion tendon pain.

 

How To Rehab Achilles Tendinopathy

While Achilles Tendinopathy is a straight forward diagnosis, there is no consensus on the most effective way of intervening. When we dive into the literature we find numerous interventions including stretching, neuromuscular re-education, manual therapy, patient education/activity-modification, heel lifts, night splints, orthoses, taping, low-level laser therapy, iontophoresis, dry needling, and exercise. Out of all these, which do you think is the ONLY intervention that is back up by strong evidence? You guessed it, exercises! A mechanical load has shown to decrease pain when imposed on midportion Achilles tendinopathy. That is not to say there is no benefit with the alternative interventions when dealing with Achilles tendon pain; activity modification and iontophoresis are actually back up by moderate level evidence. Manual Therapy has also been demonstrated to mitigate pain through pressure massage.

Achilles Tendinopathy

Why is it that you have tried every injection, massage, taping technique, electrotherapy, and medication without any long term results? Here is a great image by Tendon Expert Jill Cook, showcasing just how important improving load capacity is. Rehab should primarily focus on the center of this chart, restoring the capacity of this tissue is achieved by loading.

Evidence would suggest exercise should be the first intervention in patients with mid-portion Achilles Tendinopathy.

Immediately after an injury is when activity modification is vital. Especially if the injury is from overusing the tendon. During this acute phase of tendon pain, it is key to stay moving. Here is an article that will demonstrate how you can stay active in muscles proximal to your ankle to keep the rest of the kinetic chain active. It is almost never recommended to completely rest a tendon, performing active foot and ankle movements will at a minimum allow the lower leg to stay mobile. It seems that rest is bad for the tendon and destructive to tendon health, tendons need a load to maintain its structure. It is imperative to load the Achilles tendon with the goal of stiffening the tendon and it to act as a spring again. This article will take you through many different loaded exercises ranging from isometric to eccentric to isotonic demands.

 

Isometrics For Achilles Tendinopathy

During early stages post-injury, isometrics are a great way to manage pain while simultaneously loading the tendon. The pain created due to the Achilles tendinopathy is not fun, thankfully the pain response has been shown in the literature to change fairly quickly. A Single bought of isometric loading can be enough to reduce one’s pain. Just because pain is mitigated with an exercise does not mean the pathology is no longer present. Sticking to a 6-12 weeks progression of exercises seems to be the most effective program in rehabbing Achilles Pain. To be clear rehabbing doesn’t mean we are fixing the pathology, rather the goal is here is reducing pain and improving function. We don’t have evidence to say a degenerated tendon can change back to a normal tendon. Seek a rehab professional to guide you through graded exposure to the tendon.

Ideally, these isometric contractions are performed to about 70% of your maximum contraction, they are held for 45 seconds,ย and are repeated for 5 rounds with a 2-minute rest break in between. 70% is heavy! Essentially load as heavy as tolerable here.

Supine Calf Isometric With Band

Sample PrehabX Video

HOW: In a seated position place a band around the ball of your foot then pull it towards your body. Push your foot into the band as hard as you can by contracting your calves. You have the option to bend or straighten your knee with this exercise. Here I am using a hip band to apply resistance, however, you can use a resistance band or towel to create this same external load onto the calves and Achilles tendon.

FEEL: You will feel the calf muscles working with this exercise.

COMPENSATION:ย  Do not let your ankle โ€œroll outโ€. You should feel even pressure between the inside and outside of the balls of your foot.

Single Leg Heel Raise Isometric Hold

Begin by standing on one leg and raise your heel as high as you can. Hold the end position, use your arms to support you on the wall as needed. Make sure to stiffen that entire leg, this begins with activating the gluteals. Make sure you don’t bend the knee while performing this.

Knee Bent Single-Leg Heel Raise Isometric Hold

Begin by raising your heels as high as you can and hold while driving your knee towards the stable surface. Use a cushion to pad your knee into the wall. You can decide how much you load the calf by offloading the opposite leg. The more you lean onto the opposite leg the easier the hold becomes. Progress into putting a majority of your weight on the leg performing the heel raise.

Single Leg Heel Raise Weight Shift

While keeping your heel elevated as high as you can comfortably, shift your weight from side to side. This will start burning the calves! You can also perform toe walks. Toe walks are a great option for the reason you can hold onto more load.

 

Eccentrics For Achilles Tendinopathy

The current literature on eccentric loading for mid-portion tendinopathy is very strong. Eccentric exercises will load the elastic component or the spring of the tendon. Alfredson originally popularized the eccentric heel drop protocol. He originally recommended 180 heel drops a day, ย however, we now realize that a “do as tolerated” program will create the same results as the original 180 repetitions per day.

Should we stretch?

Stretching of the calf is often recommended for patients with Achilles tendon pain; when looking at the goal of improving ankle range of motion through muscle-tendon length, stretching was shown to be no better than just eccentric exercises. This means when performing an eccentric exercise, go through the entire range of motion! You should be feeling a stretch in the calf at the end of the motion. If you were looking for alternative ways to improve your ankle and calf mobility, here is a comprehensive calf mobilization video you can try!

Double Leg Heel Raise On Leg Press With Single-Leg Descend

Begin by placing your feet about hip-width apart on a leg press with your heels off the ledge. Push the balls of your feet away from you as far as you can then put all the load on one side by easing your opposite foot off of the press and slowly lower the weight. When descending with this exercise, lower the weight until you feel a stretch in the calf or Achilles tendon region.

Standing Double Leg Heel Raise Single-Leg Descend On Elevated Surface

Begin by placing your feet about hip-width apart on an elevated surface with your heels off the ledge. Raise your heels as high as you can with both legs, then put all your weight on one side and slowly lower yourself.

 

Isotonics For Achilles Tendinopathy

There have been 4 loading protocols reported in the literature for Achilles tendinopathy; these include heavy eccentric calf training, concentric training, eccentric overload training, and heavy slow resistance training. These protocols have been compared in recent reviews, no protocol seems to be superior when comparing outcomes in pain and function. While evidence indicates loading protocols are effective, the mechanisms responsible for the improvement are unclear.

For the reason that no one specific protocol seems to be superior, the research has shifted to a more pragmatic routine combining eccentric and concentric exercises together.ย  This likely means that with tendinopathy, mechanical load is therapeutic regardless of how you load the tendon. It has been demonstrated in the literature that with Achilles Tendinopathy, there is a decrease in stiffness of the Achilles, this can be improved with heavy strengthening.

Mechanical load is therapeutic for the Achilles Tendon regardless of how you load it!

Isotonic exercises are great in addition to eccentric exercises for numerous reasons. Isotonics will additionally strengthen the muscle, treat the mind-muscle connection, strengthen the kinetic chain, and address the compression loads needed for high level activities.

Double Leg Heel Raise On Leg Press

Place your feet about hip-width apart on a leg press with your heels off the ledge. Push the balls of your feet away from you as far as you can then slowly return back to starting position. When descending with this exercise, lower the weight until you feel a stretch in the calf or Achilles tendon region.

Bent Knee Double Leg Heel Raise on Leg Press

Bend your knees slightly, then push the balls of your feet away from you as far as you can then slowly return back to starting position. When descending with this exercise, lower the weight until you feel a stretch in the calf or Achilles tendon region.

Single Leg Heel Raise On Elevated Surface

Sample PrehabX Video

HOW: Begin elevating one leg and placing one foot on an elevated surface with your heel off the ledge. Raise your heels as high as you can and slowly lower yourself.

FEEL: You will feel the calf muscles working with this exercise. You should feel a stretch in the calf when you are at the bottom of this exercise.

Single-Leg Hops Wall Supported

The role of the lower leg is to act as a spring. Faster work will significantly increase the load on the Achilles tendon. The Achilles tendon will store and release energy with every step, hop, or jump we take. The single-leg hop is a great way to improve stiffness in the tendon. Building capacity is crucial for the individual looking to get back to sport or higher-level activities.

It is important to note, that other exercises such as squats, lunges, and deadlifts should be implemented to strengthen the entire kinetic chain while Prehabbing or Rehabbing an Achilles Tendinopathy. This article is focused on isolated Achilles tendon exercises.

 

Conclusion

Although we can’t reverse a degenerated tendon, we can improve symptoms of Achilles tendon pain. If you or someone you know has Midportion Achilles tendinopathy, realize prognosis is great! Magnussen et al. found success rates through a range from 60-90% when performing therapeutic exercises; this seems to be more effective in men > women, and active > sedentary population. Exercise should be the first choice in patients with mid-portion Achilles Tendinopathy based on the current literature!

Jill Cook once said “We don’t have to change the pathology to a good outcome,” ย we realize there is an improvement in function that occurs with exercises, despite the pathology remaining. Exercise makes the tendon, ย muscle-tendon complex, and kinetic chain tolerated to the imposed loads and we pain reduce.

Other interventions include Corticosteroid injections (which demonstrate short-term pain relief), Sclerosering injection (the research suggests a clinical role for sclerosis therapy for those who fail with eccentric exercises), & Platelet-rich plasma injections or PRP (which demonstrated no positive effect aside from tendon thickening when compared to placebo).

It has been suggested that noninvasive treatment should be tried for at least 4 months prior to operative interventions which include percutaneous longitudinal tenotomies, minimally invasive tendon stripping, open tenosynovectomies, open debridement and tubularization, and tendon augmentation with flexor hallucis longus.

Give these exercises a shot to [P]Rehab your Achilles Tendon and let us know what you think!

 

REFERENCES
  1. Nielsen RO, Rรธnnow L, Rasmussen S, Lind M. A prospective study on time to recovery in 254 injured novice runners. PLoS One. 2014;9:e99877
  2. Murphy et al. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy With Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Med. 2018.
  3. Magnussen, RA, Dunn, WR, Thomson, AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19(1):54โ€“64.
  4. Stevens et al. Effectiveness of the Alfredson Protocol Compared With a Lower Repetition-Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy. 2014.
  5. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of the eccentric exercise. Br J Sports Med. 2007 Apr;41(4):188-98; discussion 199. Epub 2006 Oct 24.
  6. Nรธrregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in the treatment of Achilles tendinopathy. Scand J Med Sci Sports. 2007 Apr;17(2):133-8.
  7. Martin R, Chimenti R, Cuddeford T. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018;48(5): A1-A38

 

 

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