How To Rehab Achilles Tendinopathy

The Achilles tendon is the largest tendon of the body for a good reason, it takes much of the load when we are running,  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.  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 climbers¹. This article will show you an evidence-based approach to how to rehab Achilles tendinopathy.

 

How Does Achilles Tendinopathy Occur?

Achilles Tendon injuries how to manage achilles tendon pain the prehab guys

Achilles Tendinopathy can occur after a single mechanism or due to repetitive microtrauma, the latter being the more often culprit. 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, &  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). Insertional Achilles (accounting for 20-25% of Achilles tendinopathies) and proximal tendinopathy (accounting for 9-20%) would be treated slightly differently than mid-portion tendon pain.

 

Achilles Tendon Pain

This video will give you a comprehensive breakdown on how you can address your Achilles Tendon issue through a 4  phase progression of exercises. If you are looking for a specific Achilles tendon program, look no further than our 12 week Achilles [P]Rehab Program.

 

Evidence Supporting 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 backed up by strong evidence? You guessed it, exercise!

A mechanical load has been shown to decrease pain when imposed on midportion Achilles tendinopathy. You’ll learn exercises that induce mechanical load later in this article. 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 supported by moderate level evidence. Manual Therapy has also been shown to mitigate pain through pressure massage.

Achilles Tendon interventions how to rehab achilles tendinopathy the prehab guys

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 when it comes to how to rehab Achilles tendinopathy. 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.

 

What If I Just Injured My Achilles Tendon?

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 in order for 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.

LISTEN: TALKING TENDONS WITH JILL COOK

talking tendons jill cook how to rehab achilles tendinopathy the prehab guys

Isometrics To Rehab 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 bout 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 here is reducing pain and improving function. We do not have high-quality evidence to say a degenerated tendon can change back to a normal tendon, however, that doesn’t mean you won’t feel better! Seek a rehab professional to guide you through graded exposure to the tendon if you’re concerned about how to do it yourself.

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

Supine Calf Isometric With Band

Sample [P]Rehab Exercise Library 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:  Do not let your ankle “roll out”. You should feel even pressure between the inside and outside of the balls of your foot.

 

Single Leg Heel Raise Isometric Hold

Get set up in front of a wall or an object to use for balance. Begin by lifting yourself up with both calves, shift your body weight over to one leg, and keep 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 and quadriceps. 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 To Rehab 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,  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 To Rehab Achilles Tendinopathy?

Stretching of the calf is often recommended for patients with Achilles tendinopathy; 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. That’s because an eccentric exercise is a muscle working while lengthening at the same time. This means when performing an eccentric exercise, be sure to go through the entire range of motion available! 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 To Rehab Achilles Tendinopathy

There have been 4 loading protocols reported in the literature when discussing how to rehab 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 this reason that not one specific protocol seems to be superior to another, the research has shifted to a more pragmatic routine combining eccentric and concentric exercises together.  This likely means that with tendinopathy, inducing 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.

Isotonic exercises are great in addition to eccentric exercises for numerous reasons when optimizing how to rehab achilles tendinopathy. 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 Prehab Exercise Library 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 [P]Rehabbing or Rehabbing an Achilles Tendinopathy. This article is focused on isolated Achilles tendon exercises.

Achilles [P]Rehab Programachilles tendon prehab program how to rehab achilles tendinopathy the prehab guys

The Achilles [P]Rehab Program is the ultimate resource for those looking to strengthen, protect, and optimize their Achilles tendon. This program is designed for active individuals looking to improve their performance that may be dealing with an Achilles weak link. With this 3-phase program, you will build up your Achilles tendon to handle anything life throws at you! Learn more HERE!

 

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 have a good outcome.” We realize there is an improvement in function that occurs with exercise, despite the pathology remaining. Exercise helps to make the tendon, muscle-tendon complex, and the kinetic chain more robust! A more robust system can tolerate higher demands, and when capacity exceeds the demands, typically we don’t experience injuries or pain!

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 attempted 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. https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-achilles-tendon-injuries-tendinopathy
  2. Nielsen RO, Rønnow L, Rasmussen S, Lind M. A prospective study on time to recovery in 254 injured novice runners. PLoS One. 2014;9:e99877
  3. 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.
  4. Magnussen, RA, Dunn, WR, Thomson, AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19(1):5464.
  5. Stevens et al. Effectiveness of the Alfredson Protocol Compared With a Lower Repetition-Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Controlled Trial. JJournal of Orthopaedic & Sports Physical Therapy. 2014.
  6. 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.
  7. Nørregaard 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.
  8. 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

 

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.

7 Comments
  • Filip Živković
    Posted at 22:17h, 04 June Reply

    You guys are awesome as usual, but there are a few things I want to ask you. First and foremost, how come you didn’t include the protocol with 3 sec on – 3 sec off with 85% 1RM from (I believe) Bohm et al., 2015? That seems to be a great and evidence based protocol. Secondly, don’t you think it’s hard to measure 75% 1RM in those bodyweight exercises? I found it difficult to quantify. For some it may be well above that and for some it won’t be enough intensity. Thirdly, you were talking about Jill Cook (and rightfully so), but then you go on to talk about the benefits of eccentrics, without mentioning its downsides. Yes, it trains the spring but Jill also says that it doesn’t train the muscle adequately. Take care and keep up the good work!

    • arash maghsoodi
      Posted at 18:05h, 05 June Reply

      Hi Filip, there are MANY protocols for the achilles tendon. I am familiar with Bohm’s work (amazing).There were so many paper I went through in creating this article it was impossible to add them all. Agree is VERY difficult to quantify. When working with patients, essentially the goal is to load as heavy as tolerable. It’s not to say if you aren’t on that % you are not providing optimal load, as I have seen numerous different %’s in the literature. To your 3rd point, I and going to refer back to my first comment that we can’t go TOO detailed as after performing a cost analysis with these exercises we decided the eccentrics are appropriate. Again this is designed to be a mid-portion achilles tendinopathy article, NOT insertional. Just because it doesn’t train the muscle adequately doesn’t mean it’s not worth discussing! Still think there is lots of value here. Thanks for providing the though provoking questions! and appreciate your support!

  • Rich Irwin
    Posted at 05:11h, 21 July Reply

    Great article! Really helpful.
    Once the pain is somewhat controlled, how often should the 3 exercises in Phase One be done/week? Or even /day?
    Thanks!

    • Sherif Elnagger
      Posted at 09:32h, 22 July Reply

      The frequency once pain is somewhat controlled can be 1-3 times/day, 5 times per week!

      • Rich
        Posted at 19:12h, 25 July Reply

        Great. Thanks again!

        • Sherif Elnagger
          Posted at 05:36h, 02 August Reply

          You are welcome!

        • Sherif Elnagger
          Posted at 08:33h, 04 August Reply

          You’re welcome!

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