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Injury in the Spotlight- Achilles Tendinopathy

This post will hopefully provide the reader with a simple to understand guide to what causes Achilles tendinopathy, the most common symptoms and causes and what are the most up to date treatments available for this common and often stubborn injury. Achilles tendinopathy is a classic overuse injury often caused by a change in training load or training type. This can include an increase in mileage or overall volume or an increase in intensity of hill training. Tendons are very adaptive to new stresses once the rate of change is slow but they don’t like sudden jumps in volume or intensity.

So what is the Achilles tendon?

The Achilles tendon is made up of the tendons of the two calf muscles; soleus and gastrocnemius which converge to form the tendon which attaches onto the calcaneus or heel bone. The primary role of the Achilles tendon is to transmit power from the calf muscles to the foot and heel which is important during the toe off part of the walking or running gait.

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There are two main types of Achilles injury- mid portion and insertional. It’s important to discover which one you have as they are treated somewhat differently. As the name suggests mid portion Achilles tendinopthy affects the middle part of the tendon (this part also has the least bloodflow) while insertional Achilles tendinopathy affects where the tendon inserts onto the calcaneus.

What are the main symptoms?

The most common symptom of an Achilles tendon injury is pain and stiffness in the morning time. In a lot of cases our foot is in a shortened position while we sleep and this initial lengthening and stretching of the calf complex and tendon in the morning can cause microtrauma resulting in pain. Often patients feel very stiff for the first few steps out of bed and it can take several minutes for the pain and stiffness to subside. Other symptoms include pain at the beginning of exercise, pain after exercise, occasional swelling, redness and a thickening of the tendon over time.

There are several stages of tendon injuries ranging from the initial reactive stage where the pain is often more acute due to the possibility of some inflammation in the area, to the chronic stage where we actually see a degeneration of the collagen that makes up the tendon. How we treat the injury depends on the stage of the injury as well as the patient’s own background and history.

When you visit your therapist they will take a full history from you including your sporting background, training history as well as a list of symptoms. They will also carry out a full examination and assessment looking for swelling, redness, thickening as well as assessing calf and ankle range of motion. The therapist might also assess the full kinetic chain including the foot, knee and ankle as any of these can have an effect on the Achilles tendon. They also might carry out a biomechanical assessment.

That’s all well and good, but how do we treat it?

So, the part you’re all here for- what is the treatment plan?! Well an Achilles injury, like any tendon injury, can be complicated to treat. It all depends on the individual and how thoroughly they stick with the rehab and recovery plan. Also, the Achilles tendon can be slower to heal due to the poor blood supply it receives but the good news is that with a sensible and progressive rehab and recovery plan most people recover fully from this injury and return to full training usually within 12 weeks. The initial stages involve off loading the tendon as much as possible and reducing any inflammation in the reactive stage. This can include

  • Temporarily wearing a heel lift in your shoe
  • Reducing or stopping any aggravating activity (running) temporarily
  • Taping or strapping
  • Manual therapy
  • NSAIDS (always discuss with your doctor of pharmacist before starting any medication)

Key exercises for Achilles Tendinopathy

As soon as the pain allows we starts isometric exercises to build strength in the calf complex. It has also been shown in the research that isometrics have a positive influence on tendon pain. These exercises involve doing a calf raise up onto your toes and holding. You can do these in mid range or full range (ie go the whole way up onto your toes or just halfway, depending on your pain).

  • Hold each rep for 45 seconds
  • Repeat 5 times with 15-30 seconds rest in between repetitions
  • Should be done at least 2 times daily
  • Start with double leg but as soon as pain allows switch to doing the single leg only

Weighted calf raises

When the patient has reported a reduction in pain (during everyday life or first thing in the morning) then we move onto weighted calf raises. This HEAVY SLOW RESISTANCE training has somewhat replaced the Alfredson eccentric programme that was used for many years to treat tendon injuries (and still is). While this is a very effective programme I personally find it to be very time consuming to fit in the 3×15 reps of bent knee and straight leg reps done twice daily (180 reps per day!) and have found patient compliance to be poor. There are good results to be seen by adopting the HSR calf raises instead and they are much less time consuming. So, ideally these are done in the gym on a leg press or Smith machine but they can be done at home if you have the right setup. These exercises will help build strength in the tendon and the calf muscles.

  • Aim for 3 sets of 8 reps to start with 2 mins between the sets
  • The reps need to be done slowly! 3 seconds on the way up, 3 on the way down
  • Start with 10-20% of bodyweight, so an 80kg runners would start with 8-16kg
  • Add 2-5 kg per week
  • Aim for 3-4 times per week
  • These can be done at home with a backpack on your shoulders filled with books/weights etc


If you get sore after a sessions just back off a little the next time but it is actually OK to have some pain while doing these so long as you are not very sore the next day. 3/10 for pain during these is OK with me. The key with these is to have patience; it can take 6-8 weeks to see the benefits of this training.

During this phase you might be able to get back into some running. They key is to keep the pain level below 3/10, avoid consecutive days at the start and back off if you are sorer the next day than you were. It can be difficult to be patient but it is key for successfully managing this injury.

Getting back to your sport

After this phase we introduce some sport specific movements to prepare for a full return to running. This can be some running drills, strides, plyometrics and eventually a return to full training.

So that’s it, that’s the down low on Achilles tendinopathy. It can be a frustrating injury but with the correct plan you can get back to full sport and training. I hope you found this article helpful. If you are struggling with an Achilles injury (or any other injury) please feel free to contact us at the clinic for an assessment.

Happy training.

Patrick

References:

https://www.physio-pedia.com/Achilles_Tendinopathy

The 3 key stages for Achilles Tendinopathy exercises

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