Physiotherapy management of Achilles Tendinopathy
Physiotherapists are often challenged by Achilles Tendinopathy, as it is a common injury even in the non-sporting population.
We’ll talk about what Achilles tendinopathy (aka ‘tendinitis’) is, what causes it and some general guidelines to manage it.
ACHILLES TENDINOPATHY SYMPTOMS
The hallmark sign of Achilles Tendinopathy is pain that is directly on the achilles tendon (mid portion tendinopathy) or where it connects into the heel (Insertional tendinopathy).
In more severe cases, you’re likely to notice that the painful Achilles Tendon is thicker, tender to touch, and may even have what feels like a lump in it.
The common aggravating factor that is consistent across all tendinopathies, is pain with increased loading.
Here are some common physical activities that will typically aggravate Achilles Tendon pain:
Running
Landing
Jumping
Skipping
Did you know that the achilles tendon can be aggravated even with seemingly simple activities of daily living? Here are the most common activities that you may notice aggravate your Achilles Tendinopathy
Taking the first few steps in the morning may be very uncomfortable.
Walking up or down stairs (increased loading when you step down)
The first few steps after sitting for a long period of time
In addition to these common symptoms, many clients with Achilles Tendinopathy will report that when they first start their run (or exercise), the Achilles is quite painful, but after ‘warming it up’, then the pain reduces and they can continue their run. However, after their run, the pain eventually returns!
CAUSES OF ACHILLES TENDINOPATHY
Each individual will have their own unique factors that contributed to the development of their injury, but we’ll outline the main, common causes!
1: SUDDEN INCREASE IN ACHILLES LOADING
This when the Achilles Tendon has taken TOO MUCH load, TOO SOON.
Did you know that just by running and jumping, the Achilles Tendon will absorb between 6-12 times your body weight in force?!
In reality, this could look like someone going on a health kick, picking up running at the start of the year when they previously hadn’t run in the past few years.
Or in an elite sport setting, an athlete may develop Achilles Tendinopathy if their gym program suddenly went from slow and controlled strength exercises to high intensity plyometric (jumping) exercises WITHOUT a period of gradual transition.
This is the most common mechanism that we notice amongst our clients with Achilles Tendinopathy.
2: POOR BIOMECHANICS
Just like in our blog on Patellar Tendinopathy (Jumper’s Knee), a detailed biomechanical assessment is key to determine the contributing factors that are relevant to the injury.
When we treat athletes, we look at their athletic movement as a highly skilled and coordinated sequence of movements across different joints and muscles to play their sport.
We have to look at the entirety of how their body moves as a whole and identify any of the moving parts that are potentially dysfunctional or sub-optimal.
These dysfunctional parts usually lead to overcompensation of load elsewhere - commonly being the ankle and Achilles Tendon.
A common example is a runner, who seems to run with very pronated feet, more so on the injured side.
The cause of the ‘pronation’ could be genetic, structural, functional or due to footwear, and it is up to the Physiotherapist to determine why!
Whatever the cause is, over pronation undoubtedly deforms the Achilles Tendon, altering the lines of stress, so that one portion of the tendon is under more tension (and force) than the other.
This may gradually lead to an overcompensation and the development of Achilles pain.
An in-depth analysis of your athletic movement is essential to determine what your movement looks like and where it could be optimised to address the cause of your injury.
Our team at Physiologic have years of experience working with elite athletes to identify the cause of their injuries, and to prescribe effective rehabilitation protocols that get them out of pain, fixing their injury for good. Contact us to find out how we can help you get back to your competitive best!
3: MUSCULAR WEAKNESS
Your calves are made up of two main muscle groups:
1: Gastrocnemius which is thought to be the muscle that is responsible for fast, explosive movements (sprinting).
2: Soleus which is a longer, broader muscle that is responsible for endurance based activities.
Both these muscles will connect into the Achilles Tendon to produce movement, but also to absorb force.
It is thought that weakness in either of these muscle groups are a significant factor to the development of Achilles Tendinopathy.
Other muscles that Physiotherapists assess will include the gluteals (hip), Quadriceps (knee) and also how well the ‘core’ is functioning.
Even though these muscle groups aren’t directly connected to the achilles tendon, they play a role in the biomechanics of how efficiently the body moves in athletic movements.
4: PREVIOUS INJURIES
Previous injuries are a common factor to the development of Achilles Tendinopathy, and in particular, foot and ankle injuries.
Previous ankle sprains and fractures are usual culprits, as they typically result in either reduced ankle mobility and proprioception, which naturally forces the Achilles to take on more of the load absorbing duties in dynamic tasks.
A more complex mechanism of how previous injury can lead to Achilles Tendinopathy, is through a process called ‘muscular inhibition’.
Essentially, when you get an injury, there will be reduced nerve signals to the muscles around the area - meaning that those muscles won’t be able to contract well, and you may have a hard time ‘feeling’ those muscles.
When you can’t activate those muscles, they don’t get stronger, therefore leading to a shift in the workload to the Tendon to absorb more force when you’re walking or running etc.
This overcompensation may eventually lead to the development of Achilles Tendinopathy!
PHYSIOTHERAPY TREATMENT OF ACHILLES TENDINOPATHY
1: TEMPORARY PERIOD OF REDUCED LOADING
As a general principle, we will usually recommend a temporary period of reduced activity (NOT COMPLETE REST) initially, to allow the pain to settle and avoid continuous aggravation.
This is important to break the vicious cycle of doing too much, causing more damage, having more pain and so on.
Note how we did not recommend complete rest, this is important.
If you go back to our initial blog on Tendinopathies (here), one of the most effective ways to rehabilitate a tendon effectively is to LOAD IT!
This means that your Physiotherapist will advise you on what you CAN still do, while you’re recovering from your Patellar Tendinopathy.
Commonly, this may be advice to avoid dynamic exercises like jumping/running/sports, but strength exercises in the gym like squats/step ups, knee extensions may still be appropriate.
INSIDER TIP - Sometimes a small heel lift placed in your shoe can be very helpful to help relieve Achilles pain while walking. The heel lift serves to reduce the tension on your Achilles Tendon.
2: ISOMETRICS FOR PAIN RELIEF
Isometrics are a useful tool that has been proven to be a powerful pain relieving exercise in people with tendinopathies.
They are also an excellent rehab exercise that starts to encourage some collagen fibre realignment and replenishment in the injured tendon.
Here’s how we perform isometrics to help with Achilles Tendinopathies.
3: CALF MUSCLE STRENGTHENING
As mentioned earlier, one of the contributing factors of Achilles Tendinopathy is weak calves.
So to truly rehabilitate from this injury, Physiotherapists must prescribe challenging calf exercises to target the gastrocnemius AND soleus.
Due to the anatomy of these muscles, here’s a basic tip to isolate each muscle group.
GASTROCNEMIUS: Calf raises with knee straight.
SOLEUS: Calf raises with knee bent.
Check out our benchmarks that we use with clients to determine if they are strong enough to be considered ready to return to running.
4: ADDRESSING DYSFUNCTIONAL BODY PARTS
As mentioned earlier, dysfunctional joints as a result of previous injuries or poor movement patterns can be contributing to the overload of your Achilles Tendon.
So part of the rehabilitation program must address these weak links - if not, your pain is likely to come back again!
A common component to look at is the single leg step up, as this will tell us a lot about how well your lower limb is being controlled during dynamic movements.
Here’s a simple step up exercise we like to prescribe to ensure optimal biomechanics in the lower limb. Focus on not letting your knees cave in, and not allowing your foot over pronate.
5: SHOCKWAVE THERAPY
We briefly mentioned shockwave therapy in the tendinopathy blog, and we generally reserve this treatment modality for more chronic cases.
It is an uncomfortable procedure, but has been proven to be effective in encouraging better recovery in Chronic tendon injuries.
At Physiologic, we have a state of the art Piezowave shockwave machine that many clients have experienced benefit from when we treat their Achilles Tendon.
It is also helpful for calcific tendinopathy (calcium deposits within tendon) which doesn’t tend to respond well to traditional Physiotherapy care. Imaging (XRAY/US/MRI) is required to diagnose calcific tendinopathies.
6: RETURN TO ACTIVITY/SPORT LOAD MANAGEMENT
The most important aspect for the treatment and prevention of re-injury, is for the Physiotherapist to guide the client safely on their return to activity or sport.
The Physiotherapist is responsible for monitoring, adjusting and guiding the client through gradually increasing activity as their body allows.
Too much activity too soon and you’ll be back at square one.
Not enough activity and you may not reach your ultimate goals!
Speak with one of our expert Physiotherapists experienced in providing complete injury solutions for the management of Achilles Tendinopathies.
CONCLUSION
The best solutions for overcoming Achilles Tendon starts with a detailed assessment to identify ALL your unique contributing factors.
Then comes the hard work, adhering to the guidelines your Physiotherapist has set out for you, and being consistent with the rehabilitation program.
If you’re dealing with Achilles Tendinopathy, get in touch with us to see how we can help get you out of pain, and back performing at your best!
About the Author
Ryan Tan is our Clinical Director and Physiotherapist here at Physiologic Hong Kong. He’s had over 10 years of experience as a sports and musculoskeletal Physiotherapist, having looked after elite athletes such as the NZ Rugby 7’s team and more recently, some of Hong Kong’s top Trail Runners. He attributes his client’s successes to their commitment in being diligent with his individual rehabilitation programs, and curated treatment protocols for each individual. Excellent relationships with some of Hong Kong’s top Orthopaedic Surgeons also allows Ryan to provide a truly multidisciplinary team approach to his clients health care. Contact us to speak with Ryan if you are looking for an experienced Physiotherapist to guide you back to your competitive best!
