6th September 2019

How to Manage Achilles Tendon Pain.

Its the time of year when there is noticeable increase in Achilles Tendinopathy (AT), highly likely due to the the running season being in full flow and some last minute miles being crammed in. This article will simplify the management of AT.

AT is a common running-related injury, encountered by clinicians in musculoskeletal and sports injury clinics. The prevalence of AT is 9-11% in runners and generally involves long periods of rehabilitation and is frustrating for the injured runner. It comes at no surprise in clinic that when asking people with AT do they strength train and 9/10 the answer is NO!!!!. 

Progressive Loading is Critical.

Load management is a critical element in your recovery. You have two muscle in your lower leg that are important; soleus and gastrocnemius ( Calf Muscles). They need to be strong, they are highly active when running and originate from behind your knee and attach into the bone (Calcaneus) in your heel via the achilles tendon. When running your foot will hit the ground creating a ground reaction force. The strength in your achilles, soleus and gastrocnemius needs to be strong enough to manage this load. Hence my main go to treatment for AT is progressive loading of the muscle-tendon unit.  A training period of 12-16 weeks of progressive loading is recommended in AT for improvement in pain and function.

Running at a steady state, sprinting, or even running up hills all exert a different force on the tendon meaning your progressive loading phases will all vary. Below is a list of exercises that can help strengthen the AT.

A rough guide to rehabilitation.

  • Avoid irritable activity ( activity that causes your tendon to be reactive would suggest your tendon is not capable of withstanding such activity. )
  • Static hold  standing on tip toes  4 x 45 secs ( Isometric ) if highly irritable
  • Slow controlled double / single leg calf raise 4×12-15.
  • Add load progressively to double / single leg calf raises – 5kg-10kg and so on. 
  • Once sufficient strength add speed to your calf raises. 
  • Low level plyometrics  i.e steady skipping, box jump with step downs. 
  • Medium then into high level plyometrics with a run-walk programme. 

Some tendons maybe so irritated you can only manage Isometric exercises ( Contraction in a muscle with no movement, for example standing on the edge of a box with no movement 4 x 45 secs). Then progress to simple double or single leg calf raises ( 5×12-15 reps, with a 2:1:2 ratio), these are slow and controlled with lots of time under tension, if ready then progress the load of that exercise, or speed of that exercise. Strength training needs to incorporate speeds / demands of your sport. 

Rest Is Required.

Once you start lifting heavy weight rest days are required to allow tendon time to repair. Without this rest your tendon can become reactive or irritable. In the early stages of  rehabilitation, if lifting body weight only, it is an insufficient load to warrant a rest day. People may do exercises such as single leg calf raises daily providing your tendon is relatively pain free.

Strength training should be unique to the individual, this should be reflected in your rehabilitation programme. At Achilles physiotherapy we aim to educate you on the components of strength training to facilitate your recovery. 3 sets of 10 calf raises simply wont do it.

If it all Fails.

Review progressive loading criteria, has components been missed or more time required at certain stages of strength training. If you and your clinician are happy then you should consider shockwave therapy. 

Shockave Therapy 

What is Shockwave Therapy (ESWT)? 

ESWT is application of  high-energy sound waves, through a medium such as water or coupling gel, to human tissue. Recently, it has been shown to an effective intervention in lower limb tendinopathies such as greater trochanter pain syndrome, patellar tendinopathy and achilles tendinopathy, plantar fascia pain when other non-operative treatments have failed. 

Hows does Shockwave Therapy Work?

Although the exact mechanism of shockwave is not understood completely, it has been shown to create an inflammatory response, decrease the number of sensory free nerve endings. Studies are showing a 91% success rate

Multiple trials have shown that ESWT can be an effective treatment for patients with chronic achilles tendinopathy. Often people ask is shockwave better than progressive loading? A combination of loading exercises and ESWT was shown to be more effective than loading alone.

Shockwave Therapy Safety.

It has cleared by National Institute for Health and Care Excellence (NICE) for clinical use in the UK for chronic AT, as there are no major safety concerns. Clinical studies recommend 3-5 session. This is usually administered 7-10 days apart. In certain cases, additional sessions might be required, normally on the clinical judgment of the therapist.