Management of Achilles Tendinopathy.
With gyms closing and other forms of recreation no longer accessible, it appears there’s been a surge in people turning to walking and running to pass their time and maintain fitness levels. Research suggests general activity levels amongst the UK population in lockdown have reduced, however, the number of people turning to running has increased. Great news for the running movement.
New or inexperienced runners sadly appear more prone to injury than experienced runners. With this in mind, the Physiohub team will provide evidence-based but patient-friendly management plans of a series of common running injuries. These are designed for all runners, but particularly those recently infected with the running bug, that have been left frustrated at their inability to train due to injury. First one up, is the management of achilles tendinopathy (previous known as tendonitis).
Achilles Tendinopathy – What is it?
Achilles tendinopathy is an overuse injury of the achilles tendon that can be painful and can result in a loss of function. It is typically found in people who partake in running and jumping sports, but particularly those that enjoy longer distance running. Approximately 50% of all distance runners will experience achilles tendinopathy at some stage in their running life and it is thought to account for upto 12% of all running related injuries at any one time. Symptoms can occur where the tendon inserts onto the heel bone, but more commonly in the mid-portion of the achilles belly. Usually they are tender to touch.
Symptoms can include pain and sometimes swelling/thickening of the achilles tendon. Initially, symptoms present as a morning stiffness or an ache or mild pain usually at the start of a run that eases after approximately the first mile. However, if not managed well, this can progress to much more acute and persistent pain that prevents people from running. As with other tendon injuries, achilles issues are typically fairly stubborn and can take over a year to fully recover. Re-injury rate is very high, particularly if the volume/loading is poorly managed and return to high mileage is rushed.
Risk Factors:
It is thought the risk factors for developing Achilles Tendinopathy is multifactorial. Various contributing factors lead to an overload of the tendon or lead to a reduced load capacity of the tendon. This can lead to the development of a tendinopathy – which is defined as a ‘degeneration or failed healing due to continuous overload without appropriate recovery.’
High quality research has highlighted the following issues as potential risk factors for achilles tendinopathy:
· Reduced calf strength
· Reduced control/strength at the hips
· Increased bodyweight
· Abnormal ranges of motion at the ankle/subtalar joint – usually a reduced dorsiflexion (ability to bend the ankle to bring your toes towards your shins)
· Increased foot pronation.
· Training error (sudden increases in volume, intensity, duration without adequate rest).
· Family history of tendinopathy
· Recent use of fluoroquinolone antibiotics
How is it diagnosed?
A Physiotherapist or GP will diagnose Achilles Tendinopathy following a series of questioning and through observing you perform a series of movements and tests. This can be diagnosed quite easily in a virtual capacity in an online physiotherapy assessment. Ultrasound scans can be used to confirm diagnosis and to assess tendon morphology, but this is usually not required and will not usually change the management plan.
Management
From an evidence perspective, exercise based rehabilitation is the only universally recognised method for managing Achilles tendinopathy. Other modalities have been proposed such as manual therapy, electrotherapy, taping and acupuncture however these are not supported by strong evidence and will not be further discussed in this blog. The purpose of exercise based interventions is to provide mechanical load to the tendon in order to reduce pain, encourage remodelling, and improve the strength/power/endurance of the calf muscles.
Exercise Rehabilitation
The rehab of an injured achilles is typically split into 4 distinct categories and your physio will be able to guide you through these phases.
1. Symptom management and load reduction.
2. Recovery
3. Rebuilding
4. Return to sport/return to high mileage/return to previous volume
1. Symptom Management and Load reduction
The aim of this phase is to reduce a potential overload of the tendon. Following your examination, the physio will have an understanding of tissue irritability and will discuss ways to reduce load if required. Unless symptoms reach a 5/10 on the diagram below (figure 1), runners are usually encouraged to continue with activity/running in some capacity. Moderate/severe pain should be avoided as should worsening pain over time.
The main focus of achilles tendon rehab programs are heel raise exercises which can be progressed through the 4 phases accordingly. Initially, this may be conducted on flat surfaces and using both limbs to protect the injured tendon. If these early exercises cant be tolerated and pain exceeds the 5/10 threshold, then other methods to load the tendon may be adopted. These may include resistance band exercises, seated exercises or forms of isometric loading (loading without movement). Other methods of training which partially load the tendon such as cross training, biking, water-running can be employed to maintain cardiovascular fitness levels.
Figure 1: The pain monitoring model taken from SIlbernagal et al 2015
2. Recovery phase
The main aim of this phase is to improve the strength of the calf complex and improve the achilles tendons load tolerance. It is advised that exercises are performed daily. As symptoms eases and strength improvements are noted, heel drop exercises can be progressed accordingly. In this phase, this is done by increasing repetitions, speed of movement and range of motion of the exercises. Typically, this includes progressing from flat surfaces to off the edge of a step, or by introducing quick rebound heel raises. This is thought to increase the tendons tolerance of fast loads.
At this stage, addressing other issues found in the physio assessment can be incorporated. These include:
· Hip and knee strengthening exercises to address alignment and biomechanics
· Weight management discussions to address increases in bodyweight.
· Ankle range of motion exercises, often to improve dorsiflexion (bend at the ankle).
· Foot and ankle strengthening
3. Rebuilding Phase
The main aim of this phase is to progress the loading exercises to include heavier loading of the calf/achilles complex, to include plyometric (jumpy-jumpy) type exercises and progress running volume. At this stage, weight is usually added to the heel raise exercises in the form of dumbbells or weight rucksacks. 3 sets of 15 can be performed daily and again discomfort should not exceed the 5/10 as highlighted above. Although at this stage, pain may have significantly reduced and strength improved, it is advised to continue to progress the loading exercises to encourage further tendon healing. Plyometric exercises will start with double leg jumping activities and can be progressed to a variety of single leg activity as pain and control allows. In order to progress to stage 4, it is advised a runner can perform 20 single leg hops with a discomfort of less than 2/10.
4. Return to sport/return to high mileage/return to previous volume
The aim of this phase is to return to your previous level of function. For a runner, this may be to return to your previous weekly or monthly volume or to return to previous speeds. Meanwhile, it is important to continue with rehab to further improve load tolerance/tendon health. Heavy, more explosive and faster loading exercises are combined with an increase in mileage. It is important to incorporate adequate periods of rest to enable proper recovery and reduce a secondary overload. Light level exercises or activity (including short easier runs) could potentially be performed daily. Medium level exercises or activity should have 2 days rest afterwards and heavier more explosive sessions will require 3 days rest. It is important to plan monthly schedules including activities that include low, medium and high intensity exercises. These are then evaluated at monthly intervals and progressed accordingly.
The infograph below (figure 2) by Yann Le Meur summarises the phases of recovery with practical examples of exercise progression
Figure 2: Achilles tendon loading protocol. Credit: Yann Le Meur
Prevention.
As always prevention is much better than cure. Identifying overload of the tendon early is shown to reduce progression of the injury/tendonipathy and reduce the time required to return to previous function.
Summary of Key Points
Achilles tendinopathy is an overuse tendinopathy causing localised pain and restriction to function.
Exercises to load the calf complex and Achilles tendon is main focus of a treatment plan.
The main aim of a treatment plan should be to focus on activity modification and progressive tendon-loading exercises.
Prevention is better than cure. Recognise symptoms of overload early and treat with load control.
If you require further information regarding the management of Achilles Tendinopathy, please contact us via our website https://www.myphysiohub.co.uk/contact
Physiohub is a 100% online physiotherapy company. We offer online physio assessment and treatment sessions from the comfort of your home.
To book an online physiotherapy assessment with one of our experienced online physiotherapists, please see www.myphysiohub.co.uk.
Adapted from Silbernagel et al 2020. J Athl Train (2020) 55 (5): 438–447.