In order to rehabilitate an Achilles tendinopathy or tendinosis for runners and non-runners, we need to be focused on the patient’s goals as a means to set expectations and ensure the best outcome. In this video, we discuss how to properly progress a patient to minimize setbacks in the rehabilitation process. Many of our recommendations are based on the work of Jill Cook, the “Tendon Guru”, Baxter exercise progressions research on tendon loading and the original research done by Alfredson with eccentric loading programs.
What is an Achilles Tendinosis?
The Achilles tendon is the largest tendon in the body that extends from the gastroc-soleus complex (upper calf) to the calcaneus, or heel bone. While walking on level ground a significant amount of force goes through the tendon and 6-10x a person's body weight while running. During repetitive loading of the Achilles’ tendon it can accumulate small tears and a thickening that occur in an area 3-5 centimeters from the attachment point on the heel. It is considered an overuse disorder that lacks inflammation..
This zone is prone to injury partly due to impaired circulation as we age, eventually leading to full thickness tears requiring surgery or tendinosis or a tendinitis that over time can lead to pain or impaired function. The failed healing response is described by Li and Hua (2016) in 3 phases: the reactive tendinopathy, tendon dysrepair, and degenerative tendinopathy.
Who Gets Achilles Tendinosis?
Achilles Tendinopathy or tendinosis is found to occur in 30-60 year olds, but is more common with athletes like runners, basketball and tennis players who require rapid tendon loading for their sports. A few factors may cause you to develop this condition:
How do we Treat Achilles Tendinosis?
The primary treatment for Achilles tendinosis is progressive strengthening from isometric, isotonic and eccentric strengthening exercises. In our runners, we must properly introduce the last stages which reproduce the demands of their sport, therefore very individualized for each athlete to avoid a recurrence of this condition. Many will try to apply the concept of RICE (rest, ice, compression and elevation), but that has limited ability to change this condition, except for "numbing" after icing of the achilles region.
In conjunction with this progressive strengthening program, several adjuncts to treatment often include: massage, deep friction massage, ultrasound, stretching, a walking boot and heel lifts to decrease the tension while walking during the early stages of the rehabilitation process. As much as this is considered a degenerative condition, various types of anti-inflammatories can be prescribed to manage pain levels during the early stages, but have limited ability to affect the tendon in the long term. In several studies, there has been a link to poor tissue healing to tendons, muscle, bone and ligaments with the use of many anti-inflammatories, so the reliance must be limited.
The three primary Achilles tendon disorders are: midsubstance, insertional and peritendinitis. In this video, we will be discussing the rehabilitation for midsubstance Achilles tendon disorder because of fundamental differences in treatment of the other two types.
For runners, it is imperative that you go through the complete process so the tendon can properly rehabilitate for the forces in running. Unfortunately, the tendon's recovery lags beyond the muscular and cardiovascular improvements, giving a false sense of being prepared.
What are the First Steps to Take in the Rehabilitation Process?
The following phases and ideas on treatment are based on the research of Jill Cook:
Isometric and Pain Control Phase
We must reduce loads on the tendon depending on irritability of the tendon. Each patient is different in the current activity levels leading up to starting rehabilitation. Since tendons quickly lose their strength with complete rest, we have to minimize this at each stage. While performing an isometric exercise, there is no movement in the joints surrounding the target area, but the muscles are in a contracted state for a set period of time.
During this phase, the goal is to reduce pain and introduce a load to the Achilles tendon and gastrocnemius complex. We start with isometric loads of 5 x 45 seconds, 1-2 daily for 1-2 weeks. We load the gastrocnemius at full knee extension, then the soleus at 90 degrees of flexion at the knee. If we have the correct isometric load, the patient may have pain initially and then it should lessen as you continue acting as an analgesic.
The advice on how much pain is tolerable varies according to the practitioner but is dependent on how long it lasts after the completion of the exercise immediately and in the next 24-48 hours. A few examples of exercises in the phase would include: non-weight bearing against wall or strap, Heel Raising Standing (2 leg), and Heel Raise Standing (1 Leg).
We focus on strengthening from concentric to eccentric-focused loading of the Achilles tendon, kinetic chain strengthening and endurance work.
Once pain is under control, we enter into the strengthening phase, where exercises are performed in a progression from partial bodyweight, bodyweight, or bodyweight plus external resistance (like a dumbbell or using a leg press of 2-3 sets of 15 reps - slow high load 3 seconds in - then on concentric phase, then pause, then 4 seconds for eccentric phase 2-3x/week for a period of about 2-8 weeks.) A few examples of exercises in the phase would include: Heel Raise 2 legs knees extended (Gastrocnemius) and Heel Raise 2 legs knees flexed at 90 degrees (Soleus), Step-ups, Lunges, Squats, Romanian Deadlift, etc.
Energy Storage and Plyometric Exercises
During this phase, we progressively increase to more dynamic from double to single leg loading from varying speed, heights and distances. During these times, we are typically using bodyweight and eliminating any additional load due to the high forces experienced on the Achilles tendon. In this phase, we need to maintain a strength component while introducing these “return to sport” exercises.
We base our projections on the work of Baxter, et al that looked at various types of exercises and the amount of load applied to the Achilles tendon to give guidance to practitioners when developing a systematic loading progression for their patients’ treatment plans. A few examples of exercises in the phase would include: Hopping 2 leg, Forward Hopping 2 leg, Forward Jump 1 leg.
During Stage 3, you should be starting to return to your sport in a modified format. An example of this would be to start shooting baskets and doing drills, progressively increasing the speed and intensity of the drills. (For runners, we often suggest beginning with a walk / jog program at the local high school track which is typically ¼ mile in length.)
We begin with doing a light jog on the streets and walking the turns. This allows a test and some recovery. Depending on the type of runner, the starting distance is often somewhere between ½ mile to a mile . We begin to use a very conservative distance to establish a baseline from which we can build. I also recommend not running two days in a row in the early phases of your return to running or jogging. In the population of runners that are returning to sprints, the progression takes a little longer because of the intensity and force applied to the tendon with sprints, especially those that have quick changes in direction like trail runners.
During these phases I expect a slight increase in “soreness” in the Achilles tendon that resolves pretty rapidly after completion of the training for that day. We will make adjustments in our return to jogging/running schedule based on whether pain, soreness or swelling results. If symptoms last for hours up to two or three days in the region of the Achilles, we make adjustments or allow a week prior to resuming the jogging/running schedule.
We hope this gives you some more information on getting relief from an Achilles tendinosis.