Jessica Woodhouse (Injury Active Clinic, Bishops Stortford)
For the purpose of this blog post, we will be focusing on mid portion achilles tendinopathy/tendinitis.
Whether you’re an elite athlete or an everyday gym goer achilles tendinopathy could be affecting your exercise (Alfedson et al 2007). The discomfort you are likely to be feeling commonly in the mid portion of your achilles, is one of the most common sports injuries (Maffulli et al 2003). This stresses the importance for Sports Therapists like myself, to be able to review and manage this early on, allowing conservative treatment to be as effective as possible (Kader et al 2011).
Were your immediate thoughts when you felt pain to stop? Rest is good but total rest can cause the opposite effect and decrease the healing process of the achilles due to its structure (see anatomy). It is important to note this is unlikely to be an inflammatory response, it is more likely to be a failed healing response therefore; the most important thing would be to maximise the healing response by not fully unloading the tendon (Alfedson et al 2007).
Symptoms felt (The Sports Physio 2011).
- Gradual, localised pain to the achilles
- Pain association with exercise/increased intensity and stiffness after exercise.
- Painful dorsiflexion (pointing toes to celling)
- Calf Tightness
Anatomy
The main contributor to the achilles is the soleus fibres, forming the medial tendon and the gastrocnemius fibres forming the lateral portion of our achilles (Findley 2006). Made up of 95% type 1 collagen enables the tendon to be strong and flexible.
Tendon healing can be slow; therefore, stopping exercise will hinder the healing process due to the achilles poor blood supply and low metabolic rate (Findley 2006).
Why am I getting this pain?
For such a common condition there is very little support for many of the risk factors I am about to highlight. Everyone’s body is different; therefore, we will all react differently to many intrinsic and extrinsic risk factors.
The table below categorises the risk factors, which are believed to play a role in increasing and provoking the risk of achilles tendonitis/tendinopathy (Kader et al 2011 and The Sports Physio 2011).
| Intrinsic risk factors | Extrinsic risk factors |
| Gastroc-soleus dysfunction (decreasedflexibility and weakness) | Changes in training pattern-increased loading (muscle fatigue= tendon elongation and micro tearing) leading to overuse |
| Age | Poor technique-over pronation (rollingfoot inwards) on heel strike |
| Body weight | Previous injury |
| Lateral ankle instability (ankle weakness) | Footwear (lowflexibility shoes) |
| Pes Cavusdeformity (high arch) | Environmental factors- training on hard ground |
Can I exercise?
Exercise is important with achilles tendinopathy allowing lengthening of the shortened muscles and normalisation of the tendon structure. The aim of the exercise should be strengthening and increasing flexibility lost. We know loading the tendon speeds up tendon healing. However, Cook and Purdam’ (2009) model of 3 stages of achilles tendionpathy outlines the importance of distinguishing the phase of achillies tendinopathy you are in. This will allow correct management and loading of the tendon to allow full recovery.
- Reactive tendinopathy (first 10 days, acute overload)- aggressively unload tendon, rest and stretch
- Tendon Disrepair (failed healing)
- Degenerative tendinopathy (chronically overloaded tendon).
Load needs to be increased or decreased to fit the phase of tendionopathy for example reactive healing load should be decreased and degenerative tendinopathy loading should be increased. The main aim of loading the tendon is to remodel the matrix hopefully causing pain removal and elimination of achillies tendinopathy.
It is important to avoid high impact exercise. Exercise should be adjusted to you whether that’s decreasing intensity, duration, and frequency or just modifying the exercises so pain is not felt. Another great way to minimise this is biomechanical screening to allow any biomechanical issues to be highlighted e.g. over pronation of foot= more stress on achilles tendon.
An example of a model, which is used in exercise, is the Alfedson’s model of eccentric training, which is proven in many studies to be very successful (Sports Physiotherapist 2011).
This model should be implemented into your training after 10 days of suffering from achilles tendonitis. Exercises are eccentric and should be completed with discomfort, around 15 reps 3 sets 3 times a day to increase type 1 collagen production(replacing type 3 collagen, weak and inflexible) to increase strength and flexibility of the achilles (Alfredson et al 2007).
- Begin in a double heel raise, lower on affected leg with straight leg
- Begin in a double heel raise, lower on affected leg with knee bentTake a look at the video below to see the Alfredson Protocol
Overall summary and advice:
Ensure that you treat this injury as soon as possible to increase effectiveness of conservative management.
Don’t fully unload tendon, unload at the beginning of injury and gradually progress. Only eccentrically load after 10 days so achilles tendon isn’t aggravated more.
Add in stretching of gastrocnemius and soleus into your exercise programme.
Manual therapy techniques performed by a Sports Therapist, such as soft tissue massage, myofascial release and ankle mobilisations are helpful in increasing the speed of recovery and restoring ankle range. Guidance on a full strength and conditioning programme is also vital to ensure good results remain.
Thank you for reading
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Jessica Woodhouse BSc Sports Therapy References:
Alfredson, H; Cook, J. (2007). A treatment algorithm for managing achilles tendinopathy: new treatment options. Br J Sports Med. 41 (4), pp.211-16.
Cook, J.L; Purdam, C.R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports med. 43 (6), pp.409-16.
Findley, S. (2006). Achilles tendonitis. Body mechanics.pp.13-15.
Kader, D; Saxena, A; Movin, T; Mafulli, N. (2011). Achilles tendinopathy: Some aspects of basic science and clinical management. Br J Sports Med. 36, pp.239-249.
Mafulli, N; Kenward, M.G; Testa, V; Capasso, G; Regine, R; King, J.B. (2003). Clinical diagnosis of achilles tendinopathy with tendinosis. Clin J Sport Med. 13, pp.11-15.
Sports Physiotherapist in Research. (2011). Achilles Tendinopathy: Evidence Based Diagnosis and Management. Sports Injuries, Sports Physiotherapy, Tendon Injury.
