Achilles Tendinopathy
& Initial Stages of Rehabilitation
With gyms closed and warmer weather on the horizon I bet there is a good chance you've seen a sharp spike in your running volume. There’s a problem.. tendons don’t like change! Changing up the type of exercise can result in a decrease in the ability for that tendon to take load.
So unless you have ramped up your running over an 8 week period, it is going to be important to identify and understand the mechanical causes of Achilles Tendinopathy and how you would go about addressing it in the initial stages of rehabilitation.
What is the Achilles Tendon?
New research suggests that the Achilles tendon is actually composed of 2 sub two tendons one coming from the larger more superficial muscle the Gastrocnemius and another from the deeper calf muscle the Soleus muscle. These tendons travel down from their respective muscles and come together to attach into our Calcaneus (heel bone).
Did you know that a healthy Achilles can be loaded with up to 900kg of force while running?
Although this may be the case the tendons need to be able to glide on each other (remain aligned) to remain healthy. When you load through your Achilles excessively (ramping up running intensity or distance, wearing different footwear, exercising on different surfaces), there is friction between the two tendons.
The Mechanics of Injury
As the two sub tendons run down from the calf muscles, the importance here is that there is now to interfacing tendons and as they run down into the Calcaneus. These two tendons are needing to slide effortlessly and if they are in anything but a vertically aligned position then the tendons can create friction.
The alignment of the tendons is going to be governed ultimately by the positioning of foot placement throughout a gait cycle. If we were to hyper-pronate and collapse into our arch through the gait cycle (specifically the propulsion phase) then we will be loading the tendon without a vertical alignment, and create shearing and extra stress. This additional friction ultimately creates the problem that leads to pain and inflammation between those tendons.
How to Address Early Stages of Achilles Tendonitis: Pain Reduction and Introduction of Loading
1. Firstly if you are diagnosed with Achilles Tendinopathy we need to start by offloading the tendon to reduce pain experienced at the site. We can do this through the application of passive support structures such as Taping or Orthotics that will assist in promoting a neutral alignment of the Achilles tendon by supporting the arch of the foot and reducing any pronation or mis-alignment. Therefore encouraging better gliding across the tendon and less friction.
Taping: can be done as a passive support to pronation throughout a gait cycle
Orthotics/Heel Raise: a raise in the heel of a shoe can reduce the stretch placed on the tendons and help reduce pain - over the counter orthotics can play a role in assisting with support in pronation
2. Releasing a tight Gastrocnemius and Soleus (Calf). Tight calf muscles can cause restriction in range of motion of the ankle and result in additional stress to be placed on to the Achilles tendon.
Myofascial Release: We can release the calf by placing a softball or foam roller on the muscles of the calf and rolling out areas of tension or tenderness. It is important to keep your foot flat (dorsi flexed) and not point your toes (plantar flexed) whilst you're rolling to keep the muscles in your calf relaxed.
Rolling into your Calf twice x daily for 3 minutes at a time
3. Light stretching whilst in alignment: Light stretching of the calf and not allowing collapsing of the arch that could result in a more direct application of the stretch to the fibres and can help with decreasing tension. However this comes with a CAUTION it needs to be light and not for long periods. Stretching on the already irritated tendon can have an undesired response.
Light Stretching in Alignment 2 x daily @ 20 seconds (being careful not to over-stretch)
4. Isometric Loading of the Calf: Isometrically loading (loading without movement) in a calf raise either from the floor or a raised surface allows there to be less pain and graduates the tendon towards a point in which we can place more load into that tissue to improve loading tolerance.
To load through the Soleus you will need to ensure that you maintain a bent knee, whilst a loading of a Gastrocnemius requires a straight knee. These altered versions in execution are the result of differences in anatomy between the two calf muscles. The Soleus originates below the knee and the Gastrocnemius above the knee.
3 sets of 5 reps @ 10 sec hold on the left, 10 second hold on the right
Advancing the programming from here may involve a running assessment and looking further up the chain (hip and core). Evidence shows a reduced glute strength on the affected side, but we are not sure if it is developed because of the painful Achilles or if the weak glute leads to the painful Achilles. Either way, in athletic pursuits we require triple extension through the leg for optimal production of force in a running/walking stride. If you cannot push off through the glute well, you might be trying to do more of it through the knee or ankle, and such glute activation and strengthening may also need to be addressed.
Advanced progressions through Achilles tendon loading. Info-graphic from Physio-Network Gheidi N, et al (2018).
In Summary
To address Achilles Tendinopathy in the Initial Stages of Rehabilitation we have a few things that can be done at home or in the gym.
1. Improving arch support through the administration of Athletic Tapping or Orthotics/Heel Raise
2. Rolling a Ball into the Calf 2 x daily for 3 minutes at a time
3. Light Stretching in Alignment 2 x daily @ 20 seconds (being careful not to over-stretch)
4. Isometric Loading of the Soleus (bent knee) AND Gastrocnemius (straight knee) - 3 sets of 5 reps @ 10 sec hold on the left, 10 second hold on the right.
*This article was an adaptation of Episode 2. How to Treat Achilles Tendonitis during the Initial Stages and was a collaboration with Jacob Carter Physiotherapy.*
1) Finni Juutinen, T., Bernabei, M., Baan, G. C., Noort, W., Tijs, C., & Maas, H. (2018). Non-uniform displacement and strain between the soleus and gastrocnemius subtendons of rat Achilles tendon. Scandinavian Journal of Medicine and Science in Sports, 28 (3), 1009-1017
2) Ackland DC, Lin YC, Pandy MG. 2012. Sensitivity of model predictions of muscle function to changes in moment arms and muscle–tendon properties: a Monte-Carlo analysis. Journal of Biomechanics 45:1463-1471
3) Clark WH, Franz JR. 2018. Do triceps surae muscle dynamics govern non-uniform Achilles tendon deformations? PeerJ 6:e5182 https://doi.org/10.7717/peerj.5182
