What is Achilles Tendinopathy?
Achilles Tendinopathy. What is that? Well, most people are pretty familiar with what the Achilles is other than the character that Brad Pitt played while being oiled up in black leather in the movie Troy.
Most people do not know what tendinopathy means. It is the most current term used to describe a problem with tendon tissue. Let’s clarify something first. There is no such thing as “tendonitis”. This is an old thought process and old terminology. “Itis” is used to describe something inflamed or aggravated.
With these tendon issues, pain is actually preceded by mechanical stressors of tensile loading, which initiates a pathological change in the tendon. So, it is actually a disease of the tissue, not an inflammatory response, which results in thickening of the tissue, poor blood supply, collagen disorientation and thinning, fat deposition and altered fluid movement.
Where Does Achilles Tendinopathy Happen?
Most commonly, this condition occurs in the mid-portion of the Achilles as well as the insertion point, known as insertional tendinopathy, where the Achilles attaches to the calcaneus, which is your heel bone.
These changes in the tendon integrity result in deficient extensibility; strength and ineffective force transfer which results in affecting the central nervous system motor control. Motor control, there is that term again. Remember we discussed that in the previous articles? This means an alteration of the Achilles tendon integrity affects your movement efficiency.
Achilles Tendinopathy Is One Of The Most Common Overuse Injuries
Achilles tendinopathy has been found to be one of the highest overuse injuries to occur in the foot and ankle in sports, especially in runners engaging in all distances, including ultra marathons.
For the athletic population, ankle mobility deficits and training errors are the most predisposing factors towards developing this condition. Foot landing patterns and loading techniques have also been investigated in runners and have found to be contributing factors as well. There is also a correlation between Achilles and distal limb strain resulting from deficient proximal stability in the hips. As discussed previously, proper gluteal function is essential towards movement efficiency, which contributes towards preventing conditions like this.
The majority of the mechanical dysfunction lies within the eccentric portion of the loading phase for the Achilles. Eccentric, when referring to medical terminology, means the expansion phase, lowering portion or the controlled resistance against gravity movement phase.
Think about a bicep curl. When you flex your arm up, that is a concentric contraction. When you lower your arm down, that is an eccentric contraction. Regarding the Achilles, the eccentric portion is when your foot initially contacts and strikes the ground, then lowers down. Within those milliseconds of time, shock absorption and resistance are met in the joints and tissue as they act to control the forces and react properly for mechanical efficiency.
Signs & Symptoms Of Achilles Tendinopathy
Research has found that commonly reported symptoms between subjective reports and objective measures consist of:
- A person’s self-report of pain in the Achilles, pain that ranges from the lower calf to the mid-portion of the Achilles as well as into the heel.
- Most notably, the pain occurs after increased activity followed by low activity such as sleep or sitting then going to move again.
A perfect example is going for a long trail run or doing track intervals then coming home and sitting for 2 hours. When you go to move again, you’ll notice the pain. This can occur hours afterward or a day or two later. It also depends on how much stress the tissue has recently endured and how involved the condition is. If clinical exams somehow are inconclusive, then an ultrasound or an MRI can help to classify tissue dysfunction.
How To Cure Achilles Tendinopathy
Most commonly everyone thinks rest is the key. I hear it all the time. “I took some days off, felt good and then went back to my high volume running and it came back, it just won’t go away.
Then I hear the classic “I put ice on it” Anything will feel better if you don’t aggravate it and ice is just going to block the pain. Considering the issue has been found to be non-inflammatory, ice won’t have any effect with the thought process “of controlling swelling”.
Neither of these methods actually works towards correcting the mechanical and physical issue involving the tissue. Changing shoe types or running surfaces are other methods of indirectly addressing the issue.
Research has shown throughout the years through a continued revisiting of concepts and interventions in controlled studies, that the best methods involve manually addressing the tissue.
A very common protocol is known as Alfredsen’s protocol
Which involves a high volume of slow and controlled eccentric loading. This method helps to restore the proper tissue integrity as well as the motor control for re-teaching the tissue and body to accept loads and stress to the tissue.
Physical Therapy For Achilles Tendinopathy
The interventions we use in physical therapy usually consist of instrument-assisted soft tissue mobilization, commonly known as Graston. This is where we use a tool with a beveled edge and scrape in strategic directions with appropriate pressure to restore blood flow, stimulate a central nervous system reaction to relax tight tissue and also aggravate the area. Yes, I said to aggravate the area.
Since tendinopathy is a structural dysfunction of the tissue, it is imperative to cause an inflammatory process so the body can bring the proper resources to the area to heal the tissue. Now, this doesn’t mean go out and run 10 miles and excessively further load dysfunctional tissue. This means completing controlled prescribed soft tissue work, followed by a systematic approach of stretching, eccentric loading, and neuromuscular re-education.
All these methods are in an attempt to remodel the tissue back to its normal properties. We also use other manual release techniques, manual stretching and even manual interventions to the tissue while patients engage in eccentric loading.
Research has also shown the volume of eccentrics is not set. So when people ask “how many reps should I do and how often?” there is no direct answer but it has been found that the best outcomes result from patient’s going to their tolerance.
Pain is expected and is part of the tissue remodeling process but should not be exercised to debilitating levels. Gradual increases daily with a smart progression rate is always best. During this time, avoiding aggravating factors is beneficial, and yes that means holding off on running. During this time, work will be done to address the deficits appropriately so the individual can return to running or sports participation without setbacks.
Getting Back to Sports After Achilles Tendinopathy
The best results towards a return to current sport status have been correlated with the individual’s response to rehab. Everyone’s tissue and central nervous system are different. It also is challenging to determine the exact amount of tissue damage sustained so the individual’s response to activity in terms of pain and movement efficiency are the best indicators towards progress.
Generally, when someone can tolerate returning to basic activity, moving from sedentary positions, pain-free engages in a single leg heel raise pain-free, and tolerate the rehab exercises without significant pain, progression back into sports participation is generally safe. Ensuring proper movement mechanics and efficiency with single leg positions is also important within this assessment.
For any condition, it is always best to consult a licensed physical therapist. Most, if not all physical therapists have their doctorate degrees now with direct access which means you can usually get evaluated and treated without a physician referral or a “script”.
Finding a local PT in your area for a quick screening can always be beneficial in most cases. There are some factors that may vary depending on practice laws in your state and your insurance benefits but doing your research towards finding a good practitioner can help assist you along the proper path towards recovery.
For a true diagnosis of Achilles tendinopathy, the following are examples of interventions used.
Instrument Assisted Soft Tissue Mobilization
It is recommended to have a licensed professional administer this treatment or to learn from them the proper technique of how to do it yourself. Understanding the appropriate technique will ensure true recovery and avoid further injury. It is possible to further injure yourself if this technique is not properly performed.
Foam Rolling
Recommended 30-50 rolls over the muscle belly area using LIGHT to MODERATE pressure. Avoid boney prominent spots as well as the actual tendon. Only rollover muscles. Do not put yourself into tears or cause excessive pain with this technique. Follow up with stretching.
Open Chain or Unloaded Stretching
Use a strap or towel. Let your foot relax and gently pull up towards yourself. Hold 30 seconds. Repeat 2-3 times.
Closed Chain or Loaded Stretching (Gastrocnemius Muscle)
Stand with affected side back and knee straight. Keep the heel down while leaning forward with the opposite side. Hold for 30 seconds. Repeat 2-3 times. It is always good practice to stretch both sides regardless of only one side being involved to act as preventative measures on the non-affected side.
Closed Chain Second Position (Soleus Muscle)
The same stance as the first position except while keeping the heel of the back foot down, bend the knee. Hold for 30 seconds. Repeat 2-3 times.
Eccentric Loading Beginning Phase
Perform a regular heel raise on both feet. Lift up the non-involved side. SLOWLY lower down at a count of 5-8 seconds on the affected side. You may need to hold on for improved control and balance. As stated earlier there is no definitive prescription for volume. Starting with a personal tolerance of reps, sets and frequency are best. Try to progress ONE variable a little each day.
Eccentric Loading Progression Phase
Once volume with the eccentrics from the floor has improved to levels of better control and less pain, progressing to the edge of a step is next. Repeat the same technique. Up with both then lower down at a count of 5-8 seconds on the affected side. Mixing in a bent knee variation is also beneficial.
While sitting, work to raise your big toe while keeping the rest of your toes down and then alternate. Eventually, progress towards completing this movement while standing. It is harder than it looks!
Single Leg Hip Hinge
Stand with a pole behind your back. Hold it so it contacts the back of your head, mid back, and tailbone. SLOWLY teeter forward over one leg, with a slightly bent knee position while keeping the opposite leg straight behind you and maintaining contact with the three points and the bar. Return up while maintaining balance. Avoid rotating at the torso or pelvis.
Single Leg Advancements: Oscillating Technique for Isometric Stabilization
Once you can demonstrate good control for at least 30 seconds while standing on one leg, progressions are then beneficial. This technique is an easy and very beneficial one requiring only a resistance band. Stand on one leg while holding a resistance band in both hands with the other end anchored down below you. Press up and outward. Start with slow controlled presses, eventually progressing into fast quick rapid presses. Go for reps or time.
References:
- Martin, R., Chimenti, R., Cuddefor, T., Houck, J., et al. (2018) Achilles Pain, Stiffness and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. Journal of Orthopaedic and Sports Physical Therapy, Vol 48 (5), A2-A38
- Stevens, M., Tan, C. (2014) Effectiveness of the Alfredson Protocol Compared with a Lower Repetition- Volume Protocol for Midportion Achilles Tendinopathy: A Randomized Control Trial. Journal of Orthopaedic and Sports Physical Therapy, Vol 44 (2), 59-67
- Silbernagel, K., Crossley, K. (2015) A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. Journal of Orthopaedic and Sports Physical Therapy, Vol 45 (11), 876-886
- www.functionalmovement.com
About The Author
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance and Motor Control Test Certified with 8 years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures.
