Achilles Tendinopathy

Sore Achilles tendon? Painful heel? A large percentage of runners will suffer from this condition. What is it & what can be done to fix it?

Achilles tendinopathy (or Achilles tendinitis as it used to be called) is a condition involving the Achilles tendon which results in pain along the tendon or where it inserts into the heel.

This pain can often be present when getting out of bed in the morning, or getting up from sitting, and will increase with running and jumping. Sometimes the pain may “warm-up” and ease with running, only to return when cooled down or the following day. The Achilles tendon may also appear thickened on the painful side (see image below, and our blog here on why the tendon is often bigger).

The annual incidence of Achilles tendon issues in high-level runners has been reported at 9%, with a lifetime risk of 52% for elite long-distance runners and 23.9% for athletes in general (Kujala 2005). If not properly managed, Achilles issues can cause much suffering & a long stint on the sidelines. Persistent Achilles tendinopathy is associated with a significant psychosocial impact, particularly in terms of participation in daily life and valued activities. (McAuliffe 2017)

Interestingly the core of the tendon is formed during childhood & is essentially not renewed thereafter, just another advantage of being active when young! (Heinemeier 2013)

The Achilles tendon is the STRONGEST tendon in the body, and it needs to be, absorbing 4.15-8.0 body weights of force when running. (Gheidi 2018, Sinclair 2015, Willy 2016)

What else could it be?

Achilles tendinopathy can be further classified as either insertional (at the heel) or mid-portion. There are also a few other structures around that area that can mimic Achilles tendinopathy which include:

Plantaris tendon compression
Paratenon involvement
Sural nerve involvement
Partial tear of the tendon
Fascia cruris tear

A thorough examination will help to diagnose which of these you have, as it will affect the management of your condition.

To read more about the different conditions that can cause Achilles pain head to our blog here

What causes Achilles tendinopathy?

The cause is often multifactorial but can involve:

Increase in training load (can be a sudden increase in distance, frequency, speed or hills)
Changes in shoewear (switching to a shoe with a lower drop)
Running on softer surfaces (sand) and due to individual biomechanics.
Decreased calf strength
Increased BMI
Hormonal change (especially for women going through menopause
Certain medications (i.e. statins)

Do you need imaging?

The diagnosis of Achilles tendinopathy can be made without the need for imaging, however, in some instances, imaging may be used to look for additional structures that may be involved.

What should you do if you have Achilles tendinopathy?

Firstly get a DIAGNOSIS from your Sports Chiropractor! Once you have a diagnosis, then get a PLAN moving forward! A thorough assessment by your Sports Chiropractor will ensure that treatment and rehabilitation can address any issues identified, reduce the chances of you suffering another injury, and get you back out there as soon as possible.

It’s vital to see your sports chiropractor to firstly assess and diagnose your problem and secondly to create an INDIVIDUALIZED rehabilitation program.

What is our unique approach to Achilles tendinopathy?

At Health & High Performance we pride ourselves on a thorough examination to ensure an accurate diagnosis to then lead to targeted treatment, allowing you to get back to the things you love as soon as possible.
Firstly, it is important to have a thorough discussion about your problem and some of the factors that may have contributed to it. This will include a chat about training loads any lifestyle factors that may be playing a role in your pain ie sleep, stress, diet, occupation, and exercise.

Our comprehensive physical assessment protocols for Achilles tendinopathy include:

Mobility assessment of the toes, feet, spine & hips
Strength of the feet & calf muscles using our state of the art AxIT system. Read more about the AxIT system here.

Appropriate calf muscle strength is key for managing Achilles tendinopathy, and therefore assessment of its’ function is imperative for anyone suffering this condition. Seth O’Neill’s 2019 study showed those with Achilles tendinopathy demonstrate loss of strength & endurance in the calf muscles, with this weakness more evident in the soleus (lower calf muscle). Interestingly this study also revealed those with Achilles tendinopathy not only possess weakness in the symptomatic side, but also the ASYMPTOMATIC (opposite) side. This means you can’t always rely on side to side comparisons, as the “good” side may also be weak.

At Health & High Performance we utilize a variety of tests to objectively assess calf function seen in the video below.

The Kinetic chain

In addition to the assessment of your Achilles tendon, we will also assess your whole body, as issues elsewhere in the body can place more load on your Achilles i.e. weakness in the hips and legs is commonly found in those with Achilles tendinopathy. (Habets 2017)

Rehabilitation & return to sport

“Every Achilles tendinopathy is unique, treatment should be too”

Treatment

After a comprehensive examination, we are able to identify factors that contribute to your low back pain, and treatment can then focus on these.

We consider every case on a holistic basis and create Comprehensive Management Plans incorporating three primary modalities:

Manual Therapy (spinal adjustments, soft tissue)
Active Care (dynamic rehabilitation, exercise therapy, movement modification, training load management and running gait modification)
Lifestyle Advice (stress management, recovery, sleep, nutrition)

We actively integrate and openly communicate with each patient and other members of their health & performance team (GPs, coaches, personal trainers, other health practitioners etc.). This ensures that everyone is on the same page to help you recover.

Rehabilitation exercises

Immediately commencing rehabilitation: from Day 1 there will be exercises you can perform to hasten your recovery. These exercises are prescribed according to criteria (what you can/can’t do) not just based on time. In a 2017 study by Bayer et al, they compared commencing rehab at 2 days versus 9 days, and found that those starting rehab 1 week earlier, returned to their sport a staggering 3 weeks earlier! Read more here

Isometric exercises

Isometric exercises are contractions of a particular muscle or group of muscles, during which the muscle doesn't noticeably change length & the affected joint doesn't move. Isometrics can be a useful exercise to help with Achilles tendinopathy, but they don't suit everyone! Read more in our blog here, or watch the video below.

Strength exercises

When managing Achilles tendinopathy, it's important to strengthen BOTH the upper and lower calf muscles (gastrocnemius & soleus). Read about why this is the case in our blog here.

Gastrocnemius biased exercises

Exercises that target more the gastrocnemius muscle can be seen in the video below.

These exercises include:

Double leg calf raises (with foot forward, turned in, turned out, and then one foot in front of the other)
Single leg calf raises
Double leg calf raises with weight, Single leg calf raises with weight
Step up calf raises
Donkey kick calf raises
Weighted toe walks
Sled pushes

Soleus biased exercises

Exercises that target more the soleus muscle can be seen in the video below.

These exercises include:

Seated calf raise
Double leg calf raises with knee bent, Single leg calf raises with knee bent
Box step down
Soleus wall sit
Soleus bridge
Soleus lunge
Rear leg elevated split squat

Foot strength exercises

Your feet are your foundation, and the importance of foot strength in calf function can not be underestimated. It is also important not to neglect the smaller plantarflexors of the ankle including the flexor digitorum longus, flexor hallicus longus, tibialis posterior, peroneus longus and brevis.

Some exercises seen in this video which can be used to strengthen these foot muscles & long flexors include:

End range calf strength

End range calf strength can be a reflection of adequate soleus muscle strength. The larger of the calf muscles, the soleus, is important for running as it takes 6.5-8 times body weight during running (Dorn 2014).

In this blog, we discuss how to test and strengthen this end range strength. Click here to read

Just a simple calf raise?

There are so many alternatives and modifications for this simple exercise that can all serve a different purpose. Check out the video below for some great alternatives! However, it's essential to realize that calf raises alone are not sufficient to rehab Achilles tendon issues, read more in our blog here.

Pulses

Pulses are a great intermediate exercise to help transition from calf raises to jumping/hopping and can be useful for rehabilitation from: calf injuries, Achilles tendinopathy, plantar fasciopathy, ankle sprains and foot injuries. Click here to read the blog

What about stretches for the Achilles tendon?

Stretches are not recommended anymore for Achilles tendinopathy. Stretching can actually increase the compression of the tendon and aggravate it. Instead of stretching, we tend to advise strengthening the tendon.

“Is my Achilles tendon going to snap with exercise?”
In short, NO it is very rare to experience a tear of the Achilles tendon, with research showing 4% of those with Achilles tendinopathy can tear their tendon. (Yasui 2017)

How long does Achilles tendinopathy take to get better?
Tendinopathy tends to take months to resolve whilst doing the RIGHT things, and generally, the sooner you have it attended to, the easier it is to manage. So don’t put up with months of pain! Read more about this in our blog here

Need further help?

Please don't hesitate to contact us for a thorough assessment of your low back issues and to formulate a plan to get you back to health & high performance!

Health & High Performance “Realize your goals”