Achilles tendon pain is a highly prevalent injury, particularly in runners and athletes in running based sports (Lorimer & Hume, 2014), and is commonly associated with persistent symptoms, as a result Achilles tendon pain is a common injury presentation at The Injury Clinic Physiotherapy.
When assessing and managing Achilles tendon pain and dysfunction, it is important to consider and address various contributing factors.
In this blog, we will explore some common errors in Achilles tendinopathy management.
Symptom Education:
Achilles tendinopathy is a painful pathology, and completely resolving pain in a short period of time is unlikely. The focus of management and education should be on optimising tendon function to enable a return to meaningful tasks or activities (ie running, sport, gym) within tolerable levels of pain.
Education regarding tolerable pain levels is important; compared to other load related injuries, like a bone stress response where our pain threshold during loading is 0/10 on a pain rating scale, we have a higher threshold when loading the Achilles.
Traditionally this has been considered to be a level at ~3/10 on a pain rating scale. With a degree of caution, we can expose the tendon to loads that may elicit a higher pain rating of 5/10, specifically during heavier or more provocative rehabilitation exercises.
As a 5/10 pain rating can be uncomfortable, education on pain behavior and how this might feel is essential. Often a delayed pain response can occur through the Achilles 48-72 hours post exposure to this load, so education on latent pain responses needs to be clear. Activity and exercise modification (including gym exercises) should be educated, considered and implemented in the presence of latent pain responses to reduce the risk of overloading or exacerbating an Achilles tendinopathy within these timeframes.
Load Management:
Achilles tendinopathy typically occurs when the Achilles tendon has been overloaded or underloaded. In an active population, Achilles tendinopathies are typically associated with an increase or spike in exercise load.
This may not necessarily be just exercise or training volume (weekly total running distance/kilometres/time) but can also be spikes in other exercise variables such as frequency (number of days running/training) or intensity (running speeds/pace/rating of perceived exertion). Acute training load needs to be managed in relation to chronic (or previous) training load.
When developing Achilles tendinopathy symptoms, athletes may be advised or think it will be best to rest and stop running or training to let symptoms resolve. This is then typically followed by a return to pre-injury exercise load and subsequently increasing and spiking their acute training load, re-aggravating symptoms, often to a level worse than initially experienced.
This is a common error in Achilles tendinopathy management. These athletes may have been better maintaining, or slightly reducing training load (this could be kms, intensity etc.) to ensure symptoms are kept within tolerable pain levels and reduce the risk of exacerbating symptoms.
Exercise Loading:
The calf and Achilles together form a Muscle-Tendon Unit (MTU). A calf and Achilles MTU with poor strength and capacity can increase the risk of overload through the Achilles tendon and increase the risk of developing Achilles tendinopathy.
As a result, exercise and rehab for Achilles tendinopathy often targets the calf and Achilles through exercises such as t calf raises. However, a common error is that these exercises are underloaded and will not provide enough stimulus to create physiological changes within the tendon and surrounding structures.
When walking the Achilles can be loaded up to nearly 4x bodyweight, up to 8x bodyweight when running and up to 12x bodyweight when running and jumping (Demangeot et al, 2023, Kovi et al, 1992) . Additionally, when running the soleus can be exposed to 8x bodyweight (Dorn et al, 2012). So body weight calf raises just won’t cut it, and they fail to meet the stimulus needed to load the calf and the Achilles for a return to sport..
Successful rehab needs to expose the calf and Achilles to enough load for meaningful long term improvements. This is most effectively achieved in a gym environment through various loaded exercises targeting deficits and improving calf and Achilles MTU capacity. This can include but is not limited to, straight knee and bent knee calf raise variations through various contraction modes and plyometrics.
Loading into Dorsiflexion:
As previously outlined, it is common to see Achilles tendinopathy rehab not progress appropriately due to errors in exercises loading and prescription. Another common error in Achilles tendinopathy management is avoiding loading the calf and Achilles into dorsiflexion ranges. Dorsiflexion can often be a provocative position in Achilles tendinopathy presentations and as a result it is often avoided during exercise selection.
Whilst not wanting to significantly aggravate the injury, loading into dorsiflexion is a component that is required in rehab to optimise and improve overall calf and Achilles strength, resilience, performance and symptoms. Loading into dorsiflexion should be done cautiously given its increased risk or likelihood of feeling uncomfortable and painful. As previously outlined, pain education and communication is essential for Achilles tendinopathy and when loading into dorsiflexion it is important to outline tolerable pain levels, i.e. 5/10.
Neglecting other Potential Contributors:
Diet:
- Like any injury and rehabilitation, it is important to consider diet and the impact of fueling. If under fuelling, and at risk of low energy availability (LEA), regardless of how well a progressive loading and load management plan is, the Achilles and surrounding tissues ability to adapt and respond to loading stimulus is impacted and the ability to progress rehab is hindered.
Running technique:
- Running technique is different for everyone and should be assessed and managed with caution. However, as running technique can influence how the Achilles tendon and surrounding muscles are loaded, particularly at higher speeds, it may be an important consideration to assess in managing an Achilles tendinopathy presentation.
Other:
- Achilles tendinopathy can also be attributed by other factors including hormonal changes that can influence tendon health or footwear that can alter the way we load through our foot, achilles and surrounding musculature. Both hormonal changes and footwear are factors that should be considered when managing Achilles tendinopathy.
Summary:
Achilles tendinopathies are a common injury presentation.
When managing and rehabbing an Achilles tendinopathy it is important to not make common management errors regarding
- Symptom education
- Load management
- Calf and Achilles loading
- Loading into dorsiflexion
- Neglecting other potential contributing factors
Physiotherapists at The Injury Clinic Physiotherapy are experienced in the management of Achilles tendinopathy. So if you’re battling with a sore Achilles that you can’t get on top of, come and consult with one of our Geelong-based physiotherapists today.
References:
Demangeot, Y., Whiteley, R., Gremeaux, V., & Degache, F. (2023). The load borne by the Achilles tendon during exercise: A systematic review of normative values. Scandinavian journal of medicine & science in sports, 33(2), 110-126.
Dorn, T. W., Schache, A. G., & Pandy, M. G. (2012). Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance. The Journal of experimental biology, 215(Pt 11), 1944–1956. https://doi.org/10.1242/jeb.064527
Komi PV, , Fukashiro S, , Järvinen M. and Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med. 1992; 11: 521– 531
Lorimer, A.V., Hume, P.A. Achilles Tendon Injury Risk Factors Associated with Running. Sports Med 44, 1459–1472 (2014). https://doi.org/10.1007/s40279-014-0209-3
