Achilles tendinopathy

Any sport that has you running or jumping, or if you include these in your prep for them, has the potential for achilles tendon problems. It is not uncommon for people to think that they have an issue with an achilles tendon and for it to be a different tissue in the area. The pain actually being in the  toe flexors or posterior tibialis both of which sit in front of the achilles but these can be easily ruled out during the initial examination . Once it is established that it is an achllies problem we can begin work on addressing it. We now use the term tendinopathy instead of tendonitis as recent research has shown that there are rarely any inflammatory changes in the tendon.
Achilles tendinopathy comes in two different types mid portion and insertional. Mid portion tendinopathy is what we tend to think of when we are talking about classic achilles tendinopathy where the pain is in the body of the tendon, generally 2-6cm above the insertion point of the tendon. Insertional tendinopathy is, as the name suggests, around the area that the tendon inserts into the calcaneum . Tendinopathy can be caused by a number of different factors such as;
• Corticosteriods
• Fluoroquinolone antibiotics
• Hyperthermia
• Mechanical stress
If focus just on the mechanical loading and discount the other different potential causes of the tendinopathy the two types of achilles tendinopathy have slightly different causes. In mid portion tendinopathy it is thought to be more related to tensile loading, that is the force being applied to the tendon is too great and causes tissue damage. With insertional tendinopathy the issue is more related to compression of the tendon against the calcaneum than the load on the tendon. The compression occurs as the foot moves into dorsi flexion, where the foot is pulled towards the tibia or when we are walking/running as we move towards the propulsive phase of the gait cycle.
There are 3 basic stages of tendinopathy which are;
• Reactive
• Tendon disrepair
• Degenerative
The movement through these stages is not necessarily linear and can move from reactive to degenerative and back again dependant on the loading placed on the tendon.
In the reactive stage is we see a thickening and stiffening of the tendon in a response to the load in an attempt to cope with it and reduce the stress. In this stage the load has often been increased too quickly for the tendon to deal adapt too but if caught early enough this stage is where things should hopefully end as rest and subsequent a reduction in the load will allow healing to occur.
We then move onto tendon disrepair. This is again an attempt to heal the tendon and adapt to the load being placed upon it. This time we start to see tissue breakdown in the structures of the tendon. It will generally follow the reactive stage if the problem is not dealt with at that stage.
The degenerative stage tends to be in response to chronic overloading and is thought to be more common in older athlete. In this stage we see further breakdown in the structure of the tendon and is accompanied with cell death in areas of the tendon. With this stage if unresolved it can lead to tendon rupture.
When it comes to treating the injury through all the stages it comes down to managing the load placed upon the tendon. In the reactive and early disrepair stages we might simply want to reduce the stress that is causing the issue if we catch it fast enough and simply allow it time to calm down. In terms of running this might mean switching exercise type for a short period in the most painful cases to reducing the weekly volume in both number of days, distance run and speed in less severe cases. In all cases it will definitely mean dropping all leaping/bounding/jumping activities so no plyometric drills, box jumps etc.

How long for and by how much can vary depending on the severity of the problem and in all cases there is a need to remember that even though the pain has gone/reduced that there will be a period where the tendon will still be sensitive to the load placed on it. As such the return to normal levels of activity should be a gradual one to allow the tendon to adapt to the gradually increasing load, often allowing 24-48 hours between runs to ensure that they can be done pain free. Isometric exercise is useful during this stage in both helping reduce pain and maintaining strength. To perform an isometric exercise you do not move but work to hold a position so with that in mind you could stand on a step as though you were going to perform a heel raise but hold the starting position and not move up or down.
In the late disrepair/degenerative stage we can still see elements of the reactive stage as the tendon will have areas that are normal as well as those which are degenerating. Rest is again a big part of the equation and making sure that you allow enough rest between activities that stress the tendon to allow it to recover and you to move with reduced/no pain. For anyone running higher mileages it would be worth looking at other forms of training during this period to allow you to exercise but off load the tendon. Specific strengthening of the lower leg can be useful in treating the tendon in this stage and some form of seated calf raise would be the go to version.

It was initially thought that it was best to stick with eccentric exercise, the lowering portion of a movement, but it now thought that it doesn’t really matter too much either way whether you do the concentric portion as well. Adding in seated calf raises 3x per week is often enough to help here, looking to add weight when suitable. If we are dealing with insertional rather than mid portion tendinopathy then rather than doing a full ROM on a step the calf raises are done on the floor to remove the compressive element on the movement. With the later stage tendinopathy we are often looking at a long term management of the issue due to the changes that have occurred in the tendon and as such it is important to recognise the things that may set things off and aggravate it for you.

As you progress through the rehab process we need to be aware of addressing issues not just in the lower leg but all the way up into the hip. An inability to create stiffness through the hamsting will result in the  gastroc throwing greater stress into the achilles. As such our rehab needs to address this. We also need to make sure that we don’t just stop the rehab at simple strengthening movements as this is really just the beginning of the process. The system needs to flow from low load rehab to higher load, from simple strength exercises to the ability to generate force and decelerate decelerate the body. So calf raises to  hopping and bounding.

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