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Achilles tendon pain is one of the more common sporting injuries seen by our Physiotherapy team.
A typical history for an Achilles injury is a runner, usually around 35-55 years, who gradually felt a soreness on one or both Achilles tendons in the early stages of a run. It gets worse as it lasts longer in the run and aches afterwards, even when walking.
Many people are concerned about a torn Achilles but this is the least common cause. And it’s worth noting that Achilles pain is very rarely a precursor to a ruptured Achilles.
Achilles tendon ruptures happen without warning, not as a result of worsening Achilles tendon pain.
Achilles pain diagnosis
Gradual onset pain
The majority of Achilles diagnoses are for gradually worsening tendon pain. These are tendinopathies, previously referred to as “Achilles tendonitis”, and come in a few different varieties.
As mentioned above, the pain often starts in a subtle way, just noticeable at the start of one run or one morning on waking. The symptoms gradually increase and last longer until it’s there for most of the day and throughout every run.
This may be due to a simple irritation of the tendon substance. It reacts by becoming painful on loading but there’s no structural change associated with this injury.
Alternatively it may be due to breakdown of the tendon material, referred to as a degenerative tendon, which will then cause pain on loading.
Both types of injury are treated in a similar fashion but with slightly different timeframes for recovery and need for ongoing prevention.
It should be noted that these injuries are not inflammatory so anti-inflammatory medication doesn’t work. Also worth noting that unlike most tendons, the Achilles tendon doesn’t have a sheath around it. So it can’t get many of the other tendon conditions that we see elsewhere in the body (such as tenosynovitis).
Acute (sudden) onset pain
There’s a separate group of injuries that occur as a result of a single incident of overload. Often you’re running along and your heel unexpectedly drops into a pothole. Or you’re standing still and suddenly try to sprint with max force.
For this type of onset, there’s a risk of an Achilles tendon tear. Most tears only affect a small portion of the tendon but require imaging (ultrasound or MRI) to confirm the magnitude of the damage.
Achilles tendon rupture can also occur but it’s associated with a VERY loud popping noise and distinct reaction (“who the hell just shot me in the calf?” – aka the sniper reaction).
Achilles injury rehab
Achilles tendon rehab is actually quite similar for minor tendon tears and tendinopathies. The focus is on providing enough stimulus for the tendon quality to improve without causing overload.
These guidelines should help you map out a rehab plan.
- Mild symptoms are OK during your rehab exercises and training
- Worsening pain is not OK
- Sharp pain is not OK
- Strong pain is not OK
- Exercising every day is better than every 2nd day
- When the current exercises don’t challenge you or generate soreness, progress your tendon loading
- Loading can be progressed in three ways but typically only advance one of these parameters at a time
- Faster movement
- More calf stretch during movement
- Stretching is not required and can irritate the tendon for no benefit
Sample Achilles tendon rehab program
Here’s a simple rehab plan for an Achilles injury, including the reasoning behind the choice of exercises.
- Starting point (all performed daily)
- Isometric (static) calf holds – good for pain relief and gentle loading, can be performed on one or two legs depending on intensity of symptoms
- Single leg box squats – maintains leg strength in other muscle groups
- Walking lunge – maintains mobility in ankles and hips without over-stretching the Achilles tendon
- Running on flat at easy pace for 50% of regular run distance (swap for brisk walk for non-runners or if running is too painful) – provides gentle bouncing action for tendon, maintains running efficiency, improves mental state
- Next progression (no set timeframe – progress when symptoms ease on first phase exercises)
- Calf bounce exercises – leaning against a wall and bouncing gently in a small movement, on one leg or two depending on symptoms and strength
- Single leg kettlebell deadlifts – loads upper leg with isometric (static) calf loading
- Weighted walking lunges – adds some loading through range
- Running/walking – steadily progress either duration or pace or gentle rolling hills
- Next phase
- Lateral (sideways) hopping – adds some faster movements without too much loading (forward hopping adds more loading)
- Reverse lunge with weight – adds calf bracing, power and ankle/hip
- Jump lunges – adds range and power for most structures around hip and ankle
- Running/walking – progress another parameter, either faster, longer or more vertical
- Later phase – towards the latter stars of rehab, depending on the recovery goal
- Wall hopping – leaning against a wall, hop on one leg to provide higher and faster loading
- Sled pushes – high loading with a bracing-type pattern
- Weighted step overs – keeping one foot grounded on a 20cm high box, lightly touch the other heel to ground in front and behind the box
- Running/hiking – combining some speed with climbing
This program only uses three exercises each day (+ running/walking). A simple and short program is more effective than a complex, time consuming program.
Avoid rushing the progressions – premature progressions can cause symptom flare ups and delays. But slower progressions won’t cause any trouble except for a slightly longer recovery timeframe.