So in our last blog “Achilles tendinopathy – Symptoms, Causes & misconceptions”, we explained the symptoms, causes & misconceptions around Achilles Tendinopathy. Today, we are going to discuss the best exercises to “Fix” Achilles Tendinopathy.
Typically there is no one size fits all remedy with this injury, each case should be taken individually and a suitable program should be designed. There are however a few treatment modalities that have been proven to assist recovery:
1 / Non Steroidal Anti Inflammatories (NSAIDS) – As previously stated in our previous post, there is no actual “inflammatory cells” on biopsy of Achilles Tendinopathy tissue. However, Ibuprofen/ Nurofen have been specifically proven to be effective in settling pain from Achilles Tendinopathy (Cook & Purdam 2013) in the reactive (early stage) of this condition. The mechanism of how this helps is unknown as yet but over the counter Ibuprofen/ Nurofen has been proven to be more effective than stronger NSAIDS such as Voltaren. Always check with your GP before starting any NSAIDS and make sure that you eat before taking them. Stop taking them immediately if you have any side effects. Effectiveness is at its best after 4-5 days of taking them continuously.
2 / Footwear – Soft soled shoes such as running shoes have been proven to be more effective in assisting Achilles tendinopathy recovery compared to hard soled shoes such as formal work shoes. Furthermore, shoes with a small heel are more beneficial than completely flat shoes as heeled shoes allow the achilles tendon to rest. Just wearing shoes is much better than being bare foot (even around the house- particularly on tiled or wooden floor) or wearing flip flops (thongs) due to the associated toe gripping with flip flops. I also routinely advise patients with Achilles Tendinopathy to have their running shoes next to their bed so that in the morning- when the pain is often at it worse- they can benefit from the support that running shoes offer.
3 / Heel raises – Place a heel raise of 6mm or more in the shoe of your effected side. As per point 2, the heel raise allows the achilles tendon to rest and takes it off stretch.
4 / Orthotics – Now this is a controversial one as there are definitely 2 schools of thought with regards to whether or not orthotics are helpful in settling Achilles Tendinopathy. So first of all what is the purpose of orthotics- well the purpose is to change the mechanics of the foot by altering the foot position in your shoe in order to make your foot/ ankle complex more efficient. The most common use for orthotics is for people with feet that pronate ie flat feet. One school of thought states that orthotics ARE necessary as they place the foot in a more neutral position and therefore the Achilles tendon can work in a straight line. Tendons don’t like torsion or rotation and therefore the stresses distributed from the foot up into the legs can be spread equally when wearing orthotics. According to Cook & Purdam 2013: supportive strapping or bracing, orthoses, footwear and other equipment choices should also be considered in managing the athlete with in-season tendinopathy as small gains made in this realm may provide enough to allow satisfactory athlete function.
The other school of thought says that orthotics ARE NOT necessary because if you resolve all the other factors that contribute to Achilles Tendinopathy such as tendon strength, muscle imbalances further up the chain, joint stiffness, poor footwear etc. the Achilles will be strong enough to cope with the load placed on it even if its mechanics are not 100% perfect.
Both are very valuable arguments but our opinion at Fix Physio is that each case should be taken on their individual merits. Anecdotely when treating patients with acute Achilles Tendinopathy, I often find orthotics or some form of foot/ achilles taping to be helpful in the short term.
5 / Tape/ kinesiotape – We use two types of taping for achilles tendinopathy depending on the clinical presentation. Kinesio taping is an elastic adhesive tape used in this scenario to help reduce pain and facilitate motion. Rigid strapping tape is a strong, non-elastic tape used to limit joint movement in order to prevent the achilles from achieving full stretch hence allowing it to rest.
Taping is usually a good adjunct to rehabilitation of achilles tendinopathy. We will assess each patient to determine if taping is required and if needed, which would suit best. It is important to note that taping is only used to facilitate the rehabilitation process and should not be considered a long term fix.
6 / Specific graded exercises – Now this is the stage where a Physio comes into its own and the treatment regime that has best evidence is that of Jill Cook & Craig Purdam (2013). Before we start explaining this, it is important that we differentiate the 2 variations of Achilles Tendinopathy:
- Mid tendon body- this is situated in the middle of the achilles itself and is usually tender to touch and sometimes presents with an actual lump in the tendon
- Insertional Achilles Tendinopathy – this is situated where the Achilles tendon attaches into the heel bone (calcaneus) and is often caused by a Haglund’s deformity.
Stage I isometric exercises: There are 2 main types of muscle contraction types- isotonic and isometric. Isotonic muscle contraction is when the 2 muscle ends get either closer together (concentric) or further apart (eccentric).
The 2nd type is Isometric exercises which is where the muscle contracts but the 2 muscle ends stay the same distance apart.
The exercise of choice for symptomatic Achilles tendinopathy stage I is Isometric 2 leg calf raises with both hands lightly supported so as to take out the balance component of the exercise.
The specifics of this stage I exercise are as follows:
- Seconds Hold: Up to 45 seconds (patient might not be strong enough or be too irritable to do this length of time initially so patient should do however many seconds that they can cope with pain free for 4-5 sets and then gradually build from there)
- Rest time between each set: 2 minutes
- Number of sets: 4-5
- Number of times a day: several as required
Common mistakes made during Stage I-III exercise:
- Patient leaning forwards – the body should go practically vertical- focus on the load going through the heels.
- Patient bends their knee to achieve momentum – the knees should be totally straight
- Patients ankles roll out as they raise bodyweight up – the foot and ankle should be neutral throughout exercise ie a straight line from the Achilles tendon down into the foot when looking from behind.
All of these common errors must be corrected to avoid further aggravation of injury.
IMPORTANT: If the patient has a mid Achilles tendon body then he/ she should go to the end of range with his/ her 2 leg calf raise. If the patient has an insertional Achilles Tendinopathy, they should only go half to three quarters range of 2 leg calf raise so as not to compress Achilles tendon against the likely Haglunds deformity.
The patient will do this 2 leg Isometric calf raise until they can consistently do it well and pain free for the full 45 seconds, 4-5 sets.
This is when they progress onto 1 leg isometric hold for same timescales, repetitions and height of calf raises as for the 2 leg calf isometric calf raises.
ii. Stage II isotonic exercises: Once the patient with Achilles Tendinopathy can consistently complete stage I isometrics pain free then they can progress to stage II isotonic exercises.
- Number of repetitions: 6-8
- Number of sets: 4
- Time for concentric upward motion: 2 seconds
- Time for eccentric downward motion: 3 seconds
- Number of times per day: 1-2
Once the patient is able to perform this exercise consistently and pain free then they can be progressed onto 1 leg, stage II isotonic calf raises with the same number of reps, sets, speed and times per day.
This 1 leg exercise can then be progressed to being weighted- holding one weight close to their chest with both hands but stood in corner for support rather than having fingers on wall.
iii. Stage III – restore the spring – the energy storage and release component – Plyometrics exercise: This essentially means that the tendon becomes competent and safe at storing and then releasing the energy necessary to do springing activities such as jumping, hopping, skipping, running etc. This stage generally involves gradual increase in activities such as skiping, box jumps, stair running and normal running. It is advisable that this graded exercise
is also dictated by a Physiotherapist to ensure graded and safe increase in load.
iv. Stage IV- Endurance/ sports specific exercise: This is the final stage of Achilles Tendinopathy recovery and involves returning to sport gradually. Once the injured patient is pain free day to day and has successfully built his/ her strength with isometric followed by isotonic followed by plyometric exercises, that they return to endurance and sports specific exercise.
7 / Timescales – When a patient is pain free and has returned to their daily activity/ sport, it is strongly advised that the patient should continue their strengthening exercises 2-3 times per week for at least 12 months to maintain muscle and tendon capacity to prevent reoccurrence.
GET FIXED…..STAY FIXED