Chiswick-Physio BLOG

 

The Best Exercises for Achilles Tendonitis
Achilles Tendonitis
What is Achilles tendinopathy?

What is Achilles tendinopathy?

Achilles tendonitis, or what we refer to now as Achilles tendinopathy, is a painful condition that affects the Achilles tendon, which connects the heel bone to the calf muscle.

Achilles tendon symptoms include increased soreness with activity, particularly while walking, running, using stairs, or going up/downhill. The pain is usually worse in the morning on getting out of bed, but it tends to improve with mobility. 

The Achilles tendon is powerful and withstands up to twice our body weight when walking, which increases up to six times when running. It acts like a spring, storing and releasing energy quickly as we walk or run. However, repeating this activity too often without sufficient rest can cause injury and changes in the tendon’s properties, increasing the risk of developing symptoms.

It is clear from the research that modifying the load passing through the tendon is the key element that stimulates its recovery. As a result, recovery may take time, but successful treatment of this condition involves proper strengthening protocols.

How strengthening exercises can help the Achilles tendon?

Strengthening exercises can significantly impact the physiology of the Achilles tendon in those with a tendinopathy. Strengthening exercises have been shown to provide the following benefits:

  • Increased Strength > Improved tendon strength enables the tendon to better withstand stress during activities like walking and running.
  • Increased Load > Align collagen fibres, creating a stronger and more organised tendon structure that can withstand the load on the tendon during activity.
  • Improved Healing > Stimulation of collagen production is crucial for tendon healing and overall health.
    Pre-operative rehab exercises

Incorporating strengthening exercises into your routine can help improve the health and function of your Achilles tendon, thereby reducing the risk of injuries and improving your overall physical performance.

Role of exercise in reducing pain and inflammation associated with Achilles tendinopathy

Achilles tendinopathy is a condition that often causes stiffness and pain, and it can worsen if left untreated. Appropriate strengthening exercises offer several benefits, such as:

  • Pain Reduction > Injured tendons release chemicals that can irritate pain receptors, leading to increased discomfort, especially after periods of immobility. Proper exercise and movement can enhance circulation, which helps to eliminate these chemicals and reduce pain.
  • Reduced Stiffness > When fluid accumulates between injured tendon fibres, it can cause stiffness, which often worsens with immobility. However, doing the right exercises can improve circulation, reducing fluid accumulation and stiffness. Over time, as the tendon heals, stiffness gradually diminishes.
  • Strengthening > Injured tendons tend to lose strength and endurance, leading to pain during normal activities. A structured strength training program is essential to restore tendon strength and enable it to withstand daily activities and sports demands.

Importance of Correct Strengthening Exercise

Performing exercises with the correct load and intensity is crucial. Excess load can worsen the condition, while low load may not provide enough stimulus for healing and strengthening. Therefore, it is recommended that the intensity of exercise be increased gradually. 

At Chiswick-Physio, we follow a 4-stage continuum for our patients. 

  1. Isometrics (for pain and motor control)
  2. Heavy Slow Resistance (for tendon stiffness and muscle strength) 
  3. Plyometrics (jumps/hopping)
  4. Faster Loads (if returning to running activities)

This continuum starts with unloaded beginners and progresses to loaded runners. However, it’s important to remember that we shouldn’t always start at stage one. It’s crucial to determine how much load the irritated Achilles can withstand initially and then start at the appropriate continuum stage. The goal is to move up the continuum as you can tolerate it gradually.

The stage of tendon rehab you complete depends on the activities you want to return to. For example, a sedentary older adult who aims to continue walking without pain may complete stage two. Conversely, someone wanting to return to a high-level sport that involves running will be required to complete stage four. The final stage should align with the desired activities, ensuring they can be replicated without discomfort.

Tendon Load Progression

When is the load too much? 

Tendons typically improve with activity but may worsen following activity or the next day. Therefore, it’s critical to monitor symptoms 24 hours after loading. Chiswick-Physio uses the traffic light analogy to track pain and adjust exercise load.

The traffic light analogy is helpful for understanding and assessing pain levels on a scale of 0 to 10. Like a traffic light, green indicates mild pain, yellow represents moderate pain, and red signifies severe pain. This system enables individuals to express the intensity of their pain in a clear and universally understandable way.

Using the traffic light analogy can help you determine if your exercise load is too little or too much. This will give you the confidence to continue or progress your activity and rehabilitation while minimising any major aggravation of an injury or its symptoms.

https://www.chiswick-physio.co.uk/blog/pain-and-exercise/ 

Pain Scale

Best exercises for Achilles Tendinopathy

Research is very clear that modifying the load that goes through the tendon is the key element that stimulates recovery. 

Our team of specialist physiotherapists has identified five exercises that are particularly effective in treating Achilles tendinopathy as part of a rehabilitation plan. Although it may be necessary to conduct a one-on-one assessment to customise the exercises to the individual’s needs, these exercises are an excellent starting point, providing clear guidance on progressing through the initial stages of an Achilles tendinopathy rehab programme.

Isometric double-leg heel raise 

  • Stand up straight with your feet hip-width apart, with a wall or stable object nearby to assist with balance. 
  • Rise on your toes, trying to keep your weight even between both sides
  • Slowly take the weight onto the painful side as your pain allows. 
  • Four reps, 2-3 sets, 1-minute rest between sets
  • Hold this position for 30-45 seconds unless the pain reaches 6/10 on your pain scale or your heel drops.

Benefits > Helps to reduce pain and stiffness.

Isometric heel raise

Wall sit calf raise

  • Place your back against the wall.
  • Bend at the knees and drop your butt down until your legs make a 90-degree angle.
  • Hold this position and raise up on your toes.
  • Hold this position for 30-45 seconds unless the pain reaches 6/10 on your pain scale or your bottom drops.

Benefits > Helps reduce pain and stiffness while loading the deep calf muscle.

Wall sit calf raise

Isometric Single-leg heel raise – straight legs

  • Stand on a flat surface, knees straight, and feet hip-width apart. Have a wall or stable object nearby to assist with balance. 
  • Push down through the toes and front of the foot as if going up on your tip toes.
  • Lift the heels as high as possible. 
  • Lift the non-injured foot off the floor so that you are standing on just the affected leg.
  • Hold this position for 30-45 seconds unless the pain reaches 6/10 on your pain scale or your heel drops.

Benefits > helps to reduce pain and stiffness, loading the superficial calf muscle.

Isometric single leg heel raise

Loaded double-leg heel raise from the floor- straight legs

  • Stand on a flat surface with the feet hip-width apart – have a wall/stable object nearby to assist with balance. 
  • Push down through the front of the feet as if going up on your tip toes – the heels will begin to rise. 
  • Lift the heels as high as possible, and then, with control, slowly lower the heels down throughout a 5-second count.
  • 6-15 reps, 3-4 sets

Benefits > Heavy, slow resistance allows for tendon stiffness and muscular strength to be built.

Loaded double leg heel raise

Weighted squat

  • Stand upright with your feet hip-width apart and a weight placed evenly across your shoulders (back squat) or hold it securely against your chest (goblet squat). 
  • Engage the abdominal region, and in a controlled manner, sit back as if sitting in a chair. 
  • At the same time, your head and chest will come forward to maintain your balance; aim to keep your back straight. 
  • Go down as far as you feel comfortable or until your thighs are parallel to the floor. 
  • Come back up to standing and repeat
  • Ten reps, three sets

Benefits > helps to strengthen the other muscles of the lower leg and trunk.

Weighted Squat

 

If you want to achieve a high level of function or return to sport, we highly recommend consulting with a physiotherapist. You will require further progression beyond the exercises mentioned above. Before returning to your sport, a rehabilitation program should include plyometric-based exercises such as bounding, cutting, and sprinting.

Other Treatment Options

As part of a comprehensive treatment approach, your physiotherapist may use various pain management techniques to alleviate your symptoms and aid your recovery. These may include:

  • Shockwave therapy can be successfully used with conditions that have been present for more than 12 weeks in conjunction with a strengthening programme. 
  • Orthotics to address gross biomechanical alignment issues may be helpful in the short term.
  • Heel inserts for your footwear may help relieve symptoms if they occur near the heel. Your therapist will guide you on this.
  • Steroid injections are not recommended for the Achilles tendon as they can affect the integrity of the tissue and have been shown to lead to long-term problems.
  • Surgery –this should be the last option if all other treatment attempts have been exhausted.

Tendons can be frustrating to manage, especially when loads aren’t consistent. If symptoms increase following exercise therapy, it’s important to reduce loads. Complete rest should be recommended rarely. It often does more harm than good and delays the rehabilitation process.

Frequently asked questions

Is walking good or bad for Achilles tendinopathy?

Walking can either improve or worsen Achilles tendonitis, depending on the severity of the condition and the distance you walk. To ensure a successful recovery, it is important to reintroduce walking gradually, just as with any other activity. Start with gentle walking and increase the intensity slowly to avoid aggravating the condition.

What Cardio can I do without hurting my Achilles tendon?

Low-impact cardio options that won’t aggravate Achilles tendon pain include swimming, cycling, elliptical training, water aerobics, rowing, and moderate walking on flat surfaces.

Should I stretch my Achilles tendon if it hurts?

While stretching the Achilles tendon was once a common treatment practice, it’s now recognised that it will exacerbate and worsen pain. Current approaches favour a gradual strengthening programme and recommend not stretching the Achilles.

What exercises should not be done with Achilles tendinopathy?

When suffering from Achilles tendinopathy, it is important to avoid exercises that put excessive strain on the Achilles tendon. Activities with high impacts, like running and jumping and exercises that involve quick changes in direction, heavy lifting, or repetitive jumping, can worsen the condition. Hence, it is best to avoid such exercises for a faster recovery.

What is the fastest way to heal Achilles tendinopathy?

The quickest way to heal Achilles tendinopathy is through a graduated load programme to strengthen the tendon and surrounding muscles. Additionally, reducing activities that aggravate the tendon can expedite recovery.

Should I get a steroid injection?

Steroid injections are not recommended for the Achilles tendon due to their potential impact on tissue integrity and long-term negative consequences.

Does Shockwave help Achilles tendinopathy?

Shockwave therapy can be used successfully with a strengthening program for conditions present for more than 12 weeks.

Does Achilles tendinopathy ever go away?

Achilles tendinopathy can get better with the right treatment, but it may not completely go away in some cases. By managing it properly and addressing factors that contribute to it, symptoms can be reduced, and function can improve. However, occasional flare-ups or residual symptoms may persist despite treatment if exercise is increased too quickly. Regular monitoring and a comprehensive rehabilitation plan are crucial for effectively managing the condition over time.

What is the difference between Achilles tendinitis and Achilles tendonopathy?

Achilles tendinopathy is a medical condition that affects the Achilles tendon. Current research has shown it is not inflammatory, as previously thought. It used to be termed Achilles tendonitis, but since the ‘itis’ refers to inflammation, Achilles tendinopathy is now the favoured term among medical professionals.

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