Mid-portion Achilles tendinopathy treatment plan

Your Achilles tendon is the thick tendon in the back of your heel that connects your calf muscles to your heel bone.

Achilles tendinopathy or tendonitis is an overuse injury that develops when you increase the volume of your activities too quickly or beyond the tendon’s capacity. It can also occur when you don’t allow the tendon to recover between hard training sessions fully.

The Achilles tendon is sensitive to compression forces at the point where it inserts into the heel bone. Excessive compression can play a significant role in causing insertional Achilles tendinopathy.

There is one main difference between treating mid-portion and insertional Achilles tendinopathy. Namely, you have to limit the compression forces during the early stages of rehab for insertional cases.

You can do this easily by avoiding exercises that dorsiflex your ankle too much (when your toes move towards your shin). We’ll discuss this in more detail in the rehab stages coming up next.

When you have mid-portion Achilles Tendinopathy, you will feel the pain in the tendon about 5cm above the heel bone. The tendon is usually tender when pinched. You may even see or feel a thickened bump in the area where you feel the pain. The first time runners usually notice Achilles pain is towards the end of a training session or a few hours after a run. In most cases, the Achilles is stiff in the morning but then warms up as the day goes on. However, in severe cases, your tendon may remain painful and make you hobble on your foot throughout the day. Other symptoms include:

• Stiffness and discomfort are felt at the beginning of a run and disappear as the tendon warms up. However, the pain may return worse than before a few hours later.
• In more advanced cases, constant pain may stop you from running, and even walking might hurt.
• Calf and Achilles stretches may bring relief at first, but they usually make your symptoms worse later in the day.

Not everyone will have the same or typical symptoms and some people only report a lump in the tendon, without any symptoms. This is known as silent tendinopathy. You can still benefit from our rehabilitation program if you have silent tendinopathy. However, please consult a medical professional first to confirm your diagnosis.

Achilles tendinopathy can be treated effectively at home using a conservative exercise-based treatment plan outlined in the app. You should consider seeing a medical practitioner if you have any concerns about your injury. Particularly if:

• You heard or felt a ‘pop’ or a sudden sharp pain in your Achilles tendon, or it felt like someone kicked you in the back of the heel when the injury occurred. These are signs of a more serious injury to your Achilles tendon (like a tear), and you should have it assessed as quickly as possible. When you have an Achilles tendon tear, delaying treatment or following the wrong treatment advice can result in your tendon not healing correctly. The program in the app is not appropriate for treating a tear.
• You notice bruising – Achilles tendinopathy does not cause bruising.
• Any part of your leg (thigh, calf, or foot) is very swollen, red, hot to touch, or throbs with pain. These signs can indicate a blood clot has formed, and you should investigate them as soon as possible.
• You have pain at night that keeps you awake or interrupts your sleep.
• You feel pins and needles or tingling in your leg, indicating possible nerve injury. In which case, our treatment plan is not suitable for you.
• Your symptoms get worse.
• Your Achilles is not healing as anticipated. See the section below for expected healing times.

Some of the most common causes for developing Achilles tendonitis include:

• Increasing your running intensity or training volume too quickly. For example, fast or hill running
• Not allowing enough recovery time for your tendon to repair between intense training sessions
• Changing from a higher heel-toe drop running shoe to a flatter shoe can increase the load on the Achilles tendon
• Taking Fluoroquinolone antibiotics can cause tendon injuries, including tendinopathy and tears
• Inflammatory conditions like gout, rheumatoid arthritis, and psoriasis can cause tendon pain easily mistaken for simple tendinopathy. Speak to your doctor if you also have any of these inflammatory conditions to rule them out as sources of your Achilles pain.

Activities that excessively compress your Achilles tendon at the heel bone attachment can cause insertional Achilles tendinopathy. Two common ways that this compression occurs are:

• When you do multiple calf or Achilles stretches that repeatedly take the ankle into deep dorsiflexion (where the toes move towards the shin), and
• When you change from slightly heeled to flat shoes, if you’re not used to wearing them. Flatter shoes place your ankle in a little more dorsiflexion too.

It’s a common misconception that tight calf muscles cause Achilles tendinopathy. Instead, the over-stretching of the calf muscles can injure your tendon.

Treatment

There’s no one-size-fits-all treatment for Achilles tendinopathy. Instead, the right combination of rest and exercise tailored to the individual is usually the most crucial intervention. The most helpful therapies for Achilles tendinopathy include:

• Relative rest: Cut out aggravating activities and reduce your training program to avoid increasing symptoms
• Strengthening exercises for your calf and Achilles tendon to restore their strength and endurance
• Strength and control work for your core and leg muscles to reduce the load on your Achilles tendon while running

Other treatments that you may encounter:

• Calf or Achilles stretches: These are NOT a priority, and they can make your pain worse.
• Complete rest: It can be helpful to settle your pain at first. However, it’s not advisable to rest for a prolonged period because it can weaken your tendon further.
• Massage: It may help make your pain feel better, but it cannot strengthen your tendon.
• Electrotherapy: The current research does not recommend this treatment.
• Shockwave: It may be helpful in cases not responding to exercise therapy.

Recovery time

The following recovery times can give you an idea of how long your tendon’s rehabilitation will take:

• With the proper treatment starting shortly after your first symptoms arise, it can take 12 and 16 weeks to recover.
• However, if you’ve neglected your tendon pain and kept on training, it can take 6 months to a year for a full recovery.

Prevention

• Avoid sudden increases in running intensity or volume.
• Allow enough recovery time after intense training sessions.
• Vary your training – don’t go to the limit in every session.
• Do regular strength training for your calves, core, and legs in general.
• When you change from a high heel-toe drop to a more minimalist, flat shoe, transition slowly, allowing your Achilles tendon and calves to adapt.

• Cook JL. Ten treatments to avoid in patients with lower limb tendon pain. British Journal of Sports Medicine 2018;52:882.
• Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine 2016;50:1187-1191.
• Cook, Jillianne Leigh, and Craig Purdam. “Is compressive load a factor in the development of tendinopathy?.” Br J Sports Med 46.3 (2012): 163-168.
• Cook, J. L., et al. (2018). Insertional and mid-substance Achilles tendinopathies: eccentric training is not for everyone–updated evidence of non-surgical management, Taylor & Francis
• Docking S, Samiric T, Scase E, Purdam C, Cook J. Relationship between compressive loading and ECM changes in tendons. Muscles Ligaments Tendons J. 2013;3(1):7–11. Published 2013 May 21. doi:10.11138/mltj/2013.3.1.007
• Gabbett, Tim J. “The training—injury prevention paradox: should athletes be training smarter and harder?.” Br J Sports Med 50.5 (2016): 273-280.
• Lewis T, Cook J. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature. Journal of Athletic Training 2014;49(3):422-27. doi: 10.4085/1062-6050-49.2.09