Achilles tendonitis or tendinopathy treatment plan

Achilles tendinopathy

treatment plan

The Exakt Health App contains treatment plans for both insertional and mid-portion Achilles tendonitis/tendinopathy.

Research-based treatment plan

The research shows that the most effective treatment for Achilles tendonitis/tendinopathy is a carefully graded strength training program. 

If you Google it, you’ll find lots of advice about what exercises to do and quite a few different opinions on how to do them. So how do you know what is right for you? What exercises should you be doing, how many repetitions and how often? 

The Exakt Health App provides these answers

  • The app guides you safely from when your Achilles first becomes painful to full return to sport.
  • The Achilles tendinopathy treatment plan contains evidence-based exercises with clear guidance on reps, sets and frequency.
  • The app adapts the program according to your feedback and specific needs.
  • It implements a walk/run program for a safe return to running.
  • We’ve also included a maintenance program to prevent re-injury.
Achilles Tendinopathy Treatment Plan Activities Dashboard
Achilles Tendinopathy Injury Details

The App teaches you about Achilles tendinopathy

Understanding what caused your case of Achilles tendinopathy, how it heals and when to see a doctor helps you better plan your recovery and prevent re-injury.

Anatomy of the calf muscles and Achilles tendon.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 which develops when you increase the volume of your activities too quickly beyond the tendon’s capacity. It can also occur when you don’t allow the tendon to fully recover between hard training sessions.

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

Calf stretches causes compression of the Achilles tendon on the heel bone and can make insertional Achilles tendonitis worse.

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

This is easily done by selecting exercises that avoid flexing your ankle up into too much dorsiflexion (where your toes moves towards your shin). We’ll discuss this in more detail in the rehab stages lower down.

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 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. In severe cases your tendon may remain painful and make you hobble throughout the day.
 
Other symptoms include:
  • Stiffness and discomfort at the beginning of a run that disappears as the tendon warms up. Discomfort and pain may return worse than before a few hours later.
  • In more advanced states, a more constant pain stops you from running and even walking might hurt.
  • Calf/Achilles stretches can feel good at first, but typically worsen the symptoms later in the day.
Note that not everyone will have the typical symptoms. Some only report a lump in the tendon without any symptoms. This is known as a silent tendinopathy. If you have a silent tendinopathy, you can still benefit from our rehabilitation program. Please consult with a medical professional first to confirm your diagnosis.
You will feel the pain in the the back of your heel where the Achilles tendon attaches into the heel bone. It is usually pretty tender to press in that area. You may see or feel a thickened bump where you feel the pain.
 
The symptoms act in a similar way to that of mid-portion Achilles tendinopathy. The pain usually first appears towards the end of a training session or a few hours after a run.
 
In most cases that area where the tendon attaches will be stiff in the morning but then warm up as the day goes on. In severe cases your tendon may remain painful and may severely limit how much you can walk.
 
Other symptoms include:
  • Even if they feel good while doing them, calf stretches usually make the pain worse. This is because they increase the compression of the injured tendon against the heel bone.
  • Exercise (like running) may feel as if it loosens the tendon up, but then the pain often increases later in the day.
  • If your tendon is severely flared up, you will likely not be able to run without pain and even walking may be limited.
Achilles tendinopathy can be treated effectively at home using a conservative exercise-based treatment plan as 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 it felt as if someone kicked you in the back of the heel, or you felt a sudden sharp pain in your Achilles tendon when you injured your leg or while doing your exercises. This can indicate a serious tear that involves the Achilles tendon and you need to have it investigated immediately. Delaying treatment or following the wrong treatment advice when you have an Achilles tendon tear can mean that your tendon won’t heal properly. The program in the app is not appropriate for treating a tear.
  • You notice bruising – an 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. This can indicate that you have a blood clot and it should be investigated 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. This can indicate that you’ve also injured a nerve and our treatment plan may not be right for you.
  • Your symptoms are getting worse.
  • Your Achilles is not healing as expected. See the section below for expected healing times.
Some of the most common causes for developing Achilles tendinopathy include:
  • Increasing your running intensity or training volume too quickly – e.g. fast or hill running.
  • Not allowing enough recovery time for your tendon to repair between intense training sessions.
  • Changing from running in a shoe with a higher heel-toe drop to a flatter shoe – this increases the load on the Achilles tendon.
  • Fluoroquinolone antibiotics can cause tendon injuries, including tendinopathy and tears.
  • Inflammatory conditions like gout, rheumatoid arthritis and psoriasis can cause tendon pain that is easily mistaken for a simple tendinopathy. Speak to your doctor if you also have an inflammatory condition.

In addition to the points mentioned above, insertional Achilles tendinopathy is thought to be caused by activities that increases the compression force between the tendon and where it attaches on the heel bone. Two of the most common activities that can cause this are:

  • Doing lots of calf or Achilles stretches that take the ankle into deep dorsiflexion where the toes move towards the shin.
  • Changing to flat shoes when you’re used to wearing shoes with a slight heel on them. This also moves the ankle into increased dorsiflexion.

It’s a common misperception that tight calf muscles cause Achilles tendinopathy. It is rather over-stretching that can cause your tendon to be injured.

Treatment

There’s no one-size-fits-all treatment for Achilles tendinopathy. The right combination of rest and exercise is usually the most important intervention, but it has to be tailored to the individual. The most useful treatment for Achilles tendinopathy include:
  • Relative rest: cut out really aggravating activities and reduce your training program to avoid any increase in symptoms.
  • Strengthening exercises for the calf and Achilles tendon to restore its strength and endurance.
  • Improving strength and control in your core and other leg muscles to reduce the load on your Achilles while running.
Other treatments that you may encounter:
  • Doing calf or Achilles stretches is NOT a priority and they can actually make your pain worse.
  • Complete rest can be useful to help your pain calm down at first. However, it’s not advisable to rest for a prolonged period, because it will weaken your tendon even further.
  • Massage can help to make your pain feel better but it does not actually strengthen your tendon.
  • Electrotherapy is currently not recommended by the research.
  • Shockwave may be useful 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 right treatment starting shortly after your first symptoms, it can take between 12 and 16 weeks to recover;
  • if you’ve neglected your tendon pain and kept on training, it can take 6 months to a year to fully recover.

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 changing from a high heel-toe drop to a more minimalist flat shoe, transition slowly to allow your Achilles and calves to adapt.
 

The app contains two treatment plans for Achilles tendinopathy

The app contains different treatment plans for mid-portion and insertional Achilles tendinopathy, because it’s best to avoid excessive compression at the heel bone during the early stages of insertional Achilles rehab.

In order to regain full strength the workout intensities have to increase as your injury heals. The app ensures that you progress at the correct time by setting you clear targets for each stage. 

The mid-portion Achilles tendinopathy treatment plan consists of 7 stages

Achilles specific exercises

In this stage the app will help you to carefully test what exercises your Achilles tendon can currently support and use that as a base to build from.

Don’t progress the exercises too quickly. Achilles tendinopathy is an overuse injury and you can actually make it worse by doing the exercises too often or progressing them too quickly.

Only increase intensities if pain or stiffness doesn’t increase in the 24 hours following a workout. We’ve included a detailed pain guide so that you can easily tell if you’re pitching your workouts at the right level.

When to progress

The app sets you specific targets, but you can usually progress to the next stage when you are able to do 10 slow repetitions of the Single Leg Heel Raise exercise over a step without feeling pain during or after doing them.

Other workouts

This stage includes workouts that improve the general strength, control and flexibility of your lower body in positions that don’t strain your Achilles tendon.

Activities to avoid

It’s best to avoid calf and Achilles stretches as well all jumping, hopping, and running activities during this stage.

Achilles specific exercises

If you’ve researched Achilles tendinopathy exercises, you’ve likely seen that heavy slow resistance training is the best type of exercise to do. However if you jump in using heavy weights right at the start, you’ll very likely just make your pain worse.

You have to first prepare your Achilles tendon and calf muscles for heavy strength training by first building your endurance using bodyweight exercises and eventually switching to light weights.

When to progress

You can proceed to the next stage if you can walk short distances without pain and complete the assigned strength training without an increase in pain.

Other workouts

The app provides you with cross training suggestions to help maintain your fitness. Your general strength and flexibility training from the previous stage will continue.

Activities to avoid

You should still avoid all calf and Achilles stretches as well as jumping or running activities.

Achilles specific exercises

When you run, your calf and Achilles tendon has to create and absorb large explosive forces. You’ll develop this ability in stage 4, but first you have to ensure that you have enough strength to be able to safely do those explosive exercises (plyometrics).

This is achieved through heavy strength training using weights. What’s seen as “heavy” varies between people and depends on your build. So we use your body weight to determine what weights you should build up to using.

For this stage, you should aim to slowly build up to using weights that are equal to 10% of your bodyweight when you do your Heal Raise exercises (e.g. if you weigh 70kg then 7kg is your target).

When to progress

Continue to the next stage when:

  • you can walk 30 minutes and
  • do your heel raises with weights equal to 10% of your body weight and
  • complete the hop tests that the app sets you without an increase in pain.

Other workouts

You should continue your general strength and flexibility training. It may be OK to also add in some gentle calf stretches during this stage, but monitor your pain closely if you do.

Activities to avoid

You should still avoid all running and jumping activities.

Achilles specific exercises

This stage include plyometric exercises (hop sessions) that will help to restore your calf’s ability to create explosive forces and your Achilles tendon’s ability to absorb them and propel you forward.

It’s important to continue the heavy loaded Heel Raise exercises.

When to progress

You can move on to the next stage once you can:

  • Walk 30 minutes at a brisk pace and
  • complete your Heel Raise workouts with weights that are equal to 20% of your body weight and
  • complete the full hop program without an increase in your symptoms.

Other workouts

Your cross training and general strength and flexibility work should continue.

Activities to avoid

No running yet, please.

Walk/Run program

Your Achilles is now finally ready to start running again, but it won’t yet have the endurance to cope with extended periods of running. It’s important to slowly ease back into running and the safest way to do this is through a program where you alternate between running and walking.

The app provides you with a walk/run program and also helps you to progress its intensity and duration at the right time.

Workouts (Achilles and general)

The main aim of your workouts is now to maintain the strength that you’ve built over the last few months.

You’ll notice that the volume and frequency of the exercises reduce. This is to allow enough recovery time between your workouts and run sessions.

When to progress

You can progress to the next stage when you can jog 20 minutes at an easy pace without aggravating your symptoms.

Activities to avoid

You should not yet do any high intensity sessions e.g. tempo runs, interval, or hill sessions.

The focus is now on regaining your previous running endurance in your Achilles and leg muscles. You can slowly increase your running volume. Research has shown that, to avoid injury, it’s best not to increase your volume with more than 10% per week.

When to progress

You can progress to the next stage when you’re able to run your normal weekly running volume at your regular easy running pace pain free.

Workouts

The strength workouts will maintain the strength that you’ve built in the previous stages. You should aim to strength train each muscle group twice a week.

Activities to avoid

Avoid high intensity running e.g. tempo, sprint or hill sessions. Your tendon will not yet have the strength to cope with the increased forces produced during high intensity running. To gain this strength, you first have to restore your full easy run capacity.

You can now start to train with increasing speed and intensity. Remember not to ramp up the intensity too quickly and allow enough recovery time.

You should continue with your weekly strength routine to support your running activities and reduce re-injury risk. The app provides you with exercises to help with this.

The exercises in the Achilles tendonitis treatment plan increase in intensity as you recover.
Mid-portion Achilles tendinopathy reacts well to heel raises done over the side of a step.
The exercises in the insertional Achilles tendonitis treatment plan contains slightly different exercises.
It's better to initially do your heel raises only to floor level when you have insertional Achilles tendinopathy.

The insertional Achilles tendinopathy treatment plan consists of 8 stages

Why an extra stage? Because you’ve not only got to strengthen the Achilles tendon, you also have to get it used to withstanding the normal compression forces at the heel bone.

To save duplication, we’ll only highlight how the insertional treatment plan differs from the mid-portion treatment plan.

Stage 1: Find your baseline

Protect the insertion from compression by doing heel raises to floor level only and while wearing shoes.

Stage 2: Build your base strength

Achilles exercises done to floor level to avoid stretch and compression.

Stage 3: Build tendon capacity

Continue strength training to floor level only until you can do your exercises with weights equal to 10% of your bodyweight.

Stage 4: Prep for plyometrics

Test if your tendon is happy to work into a more stretched position. If so start doing the heel raises over a step. If not, then continue doing them to floor level until you can use a weight equal to 15% of your bodyweight.

Stage 5: Build explosive strength

Similar to Stage 4 of the mid-portion Achilles tendinopathy rehab.

Stage 6: Return to running

Similar to Stage 5 for mid-portion Achilles tendinopathy rehab.

Stage 7: Build easy run endurance

Similar to Stage 6 for mid-portion Achilles tendinopathy rehab.

Stage 8: Build running intensity and speed

Similar to Stage 7 for mid-portion Achilles tendinopathy rehab.

Stage 1: Find your baseline

You can safely work into compression and the tendon usually reacts well to doing exercises over the side of a step.

Stage 2: Build your base strength

Achilles exercises are done over the side of a step, into a position of stretch.

Stage 3: Prep for plyometrics

Strength training over side of step.

Stage 4: Build explosive strength

Similar to Stage 5 for insertional Achilles tendinopathy rehab.

Stage 5: Return to running

Similar to Stage 6 for insertional Achilles tendinopathy rehab.

Stage 6: Build easy run endurance

Similar to Stage 7 for insertional Achilles tendinopathy rehab.

Stage 7: Build running intensity and speed

The Exact Health App contains treatment plans for common running injuries.

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