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

Current research shows that a carefully graded strength training program is the most effective way to treat Achilles tendonitis/tendinopathy.

If you Google it, you’ll find plenty of advice about what exercises to do and different suggestions on how to do them. But, 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 a 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 Achilles tendinopathy, how it heals, and when to see a doctor helps you plan your recovery better 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 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.
You will feel the pain in the back of your heel where the Achilles tendon attaches into the heel bone. It is usually quite tender to press in that area and you may see or feel a thickened bump in the painful area.
 
The symptoms show up similarly to mid-portion Achilles tendinopathy (see above). The main difference is that insertional Achilles tendinopathy is more sensitive to stretches.
 

As helpful as what they may feel, calf stretches usually make the pain worse because they increase the compression of the injured tendon against the heel bone.

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

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 then build on that base. 

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

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

When to progress

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

Other workouts

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

Activities to avoid

It’s best to avoid calf and Achilles stretches and 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 away, you’ll likely make your pain worse.

First, you must prepare your Achilles tendon and calf muscles for heavy strength training by building your endurance using bodyweight exercises and eventually switching to lighter 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 increasing 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

At this stage, it’s still best to avoid all calf and Achilles stretches as well as jumping or running activities.

Achilles specific exercises

When you run, your calf and Achilles tendon 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 do those explosive exercises (plyometrics) safely.

You can achieve this through heavy strength training using weights. The meaning of “heavy” varies between people, and it will depend on your unique build what that means for you. We use your body weight to determine what weights you should build up to using.

During this stage, you should aim to slowly build up to using weights equal to 10% of your body weight when you do your Heal Raise exercises (For example, if you weigh 70kg, then 7kg is your target).

When to progress

Continue to the next stage when:

  • You can walk for 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 increasing your pain.

Other workouts

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

Activities to avoid

You should still avoid all running and jumping activities.

Achilles specific exercises

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

It’s essential 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 entire hop program without an increase in your symptoms.

Other workouts

You should keep up with your cross-training and general strength and flexibility work.

Activities to avoid

No running yet, please.

Walk/Run program

Your Achilles tendon is now finally ready for you to start running again. But, it won’t have the endurance to cope with extended periods of running just yet, so it’s important to ease back into it slowly. The safest way to do this is by following a program that allows you to alternate between running and walking.

The app provides a walk/run program for you that also helps you progress the intensity and duration of your runs at the right time.

Workouts (Achilles and general)

Now, the main aim of your workouts is to maintain the strength you’ve built over the last few months.

You’ll notice that the volume and frequency of the exercises will reduce, which allows you enough recovery time between your workouts and run sessions.

When to progress

You can progress to the next stage when you can jog for 20 minutes at a leisurely pace without aggravating your symptoms.

Activities to avoid

You should not yet do any high-intensity workouts—for example, tempo runs, interval, or hill sessions.

The focus is now on regaining your Achilles tendon and leg muscles pre-injury running endurance, then you can slowly increase your running volume. But note, research shows it’s best not to increase this volume by more than 10% per week to avoid injury. 

When to progress

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

Workouts

The strength workouts will maintain the strength you’ve built in the previous stages. And, it’s best to keep strength training each muscle group twice a week.

Activities to avoid

It would be best if you still avoided high-intensity running activities, for example, tempo runs, sprints, or hill sessions, because your tendon will not have enough strength yet to withstand those types of higher-level forces. So, you need to fully restore your easy run capacity first and then work up to gaining this power level in your running.

You can now start training with increasing speed and intensity. However, remember not to ramp things up too quickly. Always allow enough recovery time.

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

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 wearing appropriate shoes.

Stage 2: Build your base strength

Achilles exercises are 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 body weight.

Stage 4: Prep for plyometrics

Test if your tendon is comfortable working into a more stretched position. If so, start doing the heel raises over a small step. If not, continue doing them to floor level until you can use a weight equal to 15% of your body weight. The app guides you through this process.

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

Do your Achilles exercises over the side of a step into a stretched position. 

Stage 3: Prep for plyometrics

Do your strength training over the side of a step to prepare for plyometrics.

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

Similar to Stage 8 for insertional Achilles tendinopathy rehab

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

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