Achilles Tendinopathy: The Causes, Types, Treatment and Exercises

Achilles tendinopathy is a common presentation in our clientele here at Viva Physiotherapy.

The Achilles tendon is the largest in the body extending from the heel up into the calf muscles.

It is exposed to 6-12x our body weight during running and jumping!

As such, it needs to be very robust and trained regularly (Grävare & Crossley, 2015).

But, it can be prone to cellular degeneration when we expose it to inconsistent loads or training errors.

You may have heard Achilles Tendinopathy previously called ‘Achilles tendonitis’ which indicates that it is an inflammatory condition. However, with advances in scientific research, we know that there are no inflammatory cells present within the tendon itself.

Rather than an inflammatory response, tendons undergo a cellular change which can lead to degeneration. In some cases, there can also be co-existing or separate conditions involving an inflammatory response in the tissue surrounding the tendon, such as bursitis or peritendinitis – more on this later.

The good news is that tendons are very adaptable and responsive to appropriate load, and this is where we can help you with reducing your pain and getting you back to the things you love.
 

 

What Do Tendons Do?

It’s worth noting the role of tendons in our body.

They absorb and produce load to propel our muscles and therefore our body (whether that be up, forwards, or sideways).

They need to be strong, elastic and springy.

Running, jumping, changing direction, or producing quick movements are all examples of movements that tendons propel.

The Achilles tendon in particular is responsible for pushing off through our feet to run or walk, which is the most crucial phase in my opinion! W

ith a strong, elastic, and springy Achilles tendon, we are in the best position to excel at our chosen activity and live without pain.

Causes of Achilles Tendinopathy

Achilles tendinopathy can be caused by a variety of factors, including:

• A recent increase in activity (too much, too soon!)
• Decreased recovery time between sessions (overload)
• Jumping back into your usual training after an extended rest period
• A change in footwear or training surface
• Biomechanics and movement techniques
• Calf and lower limb weakness or tightness
• Stiff or unstable feet or ankles

 
Sometimes, lifestyle and genetic factors also predispose you to Achilles tendinopathy, such as:

• Diabetes
• High blood pressure
• Obesity
• Hormonal changes
• Older age
• Family history

Different Types of Achilles Tendinopathy

Getting an accurate diagnosis is extremely important, as the three different types of Achilles tendinopathy change how your injury is managed.

1. Mid-Portion Achilles Tendinopathy

As the name suggests, this is pain/degeneration in the ‘middle’ of the Achilles tendon, which is roughly between 2-6cm up from the heel bone. This is the most common, making up approximately 55-65% of Achilles tendinopathy cases.

2. Insertional Achilles Tendinopathy

This is pain/degeneration at the very bottom of the Achilles, where it inserts in the heel bone. Pain is more frequently felt on the outside of the heel bone, but it can be on the inside as well. It makes up approximately 20-25% of Achilles tendinopathy cases.

3. Achilles Peritendonitis

This is where we can have some inflammation. Peritendonitis is when the sheath surrounding the tendon becomes inflamed (imagine the sheath like a sleeping bag!). This means that when the tendon slides up and down within the sheath, the friction can be very painful if it’s inflamed and the pain might be quite constant, unlike the other two types which generally present with a clear pattern. You can also have peritendonitis at the same time as tendinopathy. In this case, we must treat the inflammatory condition first before moving on to treating the tendon.
(Silbernagel, Hanlon & Sprague, 2020)
 

How Do I Know if I Have Achilles Tendinopathy?

These are some of the common diagnostic signs and symptoms we see in the clinic in our clientele with Achilles Tendinopathy:
 

What you might feel or notice:

• A gradual onset of symptoms – as opposed to a partial tear or rupture, which is more of a sudden/acute pain at the time of activity.
• Pain that might ‘warm up’ with activities such as running, but then return once you’ve ‘cooled down’
• Pain and stiffness in the Achilles first thing in the morning (particularly if you’ve been very active the day/evening before)
• A preceding period of disrupted/inconsistent loading or training

What we will assess:

• Differences in muscle bulk from side to side (atrophy, weakness)
• Swelling or redness (if there is peritendonitis involved)
• ‘Noisy’ tendons as you move through range
• Poor movement quality (AKA motor control)
• Abnormal range of motion, strength and flexibility of the calves, foot and ankle
• Localised pain to the touch
• Localised pain during load – e.g. calf raises, hopping

Sometimes, we might need to order further imaging to either confirm our diagnosis or to determine how progressed your tendinopathy is.

How you clinically assess in session is just as important as your diagnosis so we can tailor your rehab specifically to your ability, needs and goals.
 

Treatment and Recovery for Achilles Tendinopathy

Treatment of Achilles Tendinopathy generally involves a combination of:

• Exercise
• Education
• Pain management
• Load management (including a targeted return to activity/sport plan)

The spectrum of tendon injury is very broad and nailing the loading so it’s appropriate for where you fall on the spectrum is crucial.

One exercise might not work for another person despite having the same diagnosis.

Some people might need a longer period of offloading and potentially some medical interventions to help manage pain – this is especially important when there is peritendinitis going on and we need to manage the inflammation first.

However, we do know that at some point all tendons respond to APPROPRIATE LOADING.

As I mentioned before, tendinopathy is a cellular change and as such requires blood flow to initiate healing and regeneration. Tendons themselves don’t have a great blood supply, so we need to encourage blood flow to the attached muscles by strengthening exercises to initiate healing. Tendinopathy can be resistant to treatment and often come back, but we know from many reputable sources that the rehab programs that have the most success involve strength training (Rio et al., 2016).
 

Strength Exercises

Here are some strength exercises you’re likely to come across during your rehab at Viva:

You can watch all these in video form for Free on the Viva Hub.
 

 

Early Stage Exercises

1. Static Calf Raise Hold (straight knee and bent knee)

• Stand in front of a mirror with your balance supported by holding onto a wall or bench
• With control, lift your heels up to rest on the balls of your feet
• Hold for 45secs
• Maintain nice, straight alignment through your feet and ankle the whole time.
• For a bent knee variation, come down into a mini squat first, then repeat the steps above.

2. Soleus Wall Sit

• Come into a sitting position with your back against the wall.
• With control, lift your heels up so you’re resting on the balls of your feet.
• Hold this position for 45secs, or continue lifting and lowering your heels to complete more reps.

3. Single Leg Calf Raises (straight knee and bent knee)

• As above, support your balance by holding a bench or wall
• On one leg, rise up onto the ball of your foot with control, taking 2 secs to get the top of your range
• Lower with control, taking two seconds to tap your heel back to the floor.
• Maintain straight foot and ankle alignment the whole time

 

Mid Stage Exercises

1. Springy Calf Raises

• Coming up into a calf raise as above, drop your heels halfway down and then quickly spring back up to the top of your calf raise.
• Continuously spring up and down for the required amount of repetitions.
• Imagine you are ‘springing’ up and down quickly on the balls of your feet

2. Tall to Shorts

• Start in standing.
• Rise up onto a double leg calf raise whilst simultaneously raising your hands above your head
• With speed and precision, drop down into a squat whilst lowering your heels to the ground and swinging your arms back by your side

 

Late Stage Exercises

1. Stair Jumps

• Start in a double leg heel raise at the bottom of some stairs
• Using your arms for momentum, spring up onto a step, landing on the balls of your feet.
• Step back down and repeat

2. Pogos

• Maintaining stiff legs and almost-straight knees, spring up and down from the ground.
• Aim for quick, short jumps off the balls of your feet with reduced contact time with the ground.

We’ll also assess the entire kinetic chain and if relevant, prescribe exercises to address discrepancies or weakness in your glutes, hamstrings, or quads which will all play a role in improving the efficiency of your legs.

These might include deadlifts, lunges, squats or glute bridges.

Once you’re progressing through your rehab, we might start to add weights to your loading so that we can achieve appropriate loading.

Recent research articles are telling us that we need to provide our tendons with HEAVY, SLOW resistance training to yield positive outcomes (Beyer et al., 2015), promote blood flow and healing, and restore their strength and springiness.

If necessary for you and your goals, we may also implement plyometric training. Plyometric exercises are explosive exercises focused on improving your spring – jumping, hopping, change of direction.

Another important consideration with Achilles Tendinopathy is footwear.

Footwear is crucial in ensuring your foot and ankle are correctly supported so that you utilise the biomechanics of your feet to push through your big toe and activate your Achilles tendon complex correctly – even with walking!

It also helps to reduce your pain, as we know certain footwear can provoke the sensitivity of the Achilles tendon (Chimenti et al., 2017).

We’re very grateful at Viva to have had some excellent experiences with BARED Footwear. Their team of podiatrists have ensured that every single shoe stabilises your foot to encourage correct joint movement and foot function.

They use their podiatric designed footbeds to offload the bones in your foot so our foot is aligned correctly, ensuring better alignment up our legs and into our hips as well.
 

TAKEAWAY MESSAGE

Tendinopathy is different for everyone. Although treatment for everyone with this injury is similar, there is no one size fits all approach.

That’s why it’s so important to get assessed so we can target your treatment specifically for you!

We know that the research shows us active treatment rehab of any form is more superior to a ‘wait and see’ approach (van der Vlist et al., 2021) – so book in to see a physio now so we can get you back to doing what you love.

And if you’re looking to just get started from home, we have a full-on-demand platform with information videos and full-length classes to help you Relieve, Restore and Perform on the Viva Hub. Click through to see our full library.

REFERENCES

Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M., & Magnusson, S. P. Heavy slow resistance versus eccentric training as treatment for Achilles Tendinopathy: A randomized controlled trial. Am J Sports Med, 43(7), 1704-11. doi: 10.1177/0363546515584760

Chimenti, R. L., Cychosz, C. C., Hall, M. M., & Phisitkul, P. (2017). Current concepts review update: Insertional Achilles tendinopathy. Foot Ankle Int, 38(10), 1160-1169. doi: 10.1177/1071100717723127

Rio, E., Kidgell, D., Moseley G. L., et al. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine, 50, 209-215.

Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Conservative management of Achilles tendinopathy. J Athl Train, 55(5), 438-447. doi: 10.4085/1062-6050-356-19

Silbernagel, K. G., & Kay M. Crossley, K. M. (2015). A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and Implementation. Journal of Orthopaedic & Sports Physical Therapy 45(11) 876-886.

van der Vlist, A. C., Winters, M., Weir, A., et al. (2021). Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. British Journal of Sports Medicine, 55, 249-256