How to Heal From Achilles Tendinopathy: Your Physical Therapy Guide
Written by Jared Packer
Dealing with an achilles tendinopathy can be a truly frustrating experience. What starts off as a subtle pain can blossom into a discomfort that lasts for months and restricts you from participating in your activity of choice. Thankfully, a large portion of people recover from achilles tendinopathy with conservative treatment, including physical therapy.
In this blog we will cover:
What is achilles tendinopathy?
Different types of tendinopathy
Signs and symptoms of achilles tendinopathy
Treatment of achilles tendinopathy
What is Achilles Tendinopathy?
Tendinopathy is often used as an umbrella term for conditions affecting tendons: both tendinitis and tendinosis. Tendinitis is an acute inflammatory state of the tendon, while tendinosis is a degenerative condition due to chronic overuse. It has traditionally been thought that tendinitis precedes tendinosis, though some experts have recently hypothesized with some evidence that the opposite is true.
Risk Factors of Achilles Tendinopathy
There are many risk factors to achilles tendinopathy, some of which we can control. These include overuse, lack of sleep, poor nutrition, and stress. The risk factor we will address in this blog is overloading of the achilles tendon - either repetitively over time, or too much at once. This highlights the need to balance our workloads, and the importance of recovery.
Tendinopathy will cause different effects depending on its location in the body. For example, the patellar tendon generally will become stiffer, while the achilles tendon will become more pliable.
Signs and Symptoms of Achilles Tendinopathy
The gold standard for diagnosis of achilles tendinopathy is currently diagnostic ultrasound or MRI. There are however signs and symptoms that indicate the presence of this condition.
Localized pain in achilles tendon
Pain in the achilles tendon following a day of overuse (especially in the morning)
Increased pain with increased tension on the achilles tendon
There are other conditions that present similarly to achilles tendinopathy, so you should consult with a physical therapist or sports medicine physician to help you diagnose this injury.
Types of Achilles Tendinopathy
Achilles tendinopathy can emerge at different locations within the achilles tendon, and will subsequently be categorized as insertional or mid-portion achilles tendinopathy.
Treatment of Achilles Tendinopathy will vary to some degree depending on the classification that you have.
How to Treat Achilles Tendinopathy
The following suggestions on treatment are for CONFIRMED cases of achilles tendinopathy.
Temporarily remove stress from the achilles tendon.
Limit or stop the activity that was hurting the achilles tendon. Give it a chance to heal, so that you can work through the appropriate progressions.
Put a heel lift in your shoes. This will put the achilles tendon into a shortened position, which will decrease the amount of repetitive stress placed on it when walking.
Don’t stretch the achilles tendon. As mentioned earlier, the achilles tendon usually becomes more pliable with tendinopathy, so the goal is not to create more range of motion. There are a few exceptions to this, which a physical therapist can help you determine.
Apply planned stress to the tendon.
Although we are still learning about this condition, the best evidence for recovery points to gradual loading of the Achilles tendon. This results in strengthening of the tendon and muscle, increasing tolerance to stress.
To give the best chances of recovery, eventually high levels of resistance should be applied. There is always a point however, where too much load will be detrimental. Using pain can be a useful guide for determining this.Use pain as a guide.
A general rule of thumb is to consider pain from 0-2 to be safe, and 3-4 to be a zone of caution in tendinopathy. Anything above a 4, and the exercises need to be regressed in some manner.
Track pain levels during the following, careful not to experience pain beyond 4/10:While performing exercises.
The hours after exercises.
The day after exercise. It should not exceed levels of discomfort that you normally experience.
It is important that you have a confirmed diagnosis of Achilles tendinopathy before you confidently exercise with pain.
Identify mid-portion vs. insertional achilles tendinopathy.
Treatment of achilles tendinopathy should vary depending on whether it’s mid-portion or insertional achilles tendinopathy.
With insertional tendinopathy, early to mid phases of recovery should avoid a loaded dorsiflexed position, as this can compress the tendon.
Tendons typically don’t respond well to compression when they are in an irritated state.
Eventually, the tendon will need to withstand some degree of compression in this dorsiflexed position because it’s a normal part of function, but doing this too soon with insertional tendinopathy can result in persistence of symptoms.
Mid-portion Achilles tendinopathy does not usually worsen from working through a dorsiflexed position. Practically this means that you can do calf raises off of a step much sooner with mid-portion Achilles tendinopathy, and these cases tend to resolve sooner due to less irritation. In addition, mid-portion tendinopathies will tolerate exercises where the knee goes over the toes earlier in the rehab process.
5. Exercises for initial phases of achilles tendinopathy.
The following can be done to treat achilles tendinopathy every day, multiple times a day, so long as they fit within the pain guidelines:
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Do sets of 30 regularly throughout the day
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Hold for 45 seconds, 3-5 reps, with 1-2 min rest between reps.
If it’s insertional, lift up halfway if all the way up on your toes is painful.
6. Exercises to strengthen the achilles tendon.
Progress through these exercises according to the pain guidelines. They should be down slowly, with a 3 second up and 3 second down.
2 leg calf raise on flat ground
2 leg calf raise on step (skip if insertional tendinopathy)
2 up 1 down calf raise
1 leg calf raise on flat ground
1 leg calf raise on step (skip insertional tendinopathy)
Do these 3 days/week. Start with 3 sets of 15 reps, and gradually work your way to 3 x 6 and add resistance. You can use a smith machine, a leg press machine, or dumbbells.
Once you can perform those with limited symptoms, increase the speed to challenge the stretch-shortening cycle of the tendon.
Quick calf raises
Quick 1 leg calf raises
2 leg pogo jumps
1 leg pogo jumps
Start with 3 x 20 and progress to 30 reps.
This is not an all inclusive list, but something to get started with.
Again, once you can do these with limited symptoms, a gradual return to your activity or sport of choice will give the best chance of avoiding re-injury.
7. Respect the healing time frame.
Tendon tissue can take 12 weeks or more to fully heal and adapt. This doesn’t mean it will take this long before you start to feel better, but keep this time frame in mind so that you don’t push yourself too hard too soon, and re-aggravate symptoms. Generally you want to keep any weekly increase in activity volume/intensity to less than 10%.
On the flip side, not doing enough will keep the tissues weak and susceptible to re-injury. Make either of these mistakes consistently and it may turn into a chronic issue.
As with most injuries, don’t forget to train to improve function and biomechanics of the trunk and legs. This way you can decrease errant forces applied to the Achilles tendon.
This includes:
Trunk stability
Hip/knee stability and strength
Foot stability
Having a physical therapist help treat and manage your case can help you to figure out the optimal amount of work to do within a specific time frame, in order to heal achilles tendinopathy and get you back to the activities that you love!
This blog is not a substitute for medical advice. If you are experiencing symptoms, consult a license healthcare provider.
