In this post we discuss why your Achilles tendon injury is not getting better and what you can do now.
This post was originally written with runners in mind but it will serve anybody who’s suffering with Achilles tendon issues.
Before I show you how you can achieve results like this, let’s take a look at what’s likely going on in your Achilles tendon and why what you’ve tried already hasn’t worked.
Most contemporary research shows Achilles tendons that have been sore for some time (3 months plus) are in a state of degeneration. In other words the tendon is not in an inflammatory state (Achilles Tendinitis) but rather one of disorganisation (Achilles Tendinosis).
This sounds worrying but don’t panic, the process is entirely reversible with the right approach.
Tendons, like the muscles they attach to require force to stay healthy. The stimulus must be at just the right level however. Too little and too much both create issues.
If you’re reading this and you’re a runner then the chances are you’ve overloaded the muscles of your lower leg at some point. While it may have gone unnoticed at the time, it was this that set the scene for your present predicament.
Since that point you’ve been running with muscles in your lower leg that are both unable to produce force or attenuate it appropriately. Both to the detriment of the structure that attaches them to your calcaneus, your Achilles tendon.
The value of every rehabilitation protocol must therefore be assessed with this in mind.
How will it improve the ability of your plantarflexors (calf muscles) to contract so you can begin to place controlled forces through your Achilles tendon again? It’s this that will effectively kick start the process of regeneration within the tendon.
With that in mind, let’s take a look at what you’ve probably tried so far.
Doing nothing has many benefits, you can get through a box set, hang out with your family a bit more, and get a few jobs done around the house.
It probably won’t magically cure your Achilles tendon however. Even if it reduces the pain for a while, the moment you begin to run again it will likely return because nothing has significantly changed.
The fact that I even have to debunk stretching as a rehab method for Achilles tendon issues is irritating. There is no evidence that stretching works for the prevention or treatment of any injury let alone Achilles tendinopathies.
It still appears in every rehab article I read on the subject however. Not only is it ineffectual, it’s also potentially problematic.
Take a read of this from a recent Runners World article on the issue of Achilles tendon rehab. This, believe it or not, is from a podiatrist who was actually promoting the use of stretching.
‘Damage occurs when the tendon is stretched 4 percent beyond its strain level and rupture occurs at 8 percent beyond its relaxed state. For the normal tendon, that’s only about a quarter of an inch. Therefore it’s very important only to feel the stretch in the calf muscles.’
Good luck judging exactly where a quarter of an inch is when you’re hanging off the edge of a step. Ridiculous. Stretching will only make you weaker. Stop it.
Corticosteroids, NSAIDs or any drug for that matter.
The use of taking any anti inflammatory drug, be it orally or via injection is instantly called into question when you know that there is unlikely to be a significant inflammatory process occurring if the issue has become chronic in nature.
Whilst drugs may provide an analgesic effect, their long term use merely allows you to damage the tendon further without knowing about it. This is rather like turning the red light off on the dashboard and continuing to drive your car.
Massage certainly feels nice to some people. Being touched while being listened to might be beneficial on some level but evidence that this will solve your Achilles tendon problems doesn’t exist unfortunately.
Whilst it may promote relaxation and improve your mood, don’t expect a miraculous return to running. I would be especially wary of any massage strong enough to cause pain, this can be counterproductive.
This is the exercise you will have been given if you’ve visited a physiotherapist for your Achilles tendon problem. It’s certainly more effective than anything else I’ve mentioned so far.
The exercise involves loading the eccentric phase (lowering the heel to the floor) of a calf raise which has been shown to promote healing of the Achilles tendon in some cases.
The weakness of this method is two fold; firstly the weakened muscles of the calf may not be able to tolerate this much force which will only exacerbate your Achilles tendon pain.
Secondly, a full return to running will also require the plantarflexors to shorten under load. A motion not trained with this approach.
Think of it as half right which will explain it’s 60% success rate in studies with injured runners.
Imagine you had a knee that was deemed to extend too far and you were told to put a brace on it in order to prevent that motion from occurring.
Not only would it cramp your style, it would also impede the ability of your leg to both absorb and produce force. It would also probably cause issues somewhere else in your body.
Sticking a post in your shoe to prevent motion at your foot is no different.
Work on your muscular system first before even thinking about this as an option. I see plenty of people that are still trying to recover from running around with their feet braced.
Ultra sound, extra corporeal shock wave therapy, electrolysis.
All these therapies are designed to kick start the healing process in one way or another, although evidence for their effectiveness is thin on the ground.
Think back to the original problem and you can see why. How do they positively influence the ability of your plantarflexors to contract? Answer, they don’t.
A different approach.
Whilst it’s very difficult to provide a rehab programme based on your individual strengths and weakness, some of which won’t just be at your ankle. It is possible to provide you with both the thought process and some of the exercises I use to improve Achilles tendon issues.
Before placing any amount of force through an injured area, it’s necessary to improve the ability of muscles likely affected by the injury to contract. In this case muscles that plantarflex the ankle as we have already discussed. This is best done with isometrics.
Isometrics are exercises that change neither the angle of the joint they act upon or the length of the target muscle.
They are an effective way of improving communication between the target muscle and the central nervous system.
It’s this communication that may have been affected by the injury and the reason why jumping straight into exercise doesn’t always work.
Use the following 4 isometrics for a minimum of 6 separate sessions before attempting to move on to phase 2 of the programme.
Phase 1 Improve communication.
Lie on your back with your hip and knee at 45 degrees. Fully plantarflex your ankle.
Keep your toes on the floor and rotate your lower leg and foot inwards as far as it will go.
Have an immovable object block your foot in this position and very gently rotate your lower leg into the object.
Note a yoga block is not an immovable object and only used for demonstration purposes here.
Hold the contraction 6 secs before rotating back to neutral and resting 5 seconds. Repeat this 6 times.
Holding the same hip and knee angles, fully plantarflex the ankle again and this time rotate the lower leg and foot out as far as it will go.
Make sure the bottom of the foot and toes remain flat to the floor before pushing out into the immovable object as before.
Hold a low intensity, sustained contraction for 6 seconds before rotating back to neutral and resting 5 seconds. Repeat 6 times.
Soleus medial and lateral.
Lie face down and bend your target side knee to 90 degrees. From this position fully plantarflex the ankle and rotate your lower leg in at the top of the movement.
Gently push up and in towards the ceiling. Focus on feeling the muscle on the inside of your calf contracting. Hold 6 x 6 seconds.
Repeat again but this time point up and out at the top of the movement. Hold 6 x 6 seconds again.
Gastroc medial and lateral.
Come back over onto your back and bend your hip and knee to 45 degrees again.
Rotate your lower leg in once more but this time pull your heel back towards your buttocks into an immovable object. Hold 6 x 6 seconds again.
Repeat again with your lower leg rotated out.
Phase 2. Strengthening.
Seated calf raises.
Performing calf raises from this position removes the contribution of the gastrocnemius as the bent knee position shortens it to the point where it can do little to assist in the movement.
Start without additional resistance to begin with and add dumbells on the top of your thighs providing the movement is pain free. Use a weight that will bring about mild fatigue.
Aim for 2 sets super slow 5 sec up and 5 sec down for 6-8 repetitions.
Perform this exercise 3 times a week for 3 weeks whilst using the isometrics before each session to ensure the target muscles are contracting optimally.
Standing calf raises.
Stand with feet shoulder width apart close to a wall for stability. Slowly rise up onto the balls of your feet before slowly returning to just above the floor and repeating.
Again use the same 5 seconds up and 5 seconds down timing and aim to complete 6-8 repetitions.
Use this exercise 3 times a week for 3 weeks again with a set of isometrics before each session.
Standing single side eccentric heel drops.
Now you should be ready to try moving on to one leg at the top of the calf raise and very slowly lowering your heel to the floor.
Make sure you still use both legs to return to the top of the movement. Use a slightly quicker concentric phase of 3 seconds and an eccentric phase of 5 seconds again.
Aim for 2 sets of 8-10 repetitions. Perform this exercise 3 times a week for 3 weeks with a set of isometrics before each session.
Chronic Achilles tendon pain in runners is likely a result of overload to the soleus and gastrocnemius muscles.
Any effective rehabilitation programme must first restore the ability of these plantarflexors to contract appropriately, before aiming to strengthen them.
This will begin to provide your Achilles tendon with the stimulus it requires to regenerate.