By Matt Bushell, Physiotherapist
Calf pain is a common complaint in the recreational athlete/runner and in the case of an Achilles tendinopathy, it often follows a bout of increased workload. This increased workload can come in the form of distance, speed, or frequency of runs and usually present as pain and stiffness both first thing in the morning and possibly at the start of activity.² The symptoms can dissipate on ‘warm-up’ or even disappear initially. As tendinopathy progresses, the pain and stiffness can become more persistent and may increase with activity.
Achilles tendinopathy can be classified as insertional or mid-portion. This refers to the location on the Achilles tendon that is reactive to the increased loading that has occurred. Identifying the area of reactivity is important as the management differs slightly. Insertional tendinopathies tend to dislike compressive forces, and this will have some impact on the types or position of exercises that are prescribed.
Step 1 in the recovery of tendinopathy is to reduce symptoms. This can be achieved through a combination of approaches. The combination and the way in which they are implemented is dependent upon individual factors. They can include:
De-loading/activity modification
Rest can often reduce the symptoms of Achilles tendinopathy, but without a structured loading program to promote strength and energy storage/release from the lower limb, the pain and symptoms are likely to increase again on return to activity.¹
Ice
Ice can be useful in aiding pain control but be sure to only apply it for a short period (your skin should not go numb) and then wait at least 1-2 hours before reapplication if required.²
Manual Therapy
Techniques such as soft tissue massage to surrounding musculature can aid in symptom management, however, this is rarely a successful long-term management and prevention plan – that’s where step 2 comes in.
Tape/orthotics/heel wedges
These adjuncts can be useful in achieving the initial change in loading by helping to reduce tension/compression or change the biomechanical forces at play but will need to be phased out to allow for a successful return to pre-injury function.²
NSAIDS (used sparingly)
There is research to say that the use of NSAIDS can interrupt the healing process of tendons, however, used sparingly for a short period of time if required appears to be of little consequence.²
Step 2 is to increase the loading capacity of the tendon:
Isometric loading
Isometric exercises involve creating tension in a muscle without any movement. An example of this in the calf region would be to stand on your toes and hold that position for a specified time. This can be a useful way to improve symptoms in the short-term, particularly in a mid-portion Achilles tendinopathy.
Isotonic loading
Isotonic loading refers to an exercise with movement. An example would again be the calf raise, but this time you will go through the entire motion for a prescribed number of repetitions. In terms of tendinopathy rehab and achieving the best tendon remodeling, we require loading that is above bodyweight. This means heavy calf raises in both sitting and standing to focus on different muscles of the calves.
Plyometric
One of the most important functions of the Achilles tendon is to store energy through the initial impact of our foot contact during running and then release that energy through the foot contact phase to aid in propulsion. This energy storage and release is as much a skill as anything else in the body, so must be retrained and practiced as symptoms and strength improve.
Finally, it is important to recognise that tendon rehab takes time. It is easy to make the mistake of losing interest in the rehab program once the initial pain and symptoms begin to subside, however increasing the loading capacity of the tendon to meet the load as you return to your activity and then beyond to ensure a ‘buffer zone’ is crucial in reducing the likelihood of recurrence.
- Cook J.L., Khan K.M., Purdam C. (2002). Achilles tendinopathy. Manual Therapy, 7(3), 121-130.
- McClinton, S. Nonsurgical management of midsubstance achilles tendinopathy. Clinics in Podiatric Medicine and Surgery, 34(2), 137-160.
