In this article we’ll give you our appraisal of all of the Achilles tendon physiotherapy treatment options that we know of. We’ve tried all of them! The truth is that no one thing will be the magic panacea for everyone. The reason why each individual Achilles tendon is ‘grumpy’ is exactly that, individual.
That said we’ll run you through the things most likely to be contributing to your symptoms and give you ideas of what to do about them. Some you may have heard, others hopefully you won’t. All inspiration and motivation, we hope, to get your Achilles issue moving in the right direction again.
Now I usually put quite a bit into these articles but this will be especially true in this article as I’ve irritated by an Achilles niggle myself for the last few months. An excellent time to review the literature…
How Do You Know If You Have Damaged Your Achilles Tendon?
Let’s clear up an important point before getting into detail. A rupture. When your Achilles snaps in two. Generally you can’t miss it. There’s a cataclysmic event. Something goes snap in a big way – many people report thinking they had been shot in the calf!
After the event you will have one end of your calf muscles at one end and the other half at the other. This can look pretty obvious although not always. If in doubt please consult your GP in the first instance who will refer you onwards.
The good news is that Achilles rupture repair has got significantly better in the last 10-15 years since we stopped operating on them! The medics will likely put you in a cast with your toes slightly pointed and slowly lower your high heel over a period of about 3 months. Magically your Achilles tendon reattaches itself. And with a much lower likelihood of re-rupture than surgery. Amazing.
If this is you follow all the medical advice you’re given and all usually goes well. We normally like to get involved when you’re out of the cast and walking again. Usually about 3 months in. It’s also possible to partially rupture your Achilles tendon which will be a less severe event than a rupture but can be tricky to heal.
The real crux of the article, however, is about the bulk of Achilles tendon problems that come on gradually for no obvious reason. You may have increased your activity, your stress levels may have increased or none of the above. All options are possible.
Answering the question have you damaged your Achilles becomes trickier and somewhat philosophical debate in these injuries! Allow me to explain…
Pain somewhere near your Achilles does not necessarily mean you have an Achilles problem. The first thing to do is to not panic. The pain in the Achilles region can be caused by calf muscles (gastrconemius, soleus and plantaris), nerves which run through the area (tibial, peroneal, sural and femoral), muscles which run behind the Achilles tendon (tibialis posterior, flexor hallucis longus, flexor digitorum longus) limitation of the ankle joints (talo-crural and talo-calcaneal) and that’s only considering localised structures.
If we consider the picture below. Our version of the Anatomy Trains superficial back line you can see how the Achilles is connected to the plantar fascia below and above to the calf, hamstring, glute, muscles of your back and to the base of you skull. And so any of these structures can, and frequently do, increase load on the Achilles tendon.
One of the key indicators Sports Therapists and Physiotherapists use to assess the injury is to feel the Achilles to see it there is any thickening of the tendon particularly when compared to the other side. Then we have an indication if there are local changes without the need for MRI scans.
But, as with much in the physiotherapy world, this does not mean you will get pain. You can get a thickened Achilles with no pain at all. It’s just an indication that your body has decided it needs to do something a bit different in that area.
This insight has been confirmed by research scanning lots and lots of Achilles and scoring the pain and incapacity levels of their owners. However, conversely, if there are changes in the tissues you are more likely to have pain.
If you’re interested in why issues in the tissues doesn’t necessarily mean pain and vice versa have a read of our previous article What Is Pain?
Where Is The Achilles Pain Coming From?
So where does the pain of Achilles tendinopathy come from if it’s not just a reflection of the state of the Achilles tendon? To start the story let’s consider the history of the naming of Achilles issues. Originally is was considered a tendinitis – that is inflammation of the tendon. Whilst Achilles issues can be inflammatory they are often not.
That led to a rethink and using the term tendinosis which suggest degeneration of the tendon, or put nicer, wear and tear. But this was found to be inaccurate so the physiotherapy world has settled on tendinopathy. There’s something wrong with the tendon. But is that true? As we mentioned above we can have no issues with the tendon and still have tendon pain.
With improvements in the quality of MRI imaging we are starting to see that the three calf muscles are all represented within the Achilles tendon. Which is confirmation of the theory that tendons are merely continuations of the fascial wrappers for muscles just without contractile muscle in them. Simple, yet beautiful, insight now being backed up with MRI studies and also cadaver research. You can see a nice representation of this muscle into tendon below:
Specifically in the Achilles tendon we are seeing that it is usually the soleus portion of the Achilles tendon where most of the changes in the physiology of the tendon take place. Equally there seems to be an involvement from the fat pad which sits between the soleus part of the Achilles and the ankle bone (calcaneum).
Real World Achilles Tendon Example
All this theory can be confusing so let’s take a real world example. Mr X, a 69 year old gentleman, popped into our clinic complaining of Achilles pain. On inspection his Achilles was very thickened and quite swollen. It was getting particularly uncomfortable around the 13th hole of Mr Xs golf round… threatening to ruin his retirement.
With the fact that the tendon was clearly thickened and swollen and given Mr X’s number of years on the planet this could have proved to be a tricky case. But we kept to our principles and sure enough he was back playing golf pain free with about 4 sessions. Had the swelling gone down? Yes. Had we changed the physiology of Achilles tendon? Probably not. Though I’d like to have seen a before and after MRI scan.
The Achilles was still thickened but more importantly it was pain free. Just going to show that the state of the tissues is not the be all and end all when it comes to the pain that we feel. So perhaps we should not so much focus on what it is or what it might be more perhaps what we can do about it.
Risk Factors For Achilles Tendon Pain
So the research is interesting. Unlike many conditions there are not many obvious pre-disposing factors that lead to Achilles tendon issues. This excellent summary of many papers concludes that if we take out any biased papers then the only consistent risk factors are ofloxacin (certain type of anti-biotic) use, alcohol consumption and a reduced calf strength.
With reduced calf strength this is consistent with other tendon issues. For example in patella tendinopathy the quadriceps will normally be weaker and inhibited in the problem side. The question is which comes first the weakness of the muscle or the inhibition of the muscle caused by the pain in the tendon. Chicken and egg surely.
From a clinical perspective there are many more factors we consider that would increase load in the Achilles region. These would include flat feet, high arches, leaning forward posture, tight / dysfunctional glutes or hamstrings, tension in muscles of the shin, back tension and even neck pain or what we call head forward posture.
This list may seem somewhat excessive but we can whittle things down to the most obvious culprits with a combination of some simple tests and some treatment to see what works for the individual in front of us.
What Can I Do To Avoid Achilles Tendon Injury?
Stretching? Probably not, at least not the calf muscles. When you stretch the calf muscles it pushes the fat pad and Achilles tendon onto the calcaneum (one of the bones in the ankle). Potentially this can cause irritation of these structures and actually lead to the development of Achilles issues. I talk more about the reasons not to stretch your Achilles in this short video:
That said, I would suggest stretching other structures which can lead to tension on the calf muscle. Primarily the hamstrings and glutes. Again you still have to ask yourself why the hamstring and glutes are tighter than they should be but there’s only so much I can write in one article!
Barring coming to see us your best bet is to do some strength training as shown in this paper from the British Journal Of Sports Medicine. This will allow gradual adaptation of the calf muscles to the load placed on it.
Equally, the classic presentation we see is when people have done “too much too soon.” Either a good runner upping their mileage too soon for a big event or marathon. Or someone who hasn’t run for a while starting to do too much training from scratch.
What Is The Best Treatment For A Sore Achilles Tendon?
In rehabilitation terms it has long been thought that eccentric strengthening programmes provide the best solution Eccentric training for Achilles tendons is the lowering down from tiptoes. This paper here show’s that it’s more effective than amongst other steroid injections.
More recently how you strengthen the tendons has been brought into more focus. The eccentric element of the training is now not thought to be as important as it once was. This paper here show’s that heavy slow resistance training is just as effective over 52 weeks as eccentric and actually more effective over the first 12 weeks.
But the truth is that strengthening doesn’t always make things better. And in many cases we’ve seen actually makes things worse. In fact one client I once saw started doing eccentric strengthening to avoid getting Achilles tendon problems and gave themselves Achilles tendon problems by doing them! I don’t want to scare people of doing strengthening but the right pace is different for everyone.
Especially in cases where the sensitivity of the nervous system is very high. Whether that’s through a period of prolonged stress or more of a local anxiety about what the limitation of an Achilles injury might mean to them or simply fearing what pain in the Achilles could be. Picture someone walking around tentatively fearing their Achilles could snap any moment. The tighter the muscle the worse the function.
In our experience we need to create the right environment to allow the Achilles to simply do what it needs to do. This may simply be tweaking a training programme to reduce slightly the load on the Achilles over time. It could be getting people to do more and fearing it less so they don’t hold themselves and their Achilles so tense.
Our formula breaks for Achilles tendons breaks down like this:
- Address any unhealthy fears / concerns / training errors
- Calm the nervous system globally using knowledge of which areas hold the most tension in most of us. This varies wildly in all of us of course but there are certain areas more likely than others
- Correct pre-disposing factors (mentioned above) that could lead to the Achilles tendon over working
- Test, using treatment, so see if any of these make an immediate impact – if so this will guide the rehabilitation
- Start strength training if appropriate or come up with a plan for gradual return to sport or everyday activities
- Localised treatment on the Achilles to release the painful bits – we find that when the reason for the tension has been removed this melts away surprisingly quickly
- Enjoy life pain free
Achilles Tendons Summary
Achilles tendon problems may seem like a mystery wrapped in an enigma but most can be treated with a combination of calming of the nervous system, some biomechanical correction and slight modification of training or just life they will normally resolve in not too much time.
I’d say 90% of the Achilles issues we see at the clinic is nothing to do with the Achilles. There are no localised changes in the tendon. These are generally easier to sort out than when there is genuinely an issue with the tendon.
If you’d like us to have a look at your Achilles (or any other problem for that matter) please fill out the form here and we’ll be in touch.