Posts tagged achilles tendinopathy
How Heavy Should I Load My Achilles Tendon After An Overuse Injury?

In the achilles tendinopathy (artist formally known as tendonitis) research two main themes have emerged. First, there is little to no evidence to support the use of injections of any kind into an injured tendon. Authors have advocated against steroid injections due to the risk of tendon rupture outweighing any potential benefits. Studies have also been limited in the use of PRP (platelet rich plasma) injections for tendon pain. Significant methodological concerns have impacted this area of research including the lack of large human trials, lack of placebo or alternative treatment (exercise) comparison, and small sample sizes. Without improvements in this line of research, PRP remains an expensive, experimental treatment compared to other proven treatment strategies.

Strengthening exercises remain the gold standard of care, both in the research and our Boulder Physical Therapy practice, for these tendon injuries. Although eccentric exercise was first published in the late 1990s as an effective treatment for tendinopathy, many other forms of strength training including isometric and isotonic exercise have also been shown to be effective. The key take home message from these trials remains the same, injured tendons must be progressively loaded based on their clinical presentation to recover. Initially improvements in a patient’s symptoms and function are secondary to improved strength of the surrounding muscles while long term improvements are attributed to structural healing of the tendon (remodeling).

A recent review of the evidence highlights the importance of intensity or resistance during achilles strength training exercises for patients with mid portion achilles tendinopathy (Murphy et al. Br J Sp Med. 2019). Authors reviewed the available literature on the use of heavy eccentric training for this patient population compared to a wait and see or traditional Physical Therapy approach (modalities, massage). They reviewed the data from 7 studies and reported heavy eccentric training may be superior to a wait and see approach and traditional Physical Therapy. Authors also found a trend showing these heavy eccentric exercises may be less effective than other forms of exercise (isometric, isotonic).

This review is consistent with our current understanding on tendon management. Tendons should be progressively loaded based on the tendon’s tissue tolerance and irritability. Although eccentric exercise has become popular, other forms of exercise and loading strategies should also be considered as part of the tendon loading plan of care. When it comes to tendons, one size does not fit all.

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Achilles Tendon Injury Treatments

A recent clinical practice guideline was published advising clinicians and patients on the management of achilles tendon injury (tendinopathy).  These guidelines are based on both the available medical research and medical opinions from experts in the field.  The Journal of Orthopedic and Sports Physical Therapy reported the following for management of mid portion achilles tendinopathy (Martin et al. 2018).

Grade A - Strong Evidence

Exercise - Exercise utilizes progressive loading of the injured tendon and promotes tendon healing or remodeling.  This process occurs through mechanotransduction and creates a stronger, healthier, and more resilient achilles tendon.  Evidence supports the use of both eccentric exercise or a heavy load concentric and eccentric exercise prescription.  Conversely, complete rest is not recommended due to its' negative effects on the healing process.

Grade B -  Moderate Evidence

Activity Modification - As we stated above, complete rest of an injured tendon often leads to delayed or incomplete healing of the injured tissue.  A tendon has limited blood supply and metabolism compared to other body tissues requiring exercise to facilitate the healing process.  A progressive, goldilocks approach is recommended because doing too little is just as harmful as doing too much.  As your tissue heals and becomes resilient to a certain level of activity, the load and exercise volume is increased slowly to promote further healing in the tendon.  This process is continued until you return to 100%.  Injured tendons can take up to 1 year to completely heal at the tissue level and patients are advised to continue to exercise even after resolution of their symptoms, usually around 12-16 weeks.

Grade C - Weak Evidence

A lack of ankle bending or dorsiflexion is a commonly found risk factor and corresponding impairment in patients with achilles tendinopathy.  Stretching of the calf and plantar flexors is commonly prescribed in patients with tendinopathy but the supporting evidence for this stretching is weak.  We commonly recommend utilizing strength training within the ankle's available range of motion instead of static stretching.  Recent evidence suggests eccentric strengthening is equally effective to static stretching for mobility. 


Further research is needed regarding other commonly utilized achilles tendinopathy including manual therapy.  In our Boulder Physical Therapy practice we find the utilization of joint manipulation, mobilization, and dry needling to be very effective in the short term for reducing pain and improving patient function.  These passive interventions are quickly withdrawn as patient's begin to load their injured achilles tendon tissue.  


Conflicting evidence was found for utilization of heels lifts or orthotics in the management of this condition.  We do not recommend these inserts in our practice due to their short term, limited effectiveness and potential for creating long term problems including joint tightness and muscle weakness.  



Updates on the Successful Management of Tendon Pain
Photo Credit: Scott, A. CMAJ. 2011. Mead, M. Transl Sports Med. 2018.

Photo Credit: Scott, A. CMAJ. 2011. Mead, M. Transl Sports Med. 2018.

Tendon injuries have previously been diagnosed as tendonitis and were believed to be marked by an inflammatory process in the tissue.  Our current knowledge on these injuries has been improved by a better understanding of the disease process behind tendon pain.  Current research indicates tendon pain (tendinopathies) is caused by an ingrowth of nerve and blood vessels to the injured area of the tendon leading to increased sensitivity with loading.  Further, as our body begins to heal the injured area of the tissue, tendon cells become more disorganized in nature.  Conversely, healthy tendons display high degrees of organization with tendon fibers aligned in parallel along the lines of healthy stress.  Gradual loading of the tendon through exercise promotes remodeling of the injured tissue.  In short, both under and over loading tendons lengthens the recovery process.  

A summary article on the available evidence behind tendon treatments was published in a sports medicine journal recently (Mead, M et al. Transl Sports Med. 2018).  The authors reported on a general trend against the use of injections for tendon pain.  This includes corticosteroid injections which may provide short term relief, but at the risk of further tendon injury or rupture.  Further, the research does not support the use of injections including prolotherapy or PRP at this time.  Conversely, the authors reported Physical Therapy including the use of loaded exercises, including eccentric exercise, should be considered a first line treatment for tendon pain and injury.  

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Calf Muscle Weakness Remains Up To 7 Years Post Achilles Tendon Repair

Achilles tendon ruptures are most commonly seen in patients 30-40 years of age and 4-5 times more likely in males versus females.  The injury is often associated with a sudden increase in force placed upon the tendon either from rapid progressions in sport activities or trauma (ex. fall from height).   These injuries can also occur in patients who have a history of unresolved Achilles tendinopathy with residual tendon and calf muscle weakness.  Many of these patients who sustain a rupture do well with either Physical Therapy or surgical repair.

Brorsson and colleagues examined patients who underwent Achilles tendon repair after a rupture to determine how the calf muscles heal and perform following this intervention (Am J Sp Med. 2017).  66 patients were followed over time to determine how quickly their strength, power, and jumping ability returned compared to their uninvolved leg.  The authors reported a rapid improvement in strength following the surgery followed by slower recovery of strength, power, and jumping ability up to 2 years.  No further gains were found after this time point and patients continued to demonstrate weakness and limited muscle performance up to 7 years after the surgical repair.

This study highlights the importance of continuing to rehabilitate the injured extremity first in Physical Therapy and then independently at home.  Patients are encouraged to continue a lower body strength training program to both improve function and decrease risk of re injury.

Risk Factors for Achilles Tendinopathy
risk factors-achilles tendinitis-tendonitis-treatment

Achilles Tendinopathy is a common injury to the lower leg found in runners, jumping athletes, and sedentary individuals.  In our previous blog posts on Achilles Tendinopathy we have described the impact of this diagnosis on the active population.  Physical Therapy remains the gold standard for conservative care focusing on restoring joint mobility and strength to the leg, as well as, reducing the risk of future training errors caused by overload to the tendon.  Recovery from achilles tendinopathy can be slow due to the slow healing nature of the tendon and because of this we should work hard to reduce an individual's risk for this diagnosis.  

A recent article was published in the International Journal of Sports Physical Therapy to determine the known risk factors for the development of achilles tendinopathy (O'Neill et al. 2016).  Authors surveyed experts in the field using a Delphi technique to determine these known variables.  The risk factors with the strongest risk of future injury included ankle stiffness, history of calf pain, and being male.  These findings are consistent with previous research showing a loss of ankle bending or dorsiflexion remains a strong risk factor for the development of many lower extremity overuse pains.   To learn about how to reduce your risk of achilles tendinopathy speak with your local Physical Therapy expert. 

Ankle Mobility and Achilles Tendon Injury

The achilles tendon is a strong, durable structure capable of absorbing and producing large loads as we walk, hike, and run.  When the tendon is overloaded without adequate recovery periods this structure is prone to painful and limiting conditions such as achilles tendonitis and tendinopathy.  One of the important risk factors for achilles injury among athletes and patients is a lack of ankle mobility.  If the ankle is unable to bend adequately during functional movements the achilles is placed under increased load leading to tendon injury.  In our Boulder Physical Therapy practice, we commonly see a loss of ankle mobility among patients with achilles tendon injury.

During our Physical Therapy examination we often see a loss of rear foot or ankle mobility and a compensatory increase in motion at the mid foot or arch (pronation).  A recent study in the journal Clinical Biomechanics confirmed our observations (Chimenti, R. et al. 2016).  The authors assessed individuals with and without achilles tendinopathy to determine their ability to bend their ankle as well as which areas of the ankle and foot where contributing to this movement.  The group with achilles tendinopathy had significantly less ankle mobility than the control group.  Importantly, this group compensated during testing with increased mobility of their arch instead due to an inability to move through the rearfoot.

This study highlights the importance of treating the ankle in patients with achilles tendon injury.  To learn more about how to safely and effectively treat this condition contact your local PT.