Case study: Left Achilles mid portion tendinopathy
Have you been suffering with Achilles pain which never seems to be going away?? Don’t worry as the following case study will hopefully demonstrate there can be light at the end of the tunnel!
With consent kindly given by one of our clients Mike Hall, we are going to present how he managed to go from only being able to run 3 miles in July, to completing the Hardwolds 80 mile race 2 weeks ago!
In April 2018 Mike began with a gradual onset of left mid portion Achilles pain in between running a 55 mile race and a period of training including runs with heavy climbs and descents. Despite a period of relative rest in May and carrying out the often prescribed single leg ‘heel dips on a step’ the pain continued limiting his running to a maximum of 3 miles. This wasn’t ideal with his next big race of Hardwolds 80 miles coming up in a few months!
On attendance to the clinic Mike presented with reduced dorsiflexion (reduced pointing foot upwards) of the ankle and foot due to ‘tightness’ and discomfort, pain in his Achilles reproduced with a single heel raise (straight and bent knee) and specific tenderness on palpation 2-3cm in length at the mid portion of his Achilles.
Mike’s main stay of treatment revolved around a progressive loading/strengthening program to improve the Achilles’ ‘envelope of function’ and ‘tissue tolerance’ (see previous ‘blog’ to explain further - https://www.consortiumphysio.co.uk/blog/2015/12/24/tissue-regulation ) to allow a return to the demanding stresses running 80 miles will place upon it.
Mike had already started and tried this with the ’heel dip’ exercises however the key is determining where the right place is to start. Too much load will aggravate and prevent improvement (e.g. the single leg heel dip at this stage) and too little load (e.g. complete rest) will result in the symptoms coming back on a return to running (this is because the Achilles is still no better at accepting the stresses placed upon the tendon).
Stage 1 of Rehabilitation…
Here was Mike’s starting point governed by symptom and clinical response…
Standing single heel raise with straight knee (Gastroc bias) – 3 x 10, 2 x on every other day
Standing single heel raise with flexed knee (Soleus bias) – 3 x 10, 2 x on every other day
Double leg heel raise and dip on step (Note this was adjusted from single leg previously tried to using both legs to lessen the load) – 3 x 5-10, 2 x on every other day
Although single heel raises also caused discomfort for Mike it has been proven working up to a certain amount of discomfort can be accepted. This is gauged by a number of factors including not allowing discomfort to rise above a 3-4 out of 10 (0 is no pain and 10 is the worst pain imaginable).
Have you ever tried telling a runner not to run?!
The good thing is alongside the exercise program we did allow running to continue. This can often come as a surprise to some as ‘rest’ is often advised or felt the best thing to do. However as previously mentioned with the mainstay of the treatment based around improving the Achilles’ load tolerance, by not running we would be reducing this and causing ‘de-conditioning’. This is not always right for everyone but with Mike we knew he could run up to 3 miles therefore we worked around this following the below principles…
Can run distance/time up to pain being no greater than 3-4 out of 10
Always allow 1-2 day rest in-between each run
Wear trainers with higher heel drop to off load the Achilles
Avoid hill running at present (hills have greater stress on Achilles)
Avoid any friction/soft tissue massage to the area of discomfort (Can carry out soft tissue massage/foam rolling to Gastroc/Soleus away from the Achilles)
Initially avoid any Gastroc/Soleus stretching
Can carry out low impact cross training such as cycling and swimming
Next stages OF REHABILITATION…
The Achilles requires being able to absorb/manage 2.5-3 times our body weight repeatedly when running, therefore only carrying out the exercises we have started with, would not have been enough to build the Achilles’ load tolerance to run 80 miles. Approximately every 2 weeks (as symptoms/Mike’s progression allowed) the exercises were gradually progressed to involve higher resistance (using weights) and to also eventually include plyometric exercises, which stresses the Achilles to its highest level through the stretch shortening cycle/energy storage which takes place during the stance phase to push off when running.
An example of the end stage exercises includes…
Single leg hopping (flat ground progressed to on and off a step)
Squat split jumps
However caution needs to be taken when carrying out the end stage exercises to ensure the gap between the starting point of the rehabilitation has been bridged with gradual exercise progression continued to be guided by symptom and clinical response. As not bridging this gap will cause a flare in symptoms.
As the exercises progressed so did Mike’s running mileage. This coincides with the gradual build-up of the Achilles’ load tolerance. This again was done in a progressive manner still following the a-fore mentioned principles. Towards the later stages hill running was slowly introduced as part of the graded exposure of the Achilles to greater stresses. How running mileage is gradually increased is often a debate which differs among a lot of runners.
Some of the common methods used are…
Increasing the mileage by 10% each week
Step up, step back - Build up 10% for 3 weeks - Then step back 10% for 1 week – and so on
Runs - 80% low intensity running (1-2 mins slower than race pace) - 20% high intensity (race pace)
A more accurate (but more complex) method is the working out of our ‘Acute Chronic Work Load Ratios’ (previously discussed in an earlier blog of ours - https://www.consortiumphysio.co.uk/blog/2017/2/12/part-1-managing-load-to-avoid-injury-is-it-right-to-wrap-yourself-up-in-cotton-wool , https://www.consortiumphysio.co.uk/blog/2017/4/2/part-two-managing-load-to-avoid-injury-how-to-not-wrap-yourself-up-in-cotton-wool )
With Mike’s hard work and dedication his rehabilitation has been a great success. Hope you’ve found reading his story useful and also if you do suffer with Achilles problems you have been reassured that there can be light at the end of the tunnel. If you require any further advice on this subject or anything else injury related please don’t hesitate to get in touch via email firstname.lastname@example.org or give us a call on 01482 847705.
Thank you for reading,
The Consortium Team
… After the 80 miles we’re completed!