Do you suffer with a painful Achilles tendon?
Struggling to get better despite treatment?
Achilles Tendinopathy is a common problem that can easily affect both those individuals who are just beginning to gain basic fitness as well as our Olympic athletes.
So why is this the case?
The answer to this lies in how the condition occurs in the first place... Despite whatever level of fitness you may have, each individual’s soft tissues (muscles/tendons) have a load (stress & strain the tissues are exposed to) capacity. The problem arises when this is exceeded! source
To help explain this… there are various ways in which it is possible to exceed your body’s soft tissue’s load capacities. One of the most common examples of this is training error. Any individual, whether they be a novice or elite athlete can easily exceed the load capacities of their soft tissues through training error alone! A simple example of this could be a sudden change in running mileage. For a short period of time the body will probably cope with this but eventually it will start to complain. Usually this is where things can become painful. source
It is important to know that there can be a variety of sources of heel/Achilles pain (usually a physiotherapist can differentiate between these). However, an Achilles tendinopathy is usually linked to a recent change in physical activity such as training volume, intensity, frequency or type. Discomfort often increases with activity and decreases with rest. There are normally clear mechanical aggravating and easing factors present. The pain may also be local to within a finger or 2 fingers width at the mid point of your Achilles tendon or at its attachment to the heel. source
So... if this fits your presentation then I’m sure the next obvious question will be - how do I manage this effectively? Good question!
Traditional ways of thinking often still consist of advising complete rest from activities and stretching of the Achilles. However, recent research and evidence strongly suggests this is maybe the exact opposite as to what we should be doing!
So....why not stretch?
It has been suggested that this will not only prevent your Achilles problem from getting better but it could possibly make it worse (especially insertional Achilles pain). The reasons behind this are explained through the work of Cook and Purdham (2012) who found compression on the Achilles (Pressing of the tendon against bone) often aggravates the problem. Interestingly, high levels of compression are created by performing traditionally prescribed achilles and calf stretches (pulling the foot towards the shin). Performing these types of traditional exercises may be the very reason why people have often developed long term achilles problems that frequently reoccur or have never got fully better. source
So why not carry out complete rest (as if often advised)?
Usually we avoid advising people to take complete rest. If possible, it is best in the initial phase to modify your activity type and levels in order to aid reduction in pain levels. Complete rest is often detrimental, we will explain this later on.
So what should I ACTUALLY do?
Well... firstly you need to manage the discomfort, starting by modifying your loading habits (activity type, volume, intensity and frequency) and avoid periods of tendon compression. Recent research by Rio (2015) suggests mid-range isometric holds (muscle contractions where the muscle length stays the same). This can also be a successful adjunct to aid reduction in pain. Once the discomfort is manageable, the mainstay of the treatment is to improve the load capacity of the muscle tendon unit. source
So the next question... How do I improve the load capacity of the muscle tendon unit?
There are various schools of thought as to how to achieve this through specific loading exercise programmes. Since the work carried out by Alfredson in 1998, eccentric (tendon lengthening under load) ‘heel drops’ there has been a recent move towards advising a combination of both eccentric and concentric (tendon shortening under load) strengthening exercises (Silbernagel, 2007, Beyer, 2015) and ‘Heavy Slow Resistance’ exercise programmes (Kongsgaard’s, 2009). However, the jury remains out on whether concentric or eccentric exercises (or a combination) are the most beneficial. It is widely thought and agreed amongst experts however that in order for the muscle tendon unit to build the capacity required for physical activity, heavy resistance is required. A good example of this can be found by looking at the requirement of an Achilles tendon. This needs to be able to absorb 2.5-3 times your body weight to manage the ground reaction forces that are generated when you are running. source, source, source
pERHAPS MOST importantly, it is essential that we exercise the tendon at ‘optimaL' levels SOURCE in order to improve the tendon’s load capacity. However, in trying to achieve this we also run the risk that if we do too much then we can create a detrimental effect to the tendon via excessive loading. The ideal scenario is therefore to do enough to improve the tendons capacity but not go over the top and injure it more so. Similarly, if we don't stress the tendon enough, i.e complete rest then this will reduce its load capacity even further! Dye (2005) SOURCE explains this very well with his ‘Envelope of Function’. This is an extremely important principle hence why we have blogged about it in the past (link).
Achieving the ‘optimal’ loading is often the trickiest part and the biggest challenge to get right. Therefore monitoring your pain and your load response to your exercises is vitally important! Push too hard and the problem can get worse, or not pushing enough will not allow you to return to a your chosen activity in an efficient timescale!