The Achilles tendon is a strong fibrous band of elastic tissue which connects the Gastrocnemius and Soleus (calfs) to the Calcaneus (heel bone). The Achilles is a primary load bearing tendon, capable of taking up to 12 times the body weight. This can cause some issues when the tendon is injured as it is difficult to rest, and when in use takes excessive forces which can easily re-injure the tendon. Therefore Achilles injuries can sometime be prolonged, and have reoccurring flare ups which is often frustrating to deal with.
Like most tendons in the body the blood supply is rather poor, so essential nutrients to facilitate healing are delivered slowly to the injury site. This is often results in,
- abnormal collagen structure (collagen is the fibre like structure of a tendon)
- poor healing response
- absence of inflammation (inflammation is important as it starts the healing process)
This abnormal healing response is termed a tendonosis, and is often confirmed via ultra sound or MRI.
Achilles tendinitis can manifest in numerous ways, from rapid sudden onset of pain, which can be severe and immediately debilitating. Or can progress insidiously from a dull ache into a chronic persistent pain.
The tendonitis may be the result of a Gastrocnemius strain, poor bio-mechanics through the ankle and knee complex, hypermobility of the tibia – calcaneal joint (fancy name for ankle), or from an increase in training volume and or intensity.
During the acute phase of a tendon flare up basic first aid for a strain is appropriate. Rest, Ice , Compression, Elevation. Control of swelling is important, and non weight bearing may be appropriate to de-load he tendon during the initial acute phase. This will generally last 24 – 36 hours. At this point soft tissue therapy can be very useful to facilitate the healing response, mobilize the ankle joint, and rearrange collagen formation along normal fibre make ups. Physiotherapy, remedial Massage and acupuncture can be particularly good at this stage.
Exercise rehab will be an integral aspect of return to normal activity. Often people mistake a “fixed” structure for pain free. This cn be misleading as although there may be absence of pain, the soft tissue structures may not have the structural integrity to handle the forces going through them. keep in mind the Achilles is the greatest load bearing tendon in the body, therefore it must be brought up to an equivalent strength to match the demands of the activity. In average people this may be just enough to walk about, get up the stairs at work, or press down on the accelerator whilst driving. If however you are engaged in exercise, sport or a fairly physical job then pain free just wont cut it, this is where we want functional training, so the tendon can meet the demands of the activity/sport.
A comprehensive assessment should be conduct to try to discern the predisposing factors that caused the Achilles tendinitis things like an excessive pronation, tight soleus, hyper tonic Posterior compartment, poor knee alignment, weak calf group, incorrect footwear, and poor exercise technique.
Once the acute inflammation phase has abated, then exercise protocols may commence. Initial exercises will center around maintain good joint range of motion, mobility across the tibia – calcaneal joint, and low intensity strengthening exercises. It is important not to over stress the structures, healing rates and remodeling of tendons can take some time, up too 12 weeks for integrity to hold, and then 12 months for full maturation of new tendon fibres. Take home message here is patience will be paramount.
At this point we want to start to develop good strength in the calf group. The exercises will need to be graded progressively so adaptation is facilitated. Go too heavy and you run the risk of damaging the tendon again, go too light and progress will be slow and frustrating. It is difficult to put time frames on this process due to large individual variance, so it requires carefully monitoring.
One of the first goals should being able to perform unilateral calf raises, as in taking the entire body weight onto a single leg and rising up onto the toes. Performing this exercise pain free is a great indicator that your heading in the right direction. The inclusion of eccentric loaded exercises should be introduced slowly, such as slow heel drops off a step. This type of exercise produces the best strength gains and is a must in any rehab program for Achilles issues.
Some ankle-knee-hip strategies should be introduced at this point. These are simple exercises that develop natural movement patterns across the ankle. additionally they challenge the neural control at the ankle joints, and within the muscles. The proprioceptive control at this time is very important as the nervous system effective allows effective movement control. A strong muscle is pretty useless unless the neural firing patterns are working optimally
This is where we start to translate our rehab into real world activities, that is to replicate what someone does in their normal activities. This will undoubtedly include some kind of jumping protocol, to elicit the stretch shortening cycle of the tendon. This is where the tendon is lengthened under tension (stretched), and then released into a strong concentric contraction. There is alot of stored energy within the tendon during this cycle, and due to its rapid nature places a lot of pressure on the tendon. Exercises like skipping, hopping, running on the spot on toes, box jumps, lunges all produce this stretch shortening cycle, and are thus very handy in the rehab process
If we add a speed, and resistance component to these exercise we get plyometrics, which is where we should to get too for a effective rehab protocol. essentially during a plyometric movement we are producing the greatest tension on the tendon, so if our rehabbing client pulls up fine after a strong plyo session we can be confident that they have recovered optimally. At this point we can then add sports based drills, such as shooting basketballs with a jump, agility drill for rapid change of directions and challenging balance work to facilitate good neural control.
Ok folks, here is a sample Achilles rehab program I would use in a transition from strength into plyos.