The Achilles comes second only to the knee in the list of most common running injuries and it's one which often has a big life impact in terms of preventing us doing the activities we love. Uncertainty over what activity could lead to further damage to the tendon and whether rest is required are also very common and sometimes prevent effective recovery.
The Achilles is the largest and strongest tendon in the human body and connects the calf muscles (gastrocnemius and soleus) to the heel bone. It lifts the heel off the ground, transmits force into the ground in the push off phase of the gait cycle and absorbs force, which can be many multiples of body weight, in the landing phase of the gait cycle.
The Achilles tendon is a really resilient structure and when injured it usually responds positively to exercise and loading at the right level. Finding that sweet spot which balances the tendon’s current capacity for load and the loading placed on it through a combination of exercise & activity, a rehabilitation programme and daily life is key for recovery.
The return to activity is probably not going to be without setbacks, as Achilles tendons can be quick to aggravate and slow to settle. It will also require a commitment to a doing some hard, possibly painful, and quite time consuming exercises for long enough to make a change to the tendon’s load capacity (probably about 3 months) followed by ongoing awareness and management of how much stress or load is being placed on the tendon.
Causes
It’s not 100% clear what causes Achilles tendon issues but it is often linked to changes in tendon load, maybe after returning from a break in activity, or increasing speed or uphill running or wearing footwear with less cushioning and a low heel drop. It's more common in men than women, and links have also been found to reduced ankle dorsiflexion (lifting toes) and low calf muscle strength.
Signs & symptoms Pain often starts as a stiffness in the calf and Achilles tendon, initially first thing in the morning or for the first few steps of the day, which wears off quite quickly. This pain
can be at the point where the Achilles meets the heel bone or higher up towards the calf muscle. This is often accompanies by tight calf muscles and maybe by increased difficulty lifting toes up. Squeezing the tendon along its length or pulling it to the side will highlight if there is a most painful area. At the stage where the first signs of soreness are noticed it's likely that its just the outer layer of the tendon, a sort of elastic sleeve around the tendon known as the paratendon, which is inflamed, and management at this stage is much easier than when then tendon itself has become affected.
As the injury progresses the tendon fibres themselves first become inflamed and then their structure and arrangement starts to break down and spread apart. The space between them is then filled by a watery substance which leads to swelling of the tendon and pain then starts to affect running and other activities. An acute injury is a “reactive tendon”; the result of loading in excess of the tendon’s capacity. When the issues have been there for a while the injury is chronic; a “degenerative tendon” which can be managed but can be quick to aggravate into a more reactive or acute state resulting in pain and loss of function.
Assessment & Treatment Treatment of the Achilles requires loading via exercises which will feel hard, and maybe painful. This stresses the tendon fibres the right amount for that individual’s tendon capacity to effect regeneration within the local cellular structures of the fibres and also to build strength in the whole leg/hip kinetic chain to support the tendon better. Exercises should get harder every 2-4 weeks in a 12 week process which needs to be seen through to its conclusion for the best possible result.
An assessment needs to be very individual to determine what level of load and type of exercise is appropriate for that tendon’s capacity and to then respond in line with changes seen in the tendon. Depending on the initial capacity of the tendon exercises might start with isometric loading (muscle contraction without moving) such as a 45s calf raise, or slow eccentric loading (muscle loading as it lengthens, on the return against gravity or resistance) such as a calf/heel drop where raising onto tiptoes has been done with as little work as possible (eg by using the other leg) and then the heel is slowly lowered. The level of loading can be progressed by moving from double leg to single leg exercises and then adding weight (wearing a weighted rucksack or carrying a dumbell/kettlebell) as the rehab programme progresses.
What role can sports massage play in recovery?
Sports massage can play a helpful role in reducing calf tension when stretching the calf may aggravate the tendon. It can also promote tendon repair through a technique called Deep Transverse Friction on the tendon itself and optimise foot and ankle mobility to help these structures work with the Achilles tendon to absorb shock and load effectively.
Returning to activity It is possible to keep running or doing other activity while doing a rehab programme as long as it is managed so as to try to avoid tipping the tendon into an acute, reactive phase from which it will potentially be slow to settle. Any pain during exercise should be lower than 4/10 on a scale where 4 is uncomfortable (0 is no pain, 2 is annoying, 6 is dreadful, 8 is horrible,10 is agonising). It's also important that pain doesn’t increase during an activity or or a week (even if it is below a 4) so if it starts at 2/10 and increases to 3/10 its time to stop and dial back activity levels to one which is within the tendon’s capacity at that time. Build back up again slowly. Again any assessment needs to be individual to build up a picture of what load the tendon has been under and what might be provocative activities such as fast runs, or back to back run days and what activities are tolerated eg a 5k easy run might be painfree. Managing this load to avoid aggravating the tendon will help the effectiveness of the rehabilitation and then load can be slowly built up again.
Looking at the whole body
While exercises need to prioritise the calf and achilles any assessment should look at the whole leg/hip kinetic chain as our glutes and quads should play a significant role in working with the achilles to absorb ground force and any weakness in these may be contributing to the loading being placed on the Achilles. Exercises such as a calf wall squat, or a calf hip bridge target the calf muscles but also the quads and glutes respectively meaning they may be useful additional exercises.
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