How to treat Achilles tendinopathy
Tendon injuries are complex and are often managed too simplistically.
Effective treatment for Achilles tendinopathy must take into consideration the following issues:
- Tendon structure
- Pain
- Function
Treatments which only focus on trying to change a tendons structure and reduce pain will not restore tendon function. For example, adjunct treatments such as injection therapy, acupuncture, laser treatments or rubbing the tendon will not reverse degenerative changes in a tendon or restore function.
Therefore, in order to eliminate pain and improve function, the tendon must be exposed to progressive load through exercise. Hands-on interventions can be useful to dial down pain but their effects are usually short term.
Why does my Achilles tendon hurt?
More than likely, the loads have exceeded what the Achilles tendon can tolerate. In other words, you have done too much too soon or changed your activity too quickly which hasn’t allowed your tendon the necessary time to adapt to those loads.
My scan indicates that I have degenerative changes
Do not worry about tendon structure - research clearly indicates that we cannot change the structure. Degenerative changes that are often seen on a scan are often present in the asymptomatic population and will still be there long after you have recovered.
On a positive note, there is still plenty of good tissue in an injured tendon which will enable the tendon to become stronger and adapt so you should not be frightened to load your tendon.
How should I treat Achilles tendinopathy?
Firstly, do not rest a tendon. Tendons need load in order to maintain structure which is why loading a tendon is so beneficial.
Rest will result in:
- Loss of tendon structure
- Loss of function
- Change brain function
Treatment should consist of a staged loading program.
This may involve:
- Unloading the tendon initially to settle the pain i.e. cutting back on volume, frequency, and intensity of activity.
- Gradually reload to the level needed for your activity. Your physiotherapist will be able to guide you on different types of exercises that expose the Achilles tendon to different types of loads which will be aimed at enhancing strength, energy storage and release loads, endurance and compression loads.
- When returning to a certain activity it is also important to listen to your body. If you are sore the day after performing an exercise, that means you have done too much and need to rest.
Should I see a Podiatrist or Physio?
Fundamentally, exercise and restoration of function is the key foundation in the treatment of Achilles tendinopathy so this aspect of treatment should be handled by a physiotherapist. Physiotherapists also have an in-depth understanding of tendons and tendon pathology and will, therefore, be able to guide you on what exercises are the most beneficial for your situation.
If there is any biomechanical involvement that may potentially be abnormally loading the Achilles tendon then seeing a podiatrist for further assessment may be beneficial.
Physiotherapists who understand what podiatrists do from a biomechanical standpoint will know when to refer to on and vice versa, but at the core, a staged loading program is the most critical part of the treatment plan. Failing to incorporate load will lead to poor outcomes and reduced tendon capacity.
Does manual therapy help my tendon?
The short answer is no.
Tendons are designed to transmit force between muscle and bone, so, therefore, treatment should be focused on loading the tendon period.
Examples of manual therapy include but is not limited to:
- Massage
- Rubbing
- Mobilisation/manipulation
- Dry needling
- Acupuncture
- Laser
- Shockwave therapy
- Injection therapy
Needless to say, these adjunct treatments may provide some short term pain relief and maybe useful in certain situations when used in conjunction with a loading program.
Why do exercises fail?
Let's face it, exercises aren't that sexy.
All too often when a person is in pain or cannot perform a certain activity this can make them potentially vulnerable to lower quality treatments.
Exercises will often fail for the following reasons:
- It's not new
- It’s slow
- It's low cost
Tendinopathies are not a simple issue. All too often people think that because there has been a reduction in pain that the treatment they are receiving is working. This is isn’t necessarily always the case.
In order for pain to improve, the tendons capacity to tolerate load must be enhanced. This will take time so you give yourself a minimum of 6-8 weeks for strength changes to take effect.
Also, be wary of weird and wonderful promises. Do not rely on quick fixes, recipe style treatments or treatments which attempt to “fix” or “repair” a tendons structure as no such treatments exist.
Key takeaways
- Tendon injuries are complex so treatments must be tailored to the individual.
- Do not rest a tendon. Rest will result in diminished tendon structure and strength. The strength of any tissue is only as great as the load placed upon it.
- Tendons respond extremely well to progressive load which leads to greater tissue capacity.
- Poor function = persistent tendon pain
- Restoring function = eliminates pain
- Find a physiotherapist who is up-to-date with the latest evidence who understands tendons, tendon pathology, and pain science.
- A physiotherapist will be able to help restore tendon function and eliminate pain by progressively loading the tendon using exercises.
- Foot and lower limb mechanics may play a role but will depend on the individual. A referral to an experienced podiatrist who is well versed in how loads affect the foot and lower limb may be beneficial.
- Manual therapies are not essential but can be helpful. If they are going to be utilised they should always be used in conjunction with a loading program.
Daniel Bagnall
Founder & Senior Podiatrist