How to treat achilles tendon pain. In order to rehabilitate an Achilles tendinopathy or tendinosis for runners and nonrunners, we need to be focused on the patient’s goals as a means to set expectations and ensure the best outcome. In this video, we discuss how to properly progress a patient to minimize setbacks in the rehabilitation process.

0:00 Introduction of Achilles tendon and tendonosis
0:44 What is a tendonosis and understanding the achilles tendon function
3:05 What are the risk factors for developing a Achilles' Tendonosis
4:41 Research on Tendons
6:50 Other types of tendonosis
7:36 Phase 1 Isometric and Pain Relief Phase
9:54 Isometric Exercise Demonstration
12:54 Phase 2 Strength
18:35 Energy Storage and Plyometric Stage



What are the First Steps to Take in the Rehabilitation Process?

STAGE 1
Isometric and Pain Control Phase
We must reduce loads on the tendon depending on irritability of the tendon. Each patient is different in the current activity levels leading up to starting rehabilitation. Since tendons quickly lose their strength with complete rest, we have to minimize this at each stage. While performing an isometric exercise, there is no movement in the joints surrounding the target area, but the muscles are in a contracted state for a set period of time.

During this phase, the goal is to reduce pain and introduce a load to the Achilles tendon and gastrocnemius complex. We start with isometric loads of 5 x 45 seconds, 12 daily for 12 weeks. We load the gastrocnemius at full knee extension, then the soleus at 90 degrees of flexion at the knee. If we have the correct isometric load, the patient may have pain initially and then it should lessen as you continue acting as an analgesic.

STAGE 2
Strength phase
We focus on strengthening from concentric to eccentricfocused loading of the Achilles tendon, kinetic chain strengthening and endurance work.

Once pain is under control, we enter into the strengthening phase, where exercises are performed in a progression from partial bodyweight, bodyweight, or bodyweight plus external resistance (like a dumbbell or using a leg press of 23 sets of 15 reps slow high load 3 seconds in then on concentric phase, then pause, then 4 seconds for eccentric phase 23x/week for a period of about 28 weeks.) A few examples of exercises in the phase would include: Heel Raise 2 legs knees extended (Gastrocnemius) and Heel Raise 2 legs knees flexed at 90 degrees (Soleus), Stepups, Lunges, Squats, Romanian Deadlift, etc.

STAGE 3
Energy Storage and Plyometric Exercises
During this phase, we progressively increase to more dynamic from double to single leg loading from varying speed, heights and distances. During these times, we are typically using bodyweight and eliminating any additional load due to the high forces experienced on the Achilles tendon. In this phase, we need to maintain a strength component while introducing these “return to sport” exercises.

We base our projections on the work of Baxter, et al that looked at various types of exercises and the amount of load applied to the Achilles tendon to give guidance to practitioners when developing a systematic loading progression for their patients’ treatment plans. A few examples of exercises in the phase would include: Hopping 2 leg, Forward Hopping 2 leg, Forward Jump 1 leg.

During Stage 3, you should be starting to return to your sport in a modified format. An example of this would be to start shooting baskets and doing drills, progressively increasing the speed and intensity of the drills. (For runners, we often suggest beginning with a walk / jog program at the local high school track which is typically ¼ mile in length.)

We begin with doing a light jog on the streets and walking the turns. This allows a test and some recovery. Depending on the type of runner, the starting distance is often somewhere between ½ mile to a mile . We begin to use a very conservative distance to establish a baseline from which we can build. I also recommend not running two days in a row in the early phases of your return to running or jogging. In the population of runners that are returning to sprints, the progression takes a little longer because of the intensity and force applied to the tendon with sprints, especially those that have quick changes in direction like trail runners.


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