What is better to stretch or strengthen an Achilles' tendonosis? In the literature recent evidence suggests a form of strengthening is the key to a long term solution to this common ailment.

In the case of an Achilles’ Tendonosis this condition is considered a degenerative process unlike an Achilles' tendinitis that is looked upon as acute injury with inflammation in and around tendon region requiring rest, gentle range of motion and taking antiinflammatories. The approach is very different when treating a tendonosis that requires a very different approach.

In the case of a Achilles' tendinosis the injury is related to degeneration of the collagen and loss of blood supply to be the main reason for pain and weakness in the region of the mid portion or attachment of the Achilles' tendon. In a true tendinosis antiinflammatories typically don't improve the condition significantly because of the lack of inflammatory factors in the tendon and when improvements are experienced it may be time or the influence of the placebo effect.

Do we Stretch or Strengthen with an Achilles' tendinosis?

In the case of an Achilles tendinosis the recent research shows that there is greater evidence for strengthening or loading the tendon in a safe progressive manner especially in injuries lasting longer than 2 to 3 months. In addition, it is essential to avoid complete rest for the Achilles tendons because of the potential further weakening of the tendon from lack of activity and loading of the tendon. We want our patients to engage in strengthening activities that maintain the general strength of the lower extremities without excessive loading the Achilles' tendon.

All in all you may engage in stretching of Achilles' tendon and calf musculature as long as it is tolerated but more evidence points to strengthening being the key component to safely returning to your activities.

What strengthening do we start with?

In the beginning we will begin with gentle isometric exercises that can also lessen the pain and allow the patient to become more active. Isometrics are a form of exercise that causes a muscular contraction that can load the tendon without any movement of the associated joints. It is often a safe start for many patients and helps gauge the tolerance of the tendon moving forward.

Isometric exercises performed at the calf and through the Achilles' tendon can provide pain relief which allows many another strategy to avoid the use pain medications or antiinflammatories. In the case of antiinflammatories they have been shown to inhibit the ability of develop new collagen in the tendon delaying or stopping its recovery. It is not clear why isometric exercises have this effect but appear in many cases help reduce tendon pain. One of the common prescriptions is do daily loading of the tendons for 6 x for 45 second hold with one minute rests in between reach repetition. In cases of a "true" tendinosis if we have the correct load of the tendon we should first notice pain and each repetition a decrease in pain levels. It is safe to have mild discomfort but not excessive pain during or after the completion of these exercises.

We are going to provide three types of exercises you will see prescribed in early phases of physical therapy for a tendinosis. In later stages we will advance to both isotonic, eccentric to plyometric exercises for a return to the patients goals of activity. Those exercises will be covered in future videos. In certain sports having greater flexibility will help in the performance of their sport but it all depends on the demands of that sport. Engaging in light stretching in many cases will not reduce the benefits of the strengthening exercises.

Here are the three Isometric Exercises in order of degree of difficulty:

(1) Standing Bilateral Heel Raise with two up
(2) Standing Bilateral Heel Raise with two up and one down hold
(3) Standing Unilateral Heel Raise with raising up and holding on one
• All exercises should be done 6 x 45 seconds 12 daily depending on tolerance.

What are signs of improvement?

In 23 weeks we should see a few things to tell if we are seeing progress. First, we may see changes in our strength, endurance and later less pain during the performance of the exercises. I will also provide functional baselines to help the patient gauge their progress. Those include comfort with a bodyweight squats, stair climbing, distance walking prior to onset of pain, or degree of discomfort after standing or sitting for extended periods. All these baselines can give the patient cues on whether they are improving and will increase the compliance. Simply the absence of pain does not always indicate a patient is able to return to a certain activity.