Achilles Tendonitis can be difficult to treat with no single approach being effective on its own. We outline a step by step approach to treatment and rehabilitation.
Treatment for acute injuries includes rest and application of ice or cold therapy to reduce pain and inflammation. More chronic injuries may respond better to heat treatment with a strict 12-week heel drop exercise program which has been shown to be effective.
Decreasing pain and inflammation
We recommend seeking professional advice before attempting any self-help treatment. The aim of rehabilitation is to decrease the initial pain and inflammation, improve calf muscle flexibility and strength, re-establish joint coordination and gradually return to full fitness.
The first stage of treatment for Achilles tendonitis is to decrease pain and inflammation so normal daily activities such as walking can be done pain-free. This stage can last for anywhere from 3 days to several weeks depending on the severity of your condition and can be achieved with a number of methods:
Rest is very important. Achilles pain is one injury that you should listen to your body with and if it hurts rest it (unless you are working through the Hakan Alfredson’s exercise regime). If acute Achilles tendonitis is allowed to become chronic it can be very very difficult to cure.
Cold therapy can be applied for 10 to 15 minutes at least three times a day. Every two hours if possible for the first day then gradually reduce the frequency as symptoms improve. Ice can be used in a wet tea towel or reusable hot and cold gel packs are ideal as they are much less messy and can be used for applying heat later in the rehabilitation process. Ice should not be applied directly to the skin as it may cause ice burns.
Taping the Achilles tendon can help reduce the load on the tendon and relieve pain. Strips of elastic tape go from the top of the calf muscle and pass under the heel and can be beneficial in the early stages where the aim is to rest the tendon as much as possible as well as when returning running.
Place a heel lift or a heel cup of about 1cm into both your shoes to raise the heel and help take the stress off the tendon. Do not leave it there forever though, as the calf muscles may adaptively shorten over time and an increased strain will be placed on the Achilles tendon in the future.
Anti-inflammatory medication such as ibuprofen can be taken under a Doctor’s advice. This may help in the short term to reduce inflammation and pain of acute Achilles tendonitis although there is no proof long term the medication can help and may even inhibit healing.
Electrotherapy such as ultrasound applied by a professional therapist can also help reduce pain and inflammation and providing a micro-current effect on the tissues. Sports massage can help mobilize the tissues of the tendon and relax the calf muscles.
Identify the cause of the injury. Training too much too soon, training on hard surfaces, wearing the wrong shoes or shoes that are too old and not warming up are possible reasons for the injury occurring. Also, if you overpronate, the Achilles is twisted, putting more strain on it. Training habits should also be looked at. It is a good idea to keep a training diary so if you do become injured you can look back and see what might have caused it.
Once you can perform daily activities pain-free, move on to this stage. Concentrate on improving the flexibility of the calf muscles. This will help to reduce the strain on the Achilles tendon.
Stretching exercises – two calf stretching exercises, in particular, is important, one with a straight leg for the gastrocnemius muscle and one with the leg bent to target the soleus muscle. Stretching should be done regularly, three times a day initially and should be maintained long after the injury has healed to prevent the injury returning.
The plantar fasciitis night splint is excellent for helping to stretch the calf muscles and Achilles tendon. It is worn overnight and helps prevent the calf muscles from tightening up, something they are prone to do overnight. The Achilles is likely to be a lot less sore the following morning.
Sports massage applied directly to the tendon may help prevent adhesion’s forming within the tendon. These adhesion’s or ‘sticky bits’ stop the tendon sliding smoothly in its surrounding sheath. Sports massage can also be used on the calf muscles themselves to aid in improving the flexibility and general condition of these muscles.
Eccentric exercises have been proven to be very effective in the treatment of Achilles tendonitis, particularly chronic Achilles injuries. If the injury is a recent acute injury then rest is the priority until there is no pain.
If however the injury has become chronic and been around for weeks or months then beginning the Hakan Alfredson’s eccentric heel drop exercise program is advised. Eccentric exercises are those where the calf muscles get longer as they contract and involved dropping the heel down from a tiptoe position on a step.
Proprioception is the neural control or coordination of a joint. It is possible that the neural control or coordination of the ankle has been affected, especially if the injury has been severe and required a sustained period of rest. Using a wobble balance board or balancing on one leg is a good way of developing proprioception. This will help prevent spraining the ankle in the future and is a good all-round strengthening exercise for the ankle.
Returning to full fitness
When the patient has gone at least a week without pain and the range of motion at the ankle has improved then you can begin to return to training. If pain is felt when returning to training either during, after or the next day then stop.
Begin each training session with a walk to warm up followed by stretching. After training apply ice or cold therapy to the tendon for 10 minutes to help prevent inflammation from returning. Below is an example of a gradual build-up running program.
Day 1: walk 4 minutes jog 1-minute repeat four times
Day 2: rest
Day 3: walk 4 minutes jog 2 minutes repeat three times
Day 4: rest
Day 5: walk 3 minutes jog 3 minutes repeat 4 times
Day 6: rest
Day 7: walk 2 minutes jog 4 minutes repeat 4 times
Continue this gradual progression until you can confidently run and resume normal training. Gradually increase the duration of your runs. No more than 10% increase per week is the usual recommendation. If your sport demands sprinting then gradually increase the speed. Continue with the stretching and strengthening programs. It is important to do these even if you do not feel pain at this stage. Continue for at least three months. Continue to ice the tendon after training.