How to rehab your achilles tendon
Tendon Treatments to Avoid & Why You Need to Load Your Tendon to Rehab It.
Runners in my experience tend to fall into the category of Achilles tendon pain or Patella knee pain.
Personally, I had an issue with my Achilles and following a few self-tests I figured I had two issues one was Glute Max not doing its job and the other was weak Posterior Tibialis. With a bit of focused rehab time and reduced volume I managed to get it solved pretty quick.
I’ve also had some clients over the years suffer with tendon issues, mostly pre-existing when they start, sometimes I’ve found it a bit of a battle to encourage them to avoid the injection route and instead be patient and follow an exercise-based approach.
Unfortunately, the big issue with this is patience. The other issue which I find surprising sometimes is the recommendation is coming from the clinician almost if the injection represents the only viable solution, however that’s just not the case.
I decided to do a deep dive into the latest science when it comes to tendons and effective treatment modalities. I figure a little knowledge can go a long way to making better decisions, my research took me in the path of perhaps one of the World’s most renowned research scientists and clinician’s Dr Jill Cook.
So, here’s the rub;
Tendon pain and dysfunction are the presenting features of tendinopathy. Treatment should be active (exercise-based) with a consistent pattern of rehab.
If you suspect you have pain or dysfunction don’t rely on MRI’s, Ultrasound or Palpation for diagnosis, the research shows more often than not present false positives. When using these modalities, more likely the pain is coming from another source.
The best indicators are if it is the tendon are;
1/ Is it localised pain which stays localised with load and
2/ Is there an increase in pain as you increase load on the tendon.
Interestingly the most effective tests were simple movements which place incremental loads on the affected tendon for example where the Achilles is concerned;
Double leg heel raise
SL leg heel raise
Double leg jump
SL hop
If on an RPE (rate of perceived exertion) you get pain towards a 10 (scale 1-10) then most likely you have a tendon problem.
If you do have or get pain the advice is don’t rest completely because rest decreases the load tolerance of tendons and complete rest decreases tendon stiffness within 2 weeks. Not only this but it decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain leaving the tendon less able to tolerate loads.
When beginning a tendon rehab programme begin with isometrics and progress to slow heavy resistance training and when pain is stable plyometrics can and should be included because high tendon load occurs when it is used like a spring such as jumping and running.
And since our end goal is a return to running, we need to be able to mimic the loads the tendon will experience, this is called force transfer which is important since it helps with rate of force development (RFD). Tendon springs must be loaded quickly to be effective.
Don’t rely on passive treatments either because they don’t increase the load tolerance of the tendon so stuff like electrotherapy or ice might alleviate short term pain symptoms but will not speed recovery.
This goes for injection too. At best they have only been seen to offer placebo effects in good clinical trials. The rationale is that the injection will return the tendon to normal. The research, however, says there is little need to intervene in the pathology of the tendon as the evidence is it simply adapts to the pathology and is quite capable of tolerating high load.
Injections may change pain in the short term and should only be considered when a good exercise programme has been followed. Obviously don’t ignore tendon pain and it’s best to reduce volume/training especially if it will cause more overloading due to excessive spring like movements such as running.
Avoid stretching because it only serves to add compressive loads which are not helpful. Equally avoid having it massaged especially letting the therapist use deep friction type of massage. This will more than likely increase the pain because the tendon is already irritated.
Finally take your time to rehab properly. Tendons need time to build capacity, so does the muscle, kinetic chain and brain. Long term the outcome is good when a properly prescribed exercise-based programme is followed in this order.
Isometrics
Slow heavy resistance and always done single leg and single joint.
Plyometrics for spring release.
Don’t be scared of load, you won’t hurt them, bands don’t work, you can push tendons quite hard and early on. The goal is to be able to perform 30 reps in sets of 4-5 at a time. Here's how to perform calf raises well.
You have it do it well, with control and be fatigued at the end meaning you shouldn’t be able to do the next set immediately.
How to know if you’re progressing well.
If after 24 hours your normal morning stiffness to the affected tendon is the same, then the tendon is happy. If it feels worse, it just means the tendon didn’t like the load or energy storage and release used (plyometric) therefore a more moderate load should be applied the next time.
Zero pain is a very hard place to get to so don’t try. It’s better to shoot for ‘stable’ pain. If you keep searching for zero it will take a very long time to return to sport.
This is not medical advice, neither am I suggesting you ignore the advice of a physio or sports doctor. I’m making you aware of what the latest and best research says so you can have a better understanding of what has been shown to work well.
Pain is your body’s early warning detection system, it should not be ignored, it’s telling you something is not working properly, and you are getting pain because the load has gone beyond capacity. Nothing breaks in isolation, so you need to figure out the weak link and rehab accordingly. Just because you have a tendon issue does not mean this is the problem.
Of course, the really smart thing to do is have follow a good strength-based programme which will reduce the risk of this happening in the first place.