What can I do about Achilles Tendinopathy?

Achilles tendinopathy is a common cause of pain in the back of the heel, especially in runners. Although it can be persistent, physiotherapy can improve pain and get you moving again! Here we’ll discuss degenerative (chronic) Achilles tendinopathy and what to do about it.

Achilles tendinopathy is primarily an overuse injury of the Achilles tendon. There are 3 different stages of Achilles tendinopathy which have been described as a “continuum” in the research, rather than 3 completely separate stages.

Reactive tendinopathy refers to the early stage of tendon injury. This progresses to tendon dysrepair if the load on the tendon is not reduced (e.g. if you continue running with a painful tendon).

Over time, with more overloading and no treatment, the problem develops into a degenerative tendinopathy. The actual structure of the tendon is changed, the fibres are no longed aligned and so the tendon is weaker and unable to withstand as much force.

How do I know if I have degenerative Achilles tendinopathy?

This tends to occur in older athletes (over 40’s), but it can also occur in younger runners with a history of chronically overloading the tendon (e.g continuing to run on a painful tendon for several months). It tends to be present for 3 months or longer.

Degenerative Achilles tendinopathy tends to come on gradually - so you may have had a “grumbling” Achilles tendon for a few months, or even years. These tend to worsen slowly with time, especially with more running and overloading without appropriate treatment.

Some people will start off with occasional Achilles pain with running, that progresses to pain with every run, and in severe cases, sometimes pain even with walking.

Try taking a picture of your Achilles tendon from behind (or ask someone to help you with this). Often with degenerative tendinopathy, the tendon appears thicker. Sometimes you can also feel small nodules within the tendon.

Why is it important to treat this properly?

You may be wondering if it’s easier and best just to stop running and try to forget about the tendon problem completely.

While rest may help to reduce the pain, it is unlikely to resolve the problem completely once it has got to the degenerative stage. The tendon structure has changed, and is weaker as a result.

Stopping or reducing running may improve pain, but it will not strengthen the tendon. Walking around on a weakened tendon leads to a risk of Achilles tendon tears.

In advanced cases, there is a risk of rupture of the tendon (where it tears completely) - often resulting in surgery and between 6-12 months of rehabilitation. We have seen this occur in patients just from taking an inconspicuous step off the pavement - because the quality of the tendon is so poor and the strength is so little!

What to do about degenerative Achilles tendinopathy

By the time the tendon has got to the degenerative stage, some of the changes that have occured are irreversible. However, physiotherapy has been shown to help improve pain and may even decrease some of the thickening of the tendon.

Step 1: Check for any reactive tendinopathy

First of all, it’s important to make sure that your Achilles problem is purely degenerative. Sometimes you can have a reactive tendinopathy alongside a degenerative one. This is mainly because only parts of the tendon become degenerative (think of them like islands of degeneration) whilst other parts remain fairly “normal”.

If you have had a sudden flare-up of Achilles pain, often in response to a change or increase in your training, you may have a reactive tendinopathy. It is important to treat this first and make sure it has settled down before starting rehab for degenerative tendinopathy, as the exercises are different. Have a look at our previous blog on treatment for reactive tendinopathy.

Step 2: Reduce the load

By this, we don’t mean complete rest. Rest will actually continue to weaken the tendon, which may go on to cause further problems. It’s about doing less - not nothing.

This may mean reducing your running speed or distance, or reducing the frequency of the runs that you complete and having more rest days. Try to avoid hill running where possible as this puts more strain on the tendon.

If you run a few times a week it may be helpful to replace 1-2 of these with a different activity, such as cycling or cross training.

Unlike reactive tendinopathy, it has actually been shown that it is okay to continue running alongside your rehab exercises for degenerative achilles tendinopathy as long as the pain levels are reasonably low.

This study found that there was no significant difference in the rate of improvement of Achilles tendinopathy pain if patients ran alongside their rehab programme, as long as the pain when running was no more than a 5/10 (where 0 is no pain and 10 is the worst pain imaginable) and the pain subsided by the following morning.

Step 3: Eccentric strengthening exercises

One of the most important exercises for a degenerative Achilles tendon problem is eccentric strengthening. Eccentric means lengthening of the muscle and tendon under tension. In this instance, slowly lowering down to the floor from being on tip toes, rather than just dropping down. Eccentric strengthening can actually help to re-organise collagen structure in the tendon, making it stronger and giving it the ability to withstand more load.

Before starting these exercises, make sure there has been no recent flare-up to your symptoms, as this can be a feature of a reactive tendinopathy. You may find these exercises make the pain worse rather than better in this case.

Exercise 1: Straight leg

Standing with your heels hanging over the edge of a step. Raise up onto your toes with both feet.

Then lift the good foot up (make sure you are holding onto something!) so you are standing on your toes on your injured leg.

Slowly lower your heel over the edge of the step.

Repeat 15 times, or build up to this as you feel able.

Exercise 2: Bent leg

This is exactly the same exercise as above, but completing with a bent knee.

This targets a slightly different muscle, the soleus, which is part of the calf muscle feeding into the Achilles tendon.

Repeat 15 times, or build up to this as you feel able.

How many should I do?

The original research on these exercises recommends 3 sets of 15 repetitions of each exercise, twice a day. However, this is 180 repetitions a day in total and for many people with degenerative Achilles tendinopathy, this will be too much for the tendon and cause a lot of pain.

Some pain during the exercise is okay - this is a sign that the tendon is under some stress. However, this needs to be a manageable level - think 5/10 at a maximum during the exercises, and for 24 hours afterwards.

This may mean starting on 3 sets of 5 for both exercises, and when you are able to complete these with minimal pain, progressing to 3 sets of 10, and so on. You may even need to start off by keeping both feet on the step to lower your heel if your Achilles tendon is very sore. We would always recommended doing what you feel your body can tolerate.

Be aware that you may find these exercises harder on days where you have been active and on your feet more - as the tendon has already been loaded during the day. You may need to reduce the amount of repetitions of the exercises you do on these days.

How long do I need to continue the exercises for?

The original research for these exercises suggested 12 weeks of completing them every day to improve symptoms. This follow-up study found that nearly 90% of patients were back to their previous activities a couple of years later after completing the 12 week programme. Not only that, the tendon thickness had decreased significantly and the tendon structure looked more normal on an ultrasound scan.

This study compared a “do as tolerated” programme with these exercises for 6 weeks and compared it to the original programme, completing 3 sets of 15 repetitions, twice a day. There were no differences in pain scores at the end of the 6 weeks between groups, suggesting that it may be enough to just complete what you feel able to, within your pain limits.

However, some people may find they need to continue exercises long term to maintain the tendon strength and prevent problems from resurfacing. It’s always a good idea to have an assessment with a physiotherapist to determine what is best for you to be working on.

There are more recent studies on heavy resistance strength training. This involves using gym equipment such as a seated calf machine, leg press and barbells. This has been found to be an effective way to improve Achilles tendon pain and strength, and involves training 3 times a week instead of every day.

This is only suitable for stronger tendons, and may be something you are able to progress to when your tendon is ready. Speak to your physiotherapist about getting a programme set up in the gym if you have access to one.

This is absolutely not written to substitute medical advice and it is always important to see a qualified health care professional for a formal diagnosis. If the exercise cause pain during or after completion, discontinue and consult a physiotherapist.

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