While there have been vast advances made in medical and research circles regarding the aetiology of Achilles tendon pain and dysfunction (Jill Cook & Craig Purdram being the leading lights in this field in recent years), there remains some debate about the best rehabilitation strategies for clinicians to follow.
It is a good example of how the phrase ‘evidence based practice’ could be replaced with the term ‘evidence informed practice’, allowing for clinicians such as physiotherapists to merge the research undertaken by international experts with their own clinical experience of quite simply ‘what works for the patient’.
The reality for physiotherapists working in a private setting with elite athletes and office workers is that clients like to see an improvement in their function and reduction in their pain levels from the first session. The importance of educating the client as to the causes of their tendinopathy, their role in the rehabilitation process, and the management options available to them are all crucial in establishing a good clinician-client relationship, and one in which the patient understands that they can influence their pain, and their outcome.
In this regard, I find that my practice has changed considerably over the past fourteen years – I now emphasise to the patient with an overuse injury such as an Achilles Tendinopathy, that what I do with my hands during the 30/45minute treatment session is of less importance than their role, as they are looking after the tendon for the remaining 167 hours of the week!
I have found that clients are enthusiastic to learn that they have considerable influence and control over the outcome of their injury, once factors such as biomechanical overload etc have been explained to them. This has led to a much more successful rate of recovery for Achilles tendinopathies and other overuse injuries at the clinic.
Examples of the client role in rehabilitation of Achilles Tendinopathy:
Wearing appropriately supportive footwear at all times
Athletes and runners can understand that they need to wear appropriate runners during their sport, however it is important that the overload component of an injury such as Achilles tendinopathy is considered with regard to their day-to-day activities also. For this reason, when they consider how many steps they take during day-to-day activities, the load taken through the Achilles tendon is cumulative. So it makes sense to wear appropriately supportive footwear all day – not just when they are doing their sport – in many cases this involves banning some leisure trainers and pumps! As a clinician, it is important to see what the client is wearing on their feet in day-to-day life as well as their sporting footwear. Ban those pumps and flipflops!
For those with desk jobs who consider it acceptable to wear high heels because they are sitting most of the day, it is worth pointing out that the calf and tendon are in a shortened position (plantarflexion) in this position, which is not ideal for the tendon recovery.
The role of ice/cold therapy
It is widely accepted that Achilles tendinopathies are slow to heal due to the blood supply to the tendon being poor. The application of ice is therefore not indicated in general to an area where there is a chronic degenerative process at play, such as Achilles Tendinopathy. However when a person goes for a walk, sits down for a while afterwards and then finds their Achilles is stiff when they go to stand up again, one could clinically reason that the walking has caused an acute inflammatory reaction in the tissues, and in this instance, the application of ice directly after the walk (with the tendon in a mid resting position) may break this cycle, preventing the stiffness when they go to stand up.
When clients understand this, it can become easier to understand that it only makes sense to apply ice to the area after an episode of overloading the tendon -when the possibility of an acute inflammatory reaction is taking place on the background of a chronic degenerative process.
While not every client will tolerate or wear a night splint, in those who complain of significant morning symptoms, the use of a neutral/dorsiflexion night splint can help to prevent tendon shortening overnight, and can contribute to a speedier recovery. I explain to clients that it may contribute 10% to the overall recovery, but all of these 10%s add up!
It is generally accepted with an overuse injury, that if you feel the pain during your sport only, then it can be acceptable to continue the sport while working on your rehabilitation at the same time. If the pain is affecting your day to day activites outside of your sport (eg walking to the shop), it may be more important to take a rest period from your sport. Your physiotherapist will advise you on this.
In some cases, you could consider cycling to work instead of walking, in order to reduce the cumulative load on the tendon that we mentioned earlier.
Eccentric exercises have long been acknowledged as the ‘gold standard’ of tendon rehabilitation. “Daily eccentric training for Achilles tendinopathy is a safe and easy measure, with beneficial effects on the microcirculatory tendon levels without any evident adverse effects in both mid‐portion and insertional Achilles tendinopathy.(2)” Examples of eccentric exercises can be started at a low-level for the client (ie heel raises lowering slowly to ground level with tibialis posterior firing) and then progressed to single heel raises, and the range increased with heel raises and drops over the edge of a step. We also use balance discs, gait re-education drills and reebok steps to vary the eccentric exercises prescribed. Use of an AlterG treadmill and a pool based programme can be great to add variety to a graded exercise programme also, where the client can regain the sense of painfree function in their Achilles.
Overall, it is evident that the management of an Achilles tendinopathy is multifactorial in nature, and that each physiotherapist will combine their knowledge of the latest research with their own clinical knowledge and experience. For this reason, while each physiotherapist may treat a tendon injury differently, the multifactorial nature of the condition allows for this. Sound clinical reasoning and a thorough understanding of the client’s behaviour/tasks in day-to-day life as well as during their sport are essential to prescribing an individualised management programme which will lead to the optimal outcome.
2. Br J Sports Med. Jun 2007; 41(6): e1–e5.
Published online Nov 24, 2006. doi: 10.1136/bjsm.2006.030437
PMCID: PMC2465326 Eccentric training in Achilles tendinopathy: is it harmful to tendon microcirculation? Karsten Knobloch
Photo Credit: teamworkshealth.ca