Achilles Tendon Injury – What Rehab is Forgetting
The Achilles tendon is at risk of injury with high load. Runners have a 15 times greater risk of Achilles rupture and 30 times greater risk of tendinopathy than sedentary individuals.
The Achilles tendon is the thickest and strongest tendon in the body. The three calf muscle attach to the heal via the Achilles tendon.
“Overcoming what was deemed impossible is what I will take with me and cherish the most…That (coming back from injury) will be the number-one thing that stands out because I wasn’t even able to walk.”
– Donovan Bailey (Olympic 100 m sprinter talking about his rehab for his Achilles tendon rupture). After rehab he ran sub-10 seconds for the 100 metres.
Out of the 5 clinicians in Sports Physio Ireland, two of us were unfortunate to have suffered Achilles injuries. Myself a partial tear and Joey Boland a tendinopathy. Depending on the severity of the injury the road to recovery is slightly different. The outcome of rehabilitation is positive, however, with us both returning to our representative sports. The partial tear taking slightly longer to adapt to return to play.
Overuse Achilles tendon injuries (tendonopathies) can arise with increased training volume or intensity. This happens because the load is too much for the tendon to withstand. Decreased recovery time between training sessions may also be a factor. The combination of stiffness (especially in the morning) and pain at the back of the heal is a key sign of Achilles tendinopathy. Pain often reduces during activity and may be pain-free during training only to come back with a vengeance a few hours later. Continuing to train through this causes the structure of the tendon to weaken and puts you at an increased risk of rupture.
As well as looking at injury to the Achilles itself, it is important to determine the causes of the injury in the first place. Injury is often linked to calf tightness or weakness and ankle joint stiffness. Abnormal lower limb biomechanics has been shown to cause torsional stress through the tendon. Weakness around the ankles can cause a whipping like action on the Achilles. A change in playing surface or footwear or poor footwear should also be considered.
Tendons take longer to adapt to training due to their poor blood supply. Rehabilitation takes longer than muscular injuries and is generally in excess of 3 months. Rehabilitation should include loading the tendon appropriately and correcting of predisposing factors that were linked to the injury. Progressing to plyometric and sports-specific activities when the ability to withstand load increases. `
When running approximately 5 times your body weight goes through your foot as you land. The Achilles needs to be strong enough to withstand this force before you go back to running, jumping and landing. Rehabilitation often does not put enough weight through the structure during closed change activities before progressing to running. Heal raises with 15-20 kg, Reverse lunges with greater than 20kg, Squats of greater than 20kg and SLDL of 20 kg should be a realistic expectation for everyone before returning to play or their chosen activity. Distributing the weight through two separate dumbbells makes this achievable for those who struggle with upper body strength. When thinking about the high level of repetitive load that goes through the body when running these weights are not that heavy and are what the body needs to adapt.
Soft tissue therapy including mobilisation and fractioning across the tendon are useful in improving the glide of the tendon in it’s sheath. As stickiness around the tendon is often associated with injury to the tendon.
Return to activity should be gradual.
Activity should be resumed only when local tenderness has settled and weights during rehab exercises achieved.
If long distance running is not the main aim then I would argue that the repetitive loading of that nature should be avoided. If sports are the main aim then interval running should be the focus. This is the nature of the activity they are trying to return to and also allows the tendon brief recovery periods.
MISCP, MSc Sports Medicine
Check out our social media