Check out physiotherapist Liam Gellie demonstrating some isometric calf raises on this video
The Achilles tendon is one of the strongest structures in our bodies. It connects the calf muscles to our heels, and enormous forces pass through it in order for us to push off for walking, running or jumping. Whilst rupture is an occasional issue, tendon degradation is the most common complaint. Formerly known as tendinitis, we now call this process Achilles tendinopathy and it troubles a lot of walkers, runners, and, as it happens, commonly keen gardeners in the Dandenong Ranges.
Just as in our previous month’s article where fasciitis is now fasciosis, there is no inflammation in Achilles tendinopathy, hence no ‘itis’ suffix. Due to the natural paucity of blood supply in tendons, once they are injured they are unlikely to self repair easily or quickly. The good news is that there are many things we, as patients and physiotherapists, can do to assist the speed and quality of the recovery process.
An Achilles tendinopathy is a failed healing response inside the tendon where the damage caused to the tendon exceeds the repair that takes place by the body. This typically occurs to rapid increases in loads placed through the Achilles. For the athlete this is typically from an increase in distance, reduced rest days, or a change in training type or surfaces such as hills or softer ground.
Other Contributing Factors
Biomechanical factors contribute strongly to the cause. These include poor foot biomechanics or reduced calf and hip strength which can cause excess loading on the calf and Achilles, poor running or walking technique & incorrect or worn out footwear. Another contributing factor is when the Achilles or calf is shortened over time due to chronic muscle tightness, other injury or a history of wearing high heels.
Whilst a small heel lift (4-8mm) may be used in the early stages to aid relief, it should not be used beyond a 2-4 week period for most people as it can lead to chronic shortening, and worsen the problem in the mid-long term. Reviewing foot biomechanics and footwear, and the use of orthotics, is generally extremely helpful before returning to full activity and often in early stages.
Relatively new evidence new evidence that isometric exercise can reduce pain and maintain muscle strength in the early phase of rehab. Isometric exercise is where a muscle works against resistance without movement in a joint or muscle (static hold of position). Ideally the static holds should be aimed to be sustained for a period of 45 seconds and repeated 5 times with an adequate rest period in between sets (eg. 1-2 min).
Complete rest from activity is something that may have previously been prescribed for tendinopathy but has actually been shown to be detrimental. In the early stage when trying to settle the tendinopathy down reducing provocative activities, without cutting them out completely can be useful. The use of alternative training methods including cross training, (such as cycling, rowing machine, swimming, hydrotherapy, Yoga and Pilates) can also be utilised to avoid complete rest.
Dry needling is more effective than massage though both are helpful. Frictions (pressure technique used by physios) on the tendon itself is helpful to stimulate blood flow.
Stretching is something to steer clear of as this likely to place the tendon in a position that can aggravate. Instead try using a foam roller or massage ball to improve flexibility without stirring up the tendon.
Late Stage Rehab and Return to Activity
Load management is a key component of middle to late stages of tendinopathy rehab. Tendons can adapt to load given adequate rest time. In order to allow the tendon to adapt to load, changes to training needs to be done gradually while monitoring symptoms during and after exercise, usually 10% increase in training volume per week is a safe level to increase.
Concentric (against gravity) and eccentric (with gravity) calf raises can be excellent within pain free ranges, and progressed for speed, weight and range of movement but must be carefully implemented at the right stage of recovery in order to avoid flare-ups and regression of the injury.
What About Eccentric Strengthening?
Eccentric calf raise exercises, whereby the load is only maintained during the with-gravity stage (not against gravity), have been shown to be extra effective in battling degenerative Achilles tendinopathy. These are the more chronic cases or recurrent cases. Eccentric contraction allows for increased loading of the tendon with weight but cafe must be taken with gradual progression of the program, without flare-ups, to get back to full activity.
There are a host of more invasive interventions out there, all of which have some anecdoctal evidence but no strong peer reviewed evidence of efficacy. From our experience, they are hit and miss, with the injections often causing flare-ups. The creams are worth a try though. These include:
- Plasma rich protein injections (PRP) – blood is taken & spun for higher plasma content then re-injected into the tendon, attempting to stimulate an acute inflammatory healing effect and the healing response that should come with it
- Autologous injections – as for PRP except just the patients blood from elsewhere, not spun, injected straight into the tendon
- Glyceryl Trinitrate patches or cream (GTN) – similar to angina patches to stimulate blood flow into the tendon. Gives bad headaches to some people.
- Hirudoid cream – often used for bruises, haemorrhoids. Recently trialed with tendinopathies and some encouraging signs for early evidence.
Before starting your own rehab please get some advice from a physiotherapist first. A ruptured Achilles is an unlikely but real complication of a poor or overly eager rehab program! And there are likely to be inherent causes that need attention prior to any rehab or strengthening program for it to be effective. Don’t let your stubbornness or pride be your real Achilles heel!