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Intro: What is Achilles Tendonitis?
Do you have pain behind your heel(s)? Especially with running or jumping? Even more so when going up stairs or an incline?
Did it perhaps begin as a mild ache or tightness and progressively worsen to sharp pains?
Is it possibly worse in the morning when taking those first few steps out of bed?
All of these things may be due to a tendon injury in the heel called achilles tendonitis.
As a physical therapist, I’ll say that this is a fairly common injury in people who do a lot of repetitive walking, running, or jumping throughout the day or while playing sports - or recently increased how much they were doing those things.
If you nodded your head to the questions above, I’m sure you’re ready to get over this injury and get back to feeling better. Let’s take a closer look at what achilles tendonitis is, what causes it, how to assess it, how to treat it, and cover what some of the best achilles tendonitis exercises are. It’s about time you get back to being active without feeling held back by the pain. (See Related: About Me)
Symptoms of Achilles Tendonitis
Let’s start by clearing the air. Throughout this blog I will use the term tendonitis (also spelled tendinitis) as that’s most widely recognized. But to be technical, this injury is actually supposed to be called achilles tendonosis because it’s an overuse degenerative disorder rather than an inflammatory disorder.
Achilles tendonitis is an overuse injury to a tendon that runs from the calf region down to the calcaneus (heel bone).
Repetitive activity causing repetitive stress to that tendon causes tiny microtears to it. Over time, it can build up and lead to symptoms and a stabbing, sharp pain. Some common symptoms include feeling pain, swelling, and tenderness around the bottom and back of the heel. Over even more time, it can compromise the tendon so much making it more prone to tears - ouch!
Achilles tendinopathy occurs more frequently in older men, especially those with a flatter arch and/or wearing unsupportive shoes.
There are two types of achilles tendonitis:
Noninsertional achilles tendinitis: The fibers in the middle of the tendon (2-6cm up from the insertion) start to break down, swell, and thicken especially in people who are younger and more active.
Insertional achilles tendinitis: The fibers lower near the heel bone start to break down especially in long-distance runners.
Common Causes of Achilles Tendonitis
As a PT, of course I saw many women with achilles injuries also, but it was more prominently men that I saw. Especially golfers, volleyball players, and runners from my observation. These are people who are wearing no shoes or flat golf shoes, likely aren’t warming up before activity, and are possibly getting into too much too soon.
But I also saw it in people who were less active but tried to begin a brand new workout program, jogging program, or hobby that was simply too much too soon and ended up being too much for their heel(s) to tolerate.
Other common causes of achilles tendinitis besides activities:
A bone spur
Tight or weak calf muscles (poor mobility)
Leg length discrepancy
Forefoot varus deformity
Pes cavus hypomobility of the subtalar joint
Overpronation (foot flattening when walking or running)
What does the research say about this?
The achilles tendon has the highest rupture rate of any tendon in the body.
It's 20x more common in males ages 30-39, especially those that play badminton.
Re-rupture rates are higher with conservative treatment at 13% versus only 4% with surgical repair.
Although rehab is a long process, it's very necessary since the re-rupture rate for this injury is very high at ~27%.
It may affect 9% of recreational runners and cause up to 5% of professional athletes to end their careers
It may affect 9% of recreational runners and cause up to 5% of professional athletes to end their careers
Location and Muscles Affected by Achilles Tendonitis
The tendon affected is called the achilles tendon and it was named after the ancient Greek mythological figure Achilles in the late 1600’s. Apparently his mama held him by the heel when he was a baby to dip him in water. So his body was invulnerable because it was all submersed, but his heel was not deeming it vulnerable. Ever heard of the expression achilles heel? It’s a vulnerable or weak spot. Anyways, here’s how to feel for the achilles tendon.
Do this: feel your calf muscles with your hands right now. Massage them and work your way downward toward the heel. As those muscles (gastrocnemius and soleus) begin to narrow they eventually turn into the achilles tendon. That tendon will feel like a thick rope - that’s it!
Photo Credit: Fairview
Testing for Achilles Tendonitis
Testing for achilles tendonitis typically begins in Physical therapy with some range of motion (ROM) tests, manual muscle selective tissue tensioning tests (testing tendon strength), muscle length tests (testing flexibility), manual muscle testing, palpation tests, and special tests.
How to Test for Achilles Tendonitis: The most widely used diagnostic test for this is literally palpation. You’ll feel tenderness and pain directly over that tendon - how easy! It’s a well localized pain. In addition, you may have limited muscle length/flexibility in your calves (on that painful side compared to the uninjured side) and also strong but painful calf muscle testing. Large bone spurs may also be palpable.
Typical test results: tenderness to palpation, decreased and possibly painful flexibility, strong but painful tendon strength testing (but possible mild weakness on injured side), and possible swelling.
One 2019 study looked into how achilles tendonitis leads to mechanical changes of the tendon like reduced tendon stiffness and increased strain. Researchers from this study proposed that it’s because of the non-resolution of strength deficits that symptom recur due to being unable to dissipate forces during stretch-shortening cycle (SSC) activities like running or jumping. It seems they don’t believe 12-weeks is enough for full recovery. Instead, most people take a year or more to recover full strength, even if pain is gone. Strength-training has been shown effective at improving pain and disability for achilles tendinitis – on average a 55% reduction. So if you injure your achilles - strength train!!
It’s typically suggested you perform 6-8 weeks of Physical therapy and that often yields great results. Then if there is no improvement, your Physician may suggest further testing like getting an Xray, MRI, or ultrasound to determine if there is more extensive damage near the heel or something else going on. You may also be given an ankle brace to rest the tendon further.
Conservative Treatment for Achilles Tendonitis
Disclaimer: The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment. Never disregard professional medical advice, or delay in seeking it, because of something you have read on this website. Never rely on information on this website in place of seeking professional medical advice.
Now that you better understand what achilles tendonitis is, what causes it, and which tendon is involved, let's now cover what you’re likely most interested in learning about: treatment for achilles tendonitis.
Physical therapy treatment should always be 100% customized to you: the stage of your injury (recent/acute or chronic), your history, your activity level, your job, your impairments, your abilities, and your goals.
With that said, the below treatments are general treatments often prescribed by Physical therapists for achilles tendonitis. Always consult your Physician before beginning any new exercise program.
Treatments for Achilles Tendonitis (from basic to advanced):
Rest (less or modified repetitive aggravating activity)
Joint mobilization (level depends on stage of injury; plus mobilization with movement (MWM))
Range of motion exercise (without a pain-free range)
Stretching (plus contract-relax technique)
Strengthening exercise (including isometrics)
Stability/balance training (double-leg and single-leg)
Functional exercise (form training for squats, jumping, and running - progressing slowly over time)
Manual/Massage: soft tissue massage, deep tissue massage, cross friction massage (if not an acute injury), dry needling
Modalities: Ice, Ultrasound
Ankle Brace (if prescribed and more severe)
Shoes, heel lifts, or orthotics (get fit for more supportive shoes or inserts, especially the shoes you wear during whatever activity it is that’s aggravating it)
Acute tendinitis properly heals in 3-6 wks typically, so it’s a fairly quick recovery process if addressed right away. With improper treatment and no exercise modification, this injury could last up to two years, so it’s important to address it properly right away.
Below are some products from Amazon that are often useful for addressing patellar tendonitis pain:
If those conservative treatments don’t help then PRP injections, corticosteroid injections, or even surgery may be needed (especially if there are tears or more severe injuries included).
Surgeries for this injury often include:
Gastrocnemius recession (the gastroc is lengthened)
Debridement and repair (to clean things up and remove damaged tissue)
Tendon transfer (when tendon damage is severe, it may need to be replaced using tendon from elsewhere)
Physical Therapy Exercises for Achilles Tendonitis
In the following videos, I share how to test for achilles tendonitis, how to feel for tenderness, and how to improve range of motion, flexibility, and strength.
Mobility, Range of Motion, and Stretching Exercises for Achilles Tendonitis
The Best Achilles Tendonitis Strengthening Exercises
The Best Balance Exercises for Achilles Tendonitis
Note: Don’t ignore the hips and knees! You should also strengthen above and below in the kinetic chain, so strengthen those glutes and ankles, too for better shock absorption. This can decrease how much overpronation / flattening occurs at the foot/feet.
Mission: Mobilize, Modify, Move
It’s my goal to ensure you learn three things with every blog post: how to mobilize your body, how to modify exercise, and how to optimize your movement.
Above I shared a video for ankle mobility and stretching. I also shared some great ankle strengthening exercises. Strengthening the ankles helps stimulate blood flow to the muscles and tendons and repair the tendon.
Now, let’s cover some ideas for how to modify exercise if you have Ankle Tendonitis:
Consider adjusting your workout split to focus more on the upper body and core more often - temporarily until your heel feels better.
Modify lower body exercises by working within a comfortable range of motion, using lighter loads, slowing things down, and adjusting your stance. For example, if you’re doing a squat try these things:
Don’t go down as deep
Do it bodyweight or lighter load than usual
Go slower so you can really focus on form
Consider doing it in front of a mirror so you can watch your knee alignment
Try out different stances: narrow, wide, wider, toes forward, toes more turned outward
Consider lifting the heels so less dorsiflexion is needed from lower body exercises (heels can be elevated on top of a plate, yoga wedge, or book)
Throughout the day, modify any of the repetitive movements you make as that’s possibly the true cause of the inflammation. Or take more breaks while doing them. For example, if you stand all day for work then maybe you should set an alarm every hour to take a 1-minute break and stretch your calves out.
Wear better shoes!
Finally, if you plan to continue to strength train, I suggest you try these things out to move more optimally:
Warm-up appropriately prior to lifting. Try doing some bodyweight calf raises off the edge of a step or box first to lengthen and strengthen it.
During strengthening exercises, an eccentric-accentuated focus is shown to be effective for tendonitis. It helps to increase collagen synthesis (creation) and decrease the tendon thickness back to normal. So let’s say you’re doing a calf raise. Lower the heels down over the course of 4-seconds and then come up onto the tip toes over the course of 1-second. “Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.” [Reference]
Definitely modify or skip these exercises temporarily if you have >4/10 discomfort: squat, any type of lunge, step-up, split squat, and calf raises. Remember your heel will likely feel better if you elevate the heels during exercise in the beginning. Then eventually progress to having the feet flat on the floor. Then once you feel better, you can introduce those exercises above back in slowly to increase tendon tolerance, as tolerated.
While choosing strengthening exercises, consider doing more unilateral work so you can go lighter on the injured side temporarily. For example, lunges, Bulgarian split squats, step-ups, or single-leg calf press machine are unilateral. Whereas squats, box squats, standing calf raises, or split squats are bilateral.
During cardio, choose flat surfaces and avoid inclines or hills at first. Then slowly add those back in once you feel better.
During cardio, temporarily decreased volume or intensity of training. For example, if you like to jog everyday, maybe you’re doing too much. Consider scaling back the distance to ⅓ or ½ of your normal distance temporarily as that may not flare up your knees as quickly. Or you could also decrease the intensity but slowing down from 9min/mi to 10min/mi. Or another option is to switch to a lower impact form of cardio like cycling, elliptical, rowing, etc..
During sports, you may need to scale back the intensity and frequency of your training temporarily. Take time off jumping and high impact work - yes, rest. Use that time to do rehab-based exercises until your symptoms subside. Then, you can build back up with more advanced strengthening exercises that load the tendon and eventually work on speed training and plyometric work.
If any of what I said is confusing or you want additional help with addressing your impairments, be sure to watch the webinar “Outsmart your Injury” to learn more about exercise modification and how you can take control of your injury instead of letting it control you. Then reach out and let’s chat!
Have tight calves and want to improve your ankle mobility?! Check out Applied Mobility which is my online course teaching you all about the importance of staying limber and how to do so in just 5min/day of mobility exercise. The course also includes 12+ weeks of mobility workouts to follow along! Learn more about Applied Mobility here.
Thanks for reading!
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