What is Achilles Tendinopathy and what to do about it

What is Achilles Tendinopathy and what to do about it
What is Achilles Tendinopathy and what to do about it
 
Tendinopathy has replaced the term tendinitis to reflect the latest research on the source of the tendon pain (look for future articles to come on the causes of tendon pain).
 
Achilles Tendinopathy is common in elite and recreational athletes, active individuals and 'weekend warriors'.
 
The most common type of Tendinopathy is in the midtendon, i.e. about 1” or so above the attachment to the heel bone. Less common is an insertional Tendinopathy, which is pain at the Achilles attachment into the heel bone. The site of the pain can be swollen and/or thickened or normal in appearance.  The pain can be brought on by activity and becomes increasingly painful as the activity progresses.  However, quite commonly the Achilles pain will diminish as the tendon “warms up”.
 
The first goal of manual physical therapy is to decrease the stress on the achilles which is termed unloading.  Unloading must include a careful biomechanical assessment of the foot, ankle, knee, hip, pelvis and lumbar spine looking for areas that can increase the stress on the achilles. The problem areas are addressed by a combination of joint manipulation, joint and soft tissue mobilization, stretching, therapeutic exercise, taping and modalities such as electrical stimulation.  
 
The unloading component can also involve wearing the correct footwear, using a heel lift, taping, using a night splint and possibly orthotics. Often a ‘low dye’ foot tape, which supports the arch, is used to determine if orthotics will be helpful.  The most critical component of unloading is education on  what activities can be continued during the acute phase, how often, how far, and what intensity i.e. how much walking or running can be continued during the acute phase.   
 
The second goal of manual physical therapy is to begin a specific therapeutic exercise program.  If the tendon pain is quite acute or occurs during the competitive season, isometric exercises have shown very promising results.   Isometric exercises involve a prolonged static tensioning (10-30 seconds) of the calf muscles and achilles tendon.
In less acute situations a therapeutic exercise program consisting of both eccentric and concentric exercises are utilized.  An eccentric contraction is tensioning a muscle and tendon while it lengthens, while concentric exercise is tensioning the muscle and tendon while it shortens.  The latest research and expert opinion supports incorporating both the eccentric and the concentric exercises.  The exercise program is designed to put a gradual increase in strain and loading on the achilles to reduce pain, promote healing, improve flexibility and increase strength.  There is a fine balance between applying the correct amount of loading and not overdoing it.  Sport specific and harder plyometric-based exercises can be added later if needed.
 
It is important to continue with the exercise program as quite often results are not immediate.  It may take months to see an improvement in symptoms.  Once the symptoms become manageable it is important to continue with a regular achilles  loading ‘maintenance’ exercise program.
 
It is best to check with your manual physical therapist about the correct exercise dosage and technique before starting an exercise program on your own.  A program should be individualized and based on the best available research and clinical judgement.
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