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The Achilles Heel: Tips for Alleviating Tendon Pain

Achilles tendinopathy is more than just a painful condition. It’s a condition that has the potential to impact an individual's daily life, physical activities, and overall well-being. If you’re dealing with this condition, it’s important to have it treated quickly as the longer it persists without appropriate treatment, the more difficulty it becomes to treat and the more likely it progresses into a chronic condition

Let’s take a closer look at what this condition is and how we go about treating it at Kinetix. You may have noticed that I referred to this as a tendinopathy and not a tendinitis. Tendinitis, used to indicate an inflammatory process, is discouraged from being used as a label. Although inflammatory markers are present, inflammation is NOT believed to be the primary driver of the condition and may reflect the normal response to tendon loading and adaptation. This also means that anti-inflammatory medications are not recommended for the treatment of this condition. How did you get Achilles Tendinopathy? When a tendon is subjected to loads beyond it’s physiological capacity, it affects the tendon’s ability to adapt and recovery. The amount of capacity a tendon can handle is relative to the individual. If you are a highly active person or a regular runner, this condition typically occurs after a sudden increase in training volume. For example, if you normally run 5ks, but increase your mileage to prepare to run a half marathon, the spike in training load may exceed your tendon’s current capacity. For more sedentary individuals, tendons are generally less resilient to load because they have a lower capacity.

Goal of Therapy: In simple terms, the goal of rehab is to build more capacity in the tendon through various forms of loading and address the surrounding joints and muscles to improve the function of the kinetic chain.

What About Your Pain? While we accomplish these things, it’s important to monitor pain. We don’t want to completely rest the tendon as this wouldn’t help towards building capacity, but we don’t want to continue damaging the tendon. Typically, we will start your visit with some form of soft tissue mobilization such as myofascial release, dry needling or instrument assisted mobilization to improve blood flow, alleviate muscle tightness and reduce pain. Then we will begin working the tendon. It’s important that we monitor your response to exercise so we can determine an appropriate load. Our general rules for pain while rehabbing Achilles tendinopathy are as follows:

-Pain During Exercise: We typically ask our patients to stay at a 3 out of 10 pain or less during our sessions. Some people can still make progress with a 4 or 5 out of 10.

-Is pain worse after exercise? This is the most important question because it gives you an understanding of how you’re responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit. So, do you have to avoid pain during exercise? Not necessarily. Is it safe to push into a little pain? Absolutely. How much exercise will vary from person to person.

What Exercises? Phase 1: Isometrics: Working on static holds is the perfect way to start introducing exercises as there is usually very little or no pain as there is no movement occurring. You will perform several holds of 30-60 seconds of various forms of standing heel raise and seated heel raise Phase 2: Heavy, Slow Resistance: Now we introduce movement through slow, controlled exercises. We typically prescribe 3-4 sets of 10-15 reps through a large range of motion. Again, exercise selection will vary depending on the individual and their goals following rehab, but expect to see variations of calf raises with knee straight and knee bent. This is also when we introduce more compound movements like squats, lunges and deadlifts. Phase 3: Develop Stretch – Shortening Cycle: While you continue to work on strength with exercises form Phase 1 and 2, we will now introduce quick exercises that prioritize a faster rate of loading. There are thousands of possibilities in this phase and exercise selection with depend on your goals for rehab. Exercises here will be different for a 65 year old looking to return to a walking program vs a 19 year old looking to return to collegiate lacrosse. Expect to see jumping and hopping progressions, speed ladder, change of direction or change of speed drills. Phase 4: Gradual return to sport/activity: Our goal here is to slowly reintroduce your sport or activity.

Common Errors: Too Much Rest: These individuals significantly limit their activity because they are fearful of their symptoms or what they mean. Without a structured plan, and as a way of avoiding pain, they do less and less activity over time to the point that their capacity becomes severely diminished. This becomes a vicious cycle. Doing Too Much: These people persist, or push, through their pain, which leads to a flare-up. They do too much and require a period of rest to allow that spike in symptoms to subside. Then, when they’re feeling a bit better, they try to repeat that same level of activity, but come to realize that the flare-up happens even sooner. This cycle repeats until their capacity is also severely diminished. Summary: Achilles tendinopathy is thought to occur when the intensity, frequency, and volume of Achilles tendon loading, such as during walking, running, or playing sports, exceeds your capacity to recover and adapt appropriately. Therefore, the goal of rehab is to balance out this equation, so that your capacity is greater than or equal to the various loads you’re experiencing on a day-to-day and week-to-week basis. Be patient with this process as it can take months or even years! You goal is to focus on building tendon capacity through exercises while monitoring your pain. If you go from running 1 mile with a 3/10 pain to running 3 miles with a 3/10 pain over the course of 3 months, that’s actually significant progress. The pain may seem like it’s staying the same, but technically it’s getting better because it requires more activity to reach the same level of pain that you initially experienced. Unfortunately, there is no quick-fix for this problem. Make an appointment with one of our physical therapists to get more specific guidance for your case of Achilles tendinopathy.

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