This post follows on from our previous post on Achilles tendinopathy. Both posts summarise the recent article by Peter Malliaras (see reference below) in the Journal of Physiotherapy which provides a comprehensive review of the latest research and discusses the most effective evidence-based management of Achilles pain. If you have not read the previous post then we suggest you do this before reading this article!
The Four Primary Areas Of Achilles Tendinopathy Management With Physiotherapy
Effective physio management of Achilles tendinopathy involves considering four key areas.
1. Screening and Assessment
The initial screening and assessment are essential to identify individuals who may require medical management through referral to a medical specialist or for imaging, e.g. an MRI. This step helps rule out red flags and ensures that physiotherapy is the most appropriate management option at this stage.
3. Secondary Physiotherapy Management
While the foundation of management for Achilles tendinopathy involves education, exercise progression and load management, some other techniques can be helpful in some cases. There is less evidence supporting these secondary techniques, but for some clients they can provide pain relief which can be very helpful in allowing them to progress more consistently through their strength exercises, maintain their running volume to a greater degree, and just have less symptoms their daily routines. These secondary management techniques include using ice or heat, taping, heel wedges, footwear choice, and advice on using non-steroidal anti-inflammatories for shorter-term cases, or pain medication for longer-term symptoms
2. Primary Physiotherapy Management
Primary physiotherapy management focuses on education, exercise, and activity advice. The primary goal here is to empower clients with knowledge about their condition and its various contributors. This approach encourages self-management through load modification (e.g. adjusting running volumes) and exercise strategies to build strength. A key focus is helping clients understand acceptable symptom levels during their exercise and other activity, because it is normal to experience some pain and we want clients to be confident about how much discomfort is ok to push through during their exercises, and when they may need to pull back a bit.
4. Involve A Multidisciplinary Team When Needed
This post is looking specifically at physiotherapy management of Achilles pain. However, in line with the importance of using a biopsychosocial model to manage this condition, we need to remember that sometimes part of a physios role is to refer a client to other health providers when appropriate. This may involve professionals from various fields such as dietetics and exercise physiology to manage weight or psychology to address mood-related issues.
Individualised Treatment Is Critical For Achilles Pain
Like many injuries and conditions, each person’s case of Achilles pain will respond differently. There are a multitude of factors that can influence our pain response (see our previous post on Achilles pain factors and the biopsychosocial approach) so it makes sense that each person’s management program needs to be tailored specifically for them. Just trying to use a generic “Achilles Protocol” across different cases is unlikely to be effective. The foundation of each person’s program will be similar (i.e. using the primary physiotherapy management techniques described above), but factors such as the exercise starting point and rate of progression, and the addition of secondary treatments into the program, will vary widely between clients.
Non-Physio Management Options For Persisting Cases Of Achilles Pain
Although the above guidelines are successful in the majority of cases, some cases may not respond adequately. Reasons for this may include being unable to adhere to the exercise program prescribed (e.g. due to other medical conditions), or simply being unable to sustain motivation for exercise consistency over a relatively long period of time. In these cases secondary management can be considered, usually involving referral for imaging and/or specialist care through a sports physician or orthopaedic surgeon, although it is worth noting that surgery is very rarely indicated.
The focus of this post is on the physiotherapy management of Achilles pain, especially the role of exercise, so we won’t go into the evidence base for these secondary management options.
Understanding The Role of Exercise in Achilles Tendinopathy Recovery
Exercise, in conjunction with load management and education, forms the foundation of Achilles tendinopathy management. There is lots of evidence supporting the overall effectiveness of exercise however, there is also still lots of debate about which type of exercise is best. Many programs have been trialled, but for various reasons there is no clear winner yet. This is not surprising given the variety of ways in which Achilles pain can present, plus the discussion in our previous post about the need to use a full biopsychosocial model when managing Achilles pain.
Instead of trying to find a single generic exercise program that works for everyone, Malliaras (reference below) suggests using a “Graded Exposure” model. This focuses on gradually progressing individual’s through graded exercise using a framework that allows the rate of progression to be personalised according to the each person’s pain response and physical capacity. This highlights the fact that just as each person’s physical capacity and mechanism of pain onset is different, every person’s response to pain is also different. This wide variety of both physical and psycho-social factors means that personalisation is critical when developing treatment programs for Achilles tendon pain.
Graded Exposure: A New Perspective on Exercise For Achilles Tendinopathy
The idea of using a Graded Exposure model is that exercise is progressed according to how the person is responding to pain, i.e. are they comfortable with current pain levels during exercise, or are they worried or fearful about it. This is different to a time-based or capacity-based model where the exercises are progressed according to time (e.g. you do an exercise for 2 weeks, then move to the next stage regardless of how you are feeling) or capacity (e.g. once you can do 20 reps of an exercise you move onto the next level regardless of pain response).
The graded exposure model progresses exercises based on pain and perceived threat or apprehension. A key benefit of this model is that is helps normalise pain, especially during physical activity and exercise, and this normalisation can significantly improve movement-related fear. It allows clients to become comfortable feeling some level of discomfort during exercise, and confident that it is ok work through acceptable levels of pain during exercise and their rehab program.
As noted above, personalisation is key to successfully using the graded exposure model of exercise for Achilles pain. Each person will progress at their own pace, and the exact choice of exercise will vary between individuals, but the 3 general phases to work through in the program are;
Phase 1: Isometric Exercise
This phase is essential for people who are too sore to do isotonic exercises. It’s a starting point to find a tolerable way to introduce load to the Achilles tendon.
An isometric exercise is defined as when a muscle contracts but there is no significant change in its length, and there is no movement of the joint. An example of a right calf isometric exercise might be rising up onto your toes using your left calf, then shifting your weight across to your right foot and holding this raised position. The right calf doesn’t change length and the ankle joint doesn’t move, but the calf is contracting to hold the raised position.
Phase 2: Isotonic Exercise
This should be the starting point of exercise for Achilles pain, except if you are too sore to begin here and need to start with isometric exercise as above. It focuses on building confidence and capacity to load the Achilles tendon using slow steady movements through a whole range of motion (except for insertional Achilles tendinopathy cases – see below). While you may start with a low load, research shows that progressing to slow movement under progressively heavier loads is important.
An isotonic exercise is when a muscle contracts and produces movement against a constant load. An example is a normal calf raise, where your calf contracts and lifts your body weight up onto your toes. Your symptom level would affect whether you begin with double-leg or single-leg calf raises, and a progression option would be to hold a weight in your hand to increase the load lifted by your calf/Achilles.
Phase 3: Stretch-Shorten Cycle Activities
In this phase we introduce faster movements that work into the tendon stretch-shorten cycle. It uses exercises that involve higher loads and faster movements so it’s essential to minimise risk of flare-ups by monitoring pain responses and keeping track of data like running time, pace, and step count.
The tendon stretch-shortening cycle is a spring-like mechanism that allows a muscle-tendon unit (like the calf and Achilles) to produce more force and therefore help us move more quickly. It is a cyclical pattern that involves pre-stretching the tendon (for runners this happens when your foot hits the ground and your calf contracts eccentrically to control this landing) followed by the muscle contracting concentrically (i.e. shortening) to push you forwards off the ground. The exact mechanism how it works is still being researched, but basically the muscle-tendon complex stores energy as it is stretched, then releases it as it contracts again.
The stretch-shorten phase involves progression through walking and running combinations, and also plyometric exercises including variations of jumps, hops and bounds. As with each phase of Achilles management, the time it takes each person to progress through this part of their exercise program will be very variable.
Increasing Calf Strength And Capacity Is Still Important For Achilles Pain
While individual pain responses will guide exercise progression using the graded exposure model described above, we can’t ignore the importance of calf muscle capacity, especially strength. This is because research shows that reduced calf strength is a significant risk factor for both the development and recurrence of Achilles tendinopathy.
Studies show that many people who have undergone rehabilitation for Achilles tendinopathy still experience calf strength and power limitations, even though their symptoms have either resolved or reduced to acceptable levels. This means that relying only on symptom resolution is risky because although the pain may have settled, strength deficits remain and the person is left with a significant risk factor for recurring Achilles pain. So increasing calf strength and capacity, often continuing after when the pain has resolved, is a key focus for effective long-term management of Achilles tendinopathy.
The Role Of Load Management And Activity Modification
Adjusting the amount of Achilles loading by reducing physical activity to appropriate levels is critical to successfully managing Achilles pain. The amount of activity reduction will vary according to each person’s presentation, and it is worth noting that complete rest from activity is rarely required. Education about why it is important to manage load correctly, plus advice on working within acceptable symptom levels, are important factors for success.
Do We Manage Insertional Achilles Tendinopathy Differently To Midportion Achilles Tendinopathy?
Insertional Achilles tendinopathy is when pain is felt at the bottom of the Achilles tendon where it attaches into the back of the heel bone (calcaneus), whereas midportion Achilles pain is felt around the mid-section of the tendon. Insertional Achilles pain is much less common than midportion, so there is less research specifically looking at how to best manage it.
Based on the research to date, exercise management of insertional Achilles tendinopathy should follow the same guidelines as for midportion Achilles pain except for one specific recommendation: avoid end-range dorsiflexion positions if it is painful. Dorsiflexion is when the heel drops below the level of the toes, eg doing a calf raise off the edge of a step. Loading insertional tendinopathy cases in this position will often aggravate symptoms, especially in the early stages of rehab. However, as the symptoms improve, the goal is to gradually progress to loading through the full range of ankle motion.
Physiotherapy For Achilles Tendinopathy Management – Summary
This post, as well as the previous post, provides a summary for non-physios of an article by Peter Malliaras which gives a comprehensive review of the latest research on how to best manage Achilles pain, especially in runners. The previous post focused on who tends to get Achilles pain, why it happens and how it is diagnosed. This post focuses on the best treatment options available, mainly discussing the role of exercise (which is critical for successful treatment), but also highlighting that load management and education are key parts of effective long-term treatment of Achilles pain.
If you have any questions about Achilles pain then feel free to click the button to contact us for some advice, or you can use our online booking system book to your initial assessment.
This article is based on the comprehensive research review by Peter Malliaras published in the Australian Journal of Physiotherapy in 2022. The original article was written for physiotherapists, and this post tries to make this wealth of information more accessible for the general population.
Malliaras P (2022) Physiotherapy management of Achilles tendinopathy. Journal of Physiotherapy 68:221–237.