"Never discourage anyone who continually makes progress, no matter how slow."

-Plato

Last month’s newsletter focused not only on the structure and function of the Achilles tendon but also on the major differentiators between the two varieties of Achilles tendinopathy. While the two forms of this injury are both brought about by similar factors, such as overload due to training, loss of tendon stiffness, and a decrease in strength of the calf muscle complex, (gastrocnemius and soleus) when it comes to developing a treatment plan to address the underlying issue(s), there are clear distinctions that need to be taken into account to ensure a successful treatment outcome.

When choosing a rehab specialist that you entrust to help you formulate a plan for return to sport, an adequate understanding of this specific pathology and how to effectively carry out the different stages of treatment is an absolute must. Improper management of Achilles tendinopathy can not only lead to prolonged time spent away from sport but can also increase the risk of re-injury.

Before we delve into the specifics of an appropriate rehabilitation plan, let’s quickly revisit the two types of Achilles Tendinopathy and how they differ in terms of location and etiology.

The most frequently diagnosed form of Achilles tendinopathy is known as mid-portion Achilles tendinopathy. Common symptoms include tenderness and pain along the bulk of the Achilles tendon approximately 2-6 cm above its insertion into the calcaneus. A hallmark of this type of Achilles tendinopathy is tenderness with pinching of the tendon. In more chronic and severe cases, thickening of the tendon is often noticed upon visual inspection.

The second category of Achilles tendinopathy is insertional Achilles tendinopathy. The symptoms of this specific form are similar to the mid-portion variety, but the location of pain and the mechanism of injury are somewhat different. True to their names, mid-portion tendinopathy affects the middle of the tendon, while insertional Achilles tendinopathy occurs at the insertion site of the Achilles tendon onto the calcaneus. The traditional mechanism of injury of insertional tendinopathy is direct compression of the Achilles tendon against the calcaneus.

Phases of Treatment for Achilles tendinopathy

Phase 1 – Reduce pain and irritability

The initial phase of treatment for both forms of Achilles tendinopathy is the same, to reduce pain and irritability of the tendon, regardless of where the symptoms are emanating from. The easiest way to achieve this early on is to reduce the load and/or the compression onto the tendon itself. Provocative activities, we will focus specifically on running, should be reduced and in more severe cases, perhaps ceased altogether for a short time to allow symptoms to settle. While we will investigate pain with progressive exercise a bit later on, during this stage of care we want to experience a significant level of pain reduction as quickly as possible, especially if pain is felt during activities of everyday living. Below are some considerations for the early stages of treatment to help expedite pain resolution.

• Reduce overall running volume, especially fast running.
  • A pause from hill running is especially salient for insertional Achilles tendinopathy.
• Wear shoes with a greater heel-to-toe drop whenever possible. The greater the height of the heel in comparison to the toe, the less strain there is on the Achilles tendon.
  • Consider using a heel lift if flat shoes are the only option available.
  • Avoid wearing minimalist shoes or barefoot-style running footwear.
• Avoid tight-fitting shoes that put direct pressure on the Achilles tendon itself.
• Avoid stretching the calf, especially in cases of insertional Achilles tendinopathy as this will increase the compression of the tendon at the insertion onto the calcaneus.
  • There is little evidence in the literature that calf muscle complex “tightness” increases the risk of developing Achilles tendinopathy.
• Avoid running on soft and uneven surfaces such as trail running.
• Avoid running on the treadmill. Treadmill running can place upwards of 12% additional strain on the Achilles tendon versus overground running.
• Avoid using NSAIDs (Advil, Aleve, Ibuprofen, Motrin, etc.) for pain control as there is evidence to suggest that anti-inflammatory medication can cause a delay in tendon healing.

Phase II – Calf muscle complex strengthening

Calf muscle complex weakness has been shown in the literature to be a risk factor for the development of Achilles tendinopathy. To make matters worse, pain often results in an even greater reduction in muscular strength and function. Once the symptoms of pain and irritability have calmed down, the commencement of strengthening should begin. While many interventions with questionable utility are often considered for the management of Achilles tendinopathy, strengthening exercises are repeatedly supported in the literature and should be incorporated throughout the rehabilitation process and beyond. One of the hallmarks of an appropriate strengthening program is that it is progressive. By periodically introducing greater loads when performing strengthening exercises, you not only increase the overall strength of the calf muscle complex but also improve the load capacity of the Achilles tendon, thereby enhancing its ability to store and release energy. As you’ll remember from last month's newsletter, this is critically important for runners as these structures are a few of the primary drivers of propulsion while running.

During the strengthening phase of treatment, I often prefer to focus on three distinct forms of exercise, integrating each type based on symptoms and overall patient progression.

Isometric exercises

By definition, this style of exercise occurs when muscle contraction does not result in an appreciable change in muscle length or the movement of the associated joint(s). In the early stages of Achilles tendinopathy, where sliding movement of the achilles tendon can further increase irritability, this type of exercise can be extremely effective. The level of pain reported during this type of exercise is often quite minimal.

Seated isometric calf holds are a great example of this type of exercise. When dealing with a very irritable Achilles tendon, simply pushing against a heavy load that results in minimal/no movement whatsoever, is a useful starting point.

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This exercise can be progressed to allow for 10-25 degrees of movement, ending with a prolonged period of contraction time where no additional movement takes place. Specific attention should be paid to performing this exercise on completely flat ground for those suffering from insertional Achilles tendinopathy. For those dealing with mid-portion Achilles tendinopathy, using a step or platform that allows for a small excursion of movement into dorsiflexion before plantarflexion takes place, is a potential option to increase strain on the tendon.

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Further progression of this type of exercise to a standing position will often be incorporated before moving to the next phase of strengthening. As was the case with the seated version, those with insertional Achilles tendinopathy will want to perform this on flat ground, while those with mid-portion Achilles tendinopathy may choose to utilize a step to increase the amplitude of the movement.

Heavy and slow resistance exercises

Another type of exercise that should be incorporated into an Achilles tendinopathy rehabilitation plan is exercises that allow for SLOW but full range of motion, utilizing progressively heavier loads. Heavy loads are thought to stimulate the greatest level of adaptation for both the muscle and tendon. The greater the time that the muscle is contracting, thereby increasing the time that the tendon is under tension, the better. I recommend a cadence of three seconds up/one second hold/three seconds down. Low to moderate (1-5/10) levels of pain during the performance of this type of exercise are acceptable. Some studies show that discomfort with resistance exercise is necessary to indicate adequate loading of the tendon. While exercising to discomfort is not absolutely necessary, if an increase in symptoms does occur, it is important that they have settled within a 24-hour period post-exercise.

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Plyometric exercises

As you’ll remember from the previous edition of this newsletter, one of the main functions of the Achilles tendon is to store and release energy. Full function of the Achilles tendon and the calf muscle complex while running are extremely important for forward propulsion. In order to adequately prepare an injured runner/athlete for a successful return to sport, exercises that mimic the loading demands of their sport of choice should be incorporated into the final stages of rehab before a full and unbridled return to training takes place.

One of the first exercises that I will often have a runner perform as they transition from purely heavy/slow resistance to a more dynamic form of exercise is a simple pogo jump. The goal of this exercise is to spend as little time on the ground between jumps as possible. I will often cue them to imagine they are performing the exercise on a burning hot floor. A brief ground contact time is ideal. While I’ll often begin by having them perform this exercise using both feet, for approximately 30-50 jumps, I can progress both repetitions and overall time, as well as working in a single-leg capacity as their condition improves.

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Phase III – Return to running

While this specific phase of the rehabilitation process could comprise an entire newsletter of its own, I’m going to focus on a few key principles to consider when formulating a successful return-to-run after a bout of Achilles tendinopathy.

First and foremost, have a plan. Whether you seek the guidance of a rehab professional or a running coach, having a framework in place as you prepare for a full return to running is critical. An ad hoc strategy will often yield less-than-ideal results and can put you on track for a recalcitrant issue early on.

Utilize the acronym FDI (F = Frequency, D = Duration, I = Intensity) when considering which variable of your running plan should be progressed. The first thing to increase is the number of days you are running during a given week. As you begin to approach the frequency of running you would normally undertake while uninjured, this is an appropriate time to consider completing sessions of longer duration/distance. Barring any significant increase in symptoms, brief periods of faster running are finally implemented into your running plan. Knowing that faster running ultimately places a greater demand on muscles and tendons alike, it is wise to consider adding it during the latter stages of a return-to-run plan.

One final recommendation is to continue strength training and plyometric exercise, even after a full return to running has commenced. Muscular strength and tendon stiffness are never going to fall out of fashion when it comes to enhancing running performance as well as injury rehabilitation and prevention. Strength training after a bout of Achilles tendinopathy is much like taking a course of antibiotic medication for a bacterial infection…you don’t cease taking the medication when your symptoms subside. The only difference is the number of doses recommended for this particular affliction is unlimited.

Treatment adjuncts worth avoiding

I don’t want to spend too much time on this as the framework for a successful return to running has already been established, but I would be remiss if I didn’t at least mention a few things that are better left on the cutting room floor.

· Persistent stretching – I don’t intend to start a debate about whether or not stretching has a utility when it comes to injury rehab as that is an onion of a thousand layers. What I will say is that calf muscle complex stretching has not yielded promising results in the literature as a treatment for Achilles tendinopathy, and as it pertains to insertional Achilles tendinopathy specifically, this form of self-care will often increase the irritability of the tendon and make matters worse.

· Aggressive manual/instrument-assisted soft-tissue manipulation – One of the supposed byproducts of these forms of treatment is thought to be an increase in localized blood flow and the initiation of the inflammatory process, giving rise to the early stages of tissue recovery. One thing that acute nor chronic forms of tendinopathy need to kick-start the healing process is more irritation and/or inflammation.

· Complete rest – As previously discussed, one of the primary roles of tendons is energy storage and release, both processes brought about by varying levels of loading. Tendons don’t, however, perform this duty to the best of their ability following prolonged periods of rest. This may explain why one of the most effective forms of treatment for Achilles tendinopathy is progressively increasing its capacity to handle load. While a brief period of rest/unloading will yield a short-term reduction in symptoms, it will do nothing to address the underlying issue(s).

Nothing But Good News

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Recipe of the Month

​Butternut Squash Zuppa Toscana​

We make this with plant-based sausage but you could easily substitute a sausage of your liking.

The round-up

Leaf them be?

With summer in the rearview, and the growth of your lawn significantly slowing, the focus now turns to preparing for winter. As discussed in last month's newsletter, fertilization is a critical step to allow your lawn to hit the ground running when warmer temperatures return next spring. If you live in a neighborhood full of healthy deciduous trees, fall also signals the start of leaf maintenance. Many questions surround whether you should rake your leaves, or let them be, and the potential benefits of both practices.

One of the most common reasons people rake their leaves is the same reason you mow your lawn...it keeps your lawn looking nice and tidy. Seems reason enough to continue the time-honored practice. That said, you may be bypassing a chance at improving the soil condition, thereby indirectly improving the health of your lawn by either letting some of them be or by mulching them into the lawn when you mow.

For those who prefer to rake the leaves off of their lawn, you're certainly not harming anything by doing so. For one, a thick layer of leaves across the lawn can be harmful as it will completely block out the light of the sun from hitting your lawn. Grass is a plant, and like any plant, it needs light to maintain life. A thick layer of leaves can also encourage mold growth, a common problem in lawns located in northern latitudes. So, if you have several large trees in your yard that shed copious amounts of leaves that left unattended will completely blanket your lawn, periodic raking is probably a reasonable practice.

But, for those of you who prefer to let the leaves be, or instead mulch them in with your lawnmower, this can yield major benefits. Leaves are full of nutrients such as nitrogen, phosphorus, and potassium. If you look at the numbers on any bag of fertilizer, they represent the respective percentages of these same nutrients. Decomposing leaves act as free fertilizers that slowly break down over the winter, and by doing so, feed your lawn. They provide an easy meal for insects and critters that help to improve soil quality. A thin layer of leaves can also help crowd out weeds that survive the winter, as well as assist with moisture control. Last but not least, not having to rake saves time! All of these are a major net positive for your lawn and are more than enough reason to rethink raking your leaves.

Thanks for reading! Reply any time.

~Dana

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