Achilles tendonitis - sports podiatry

This tendon is named after Achilles, who according to myth was protected from wounds by being dipped in a magical pond by his mother. She held him by the heel, which was not immersed, and later he died by an arrow wound to his heel.  

The Achilles tendon is the connection between the heel and the most powerful muscle group in the body. This has long been known as a site prone to disabling injury. Forces up to 12 times body weight may arise during sporting activity.

Achilles tendonitis anatomy

The Achilles tendon joins three muscles: the two heads of the gastrocnemius and the soleus. The gastrocnemius heads arise from the posterior portions of the femoral condyles (back of the thigh bone). The soleus arises from the posterior aspect of the tibia and fibula (the two bones in the lower leg).

The gastrocnemius is a muscle that crosses three joints: the knee, the ankle, and the sub-talar joint (major joint in the foot). The functioning of these joints and influence of other muscles on these joints has a significant effect on the tension that occurs within the Achilles tendon. As an example tight hamstrings impact the functioning of the ankle joint, the sub-talar joint, and increase tension in the Achilles tendon. The soleus muscle does not cross the knee and is a biarticular muscle (affects the movement of two joints).

The bulk of the Achilles tendon inserts into the upper back third of the calcaneus (heel bone). Some fibres run further down and insert into the bottom of the heel bone.

Achilles tendonitis Causes

Achilles tendinitis develops due to inflammation, strain, or repetitive trauma to the Achilles tendon. This occurs usually due to a repetitive activity. Symptoms are also associated with recreational activities like running, tennis and basketball.

If this is left untreated, it can develop into Achilles tendinosis, due to a degenerative change in the tendon from repetitive micro-trauma. The tendon scars and the injury becomes chronic in nature.

The majority of Achilles tendon overuse injuries occur in middle aged, athletic males. Athletes with overly pronated feet may be at greater risk for developing Achilles tendinosis. The increased pronation may put additional stress on the tendon, therefore, placing it at greater risk for injury.

Athletes with a rigid foot type also run a greater risk of all posterior group strains including Achilles tendinitis. A rigid foot type results in early heel lift during the contact phase of gait meaning that the athlete is on their toes earlier than is mechanically efficient causing the muscles and tendons in the back of the leg to work harder

Poor biomechanics

Hill running or stair climbing.

Overuse resulting from the natural lack of flexibility in the calf muscles.

Rapidly increasing mileage or speed.

Starting up too quickly after a layoff.

Trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort such as in a final sprint.

Tight muscle groups in the back of the leg.

Achilles tendonitis Symptoms

Achilles tendinitis often begins with mild pain after exercise or running that gradually worsens.

Other symptoms include:

Recurring localised pain, sometimes severe, along the tendon during or a few hours after running.

Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone.

Sluggishness in your leg.

Mild or severe swelling.

Stiffness that generally diminishes as the tendon warms up with use.

Achilles tendonitis - Treatment in the acute phase

P - R - I - C - E

Achilles tendonitis - Restoring normal function

As we get older the achilles tendon rupture goes up dramatically especially if we embark on high impact sporting activities. However it must be emphasised that the risk is still small but when recovering after any injury it is vital that when stretching or performing any exercise that there should be no pain. If any tenderness is elicited along the peroneal tendon then stop and re commence P.R.I.C.E

Peroneal tendonitis - eccentric exercises

The eccentric achilles tendonitis stretching exercises below require the use of a theraband.

Begin eccentric exercise program 7-10 days after pain has subsided Start with toes pointed, giving resistance through the theraband, slowly allow your foot into dorsiflexion (upward position). Warning: There should be no achilles tendonitis pain when doing this exercise. If there is stop!

 

Below is a video showing the uses for the rehab band (whole body).

achilles tendonitis - stretching exercises

Begin stretching regimen for gastrocnemius and soleus complex. Warning: There should be no pain in the achilles tendon when doing this exercise. If there is stop!

Perform a toe raise on a 4-6 inch box or step with both legs. Once on your toes, lift the uninvolved leg and lower yourself slowly into dorsiflexion (heel down, toe up).   Warning: There should be no achilles tendon pain when doing this exercise. If there is stop!

Achilles tendonitis - leg strengthening exercises

Perform a toe raise on a 4-6 inch box or step with both legs. Once on your toes, lift the one leg and lower yourself slowly into dorsiflexion (heel down) with the other. Repeat on the other side Warning: There should be no achilles tendonitis pain when doing this exercise. If there is stop!

 

Ankle strengthening exercises

 

Wobbleboard

 

Use of a wobbleboard is a brilliant way to strengthen muscles in the foot ankle and leg. Aim to do 5-10 minutes a day!

 

 

Theraband exercises

 

Frequency:

Three sets of 20 repetitions, 5-7 days per week

Front of Shin Basic - Push Out With your foot flat on the floor, push it outward against a wall, file cabinet or bookcase. Hold for three seconds.

Front of Shin Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line and loop the band over the outside of your foot. Push your foot out against the band.

Inner Shin Basic - Push In With your foot flat on the floor, push it inward against your other foot. Hold for three seconds.

Inner Shin Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line, and loop the band over the inside of your foot. Push your foot in against the band.

Front of Shin Basic - Push Up Place the heel of your other foot on top of the injured one. Push down with the top heel while trying to push up with the injured foot. Hold for three seconds.

Front of Shin Advanced - Band Tie the band to a desk or dresser. Sit with your leg straight and loop the band over the top of your foot. Slowly pull your foot back against the band.

to help prevent achilles tendonitis from occurring

Remember that virtually all achilles tendonitis problems happen at the contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point. It is therefore vital to strengthen the ankle and control biomechanical forces.

Golden rule- Don't ignore the problem, it won't go away!

The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family). The way you function is set and cannot be cured. What you can do however is control lower limb biomechanics by altering foot position during the contact phase of gait. This can be achieved by wearing a good shoe (see our shoe guide) with orthotics (foot beds), ankle strengthening and ankle support.

1. Check your footwear

Are your running shoes worn and in need of replacing? If so change them. Achilles tendonitis is made worse by high impact forces so a good shock absorbing shoe is a must. Lack of stability from a worn shoe can also contribute to the problem. For more advice on running trainers our running shoe advice page is worth reading. Read more->

Below are a selection of trainers that are ideal for athletes.

Trainers for a neutral or under pronating foot type

Trainers for over pronators

2. rectify Poor biomechanics with orthotics

The way your foot strikes the ground and the forces that are placed on it can have a direct effect on causing achilles tendonitis and also delaying healing times. Check our biomechanics page for detailed information. Read more->

3. Ankle strengthening

The single best exercise to improve the strength of the muscles around the ankle is eccentric loading. This is usually done none weight bearing, however the use of a wobbleboard is an excellent way to strengthen muscles around the foot and ankle in a controlled gentle manner. Whilst our clinicians have found it a brilliant way to strengthen ankle muscles, traditionally a wobbleboard was used to help balance (proprioception). Proprioception is the nerve connection from the brain to the foot. This is often damaged/ disrupted after injury and can increase the chances of injury from re occurring It can also significantly delay recovery.

Use of a wobbleboard therefore has a dual benefit in the treatment of achilles tendonitis.

4. Ankle support

Usually an athlete who has damaged their ankle only needs minimal support post injury, such as the support given by a neoprene brace. However with achilles tendonitis we recommend an ankle brace when partaking in sporting activity.

Achilles tendonitis injury prevention checklist summary

returning to sporting activity after Achilles tendonitis has subsided

The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen achillesl tendonitis injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Returning to your activity is determined by how soon your tendonitis recovers, not by how many days or weeks it has been since your injury occurred.

You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:

You have full range of motion in the injured leg compared to the uninjured leg.

You have full strength of the injured leg compared to the uninjured leg.

You can jog straight ahead without pain or limping.

You can sprint straight ahead without pain or limping.

You can do 45-degree cuts, first at half-speed, then at full-speed.

You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.

You can do 90-degree cuts, first at half-speed, then at full-speed.

You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.

You can jump on both legs without pain and you can jump on the injured leg without pain.

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