Return to Running: Rehabilitating Achilles Tendinopathy
If you’re an avid runner, it’s quite common to experience tightness or pain around your achilles tendon, calve or even plantar fascia at one point or another. This can be indicative of tendinopathy and if you’re looking to get back into running come summer, the time to rebuild is while the weather is cold.
What is Tendinopathy?
Tendinopathy refers to pain around a tendon, which connects muscle to bone. It's typically characterized by pain and stiffness, especially in the mornings, when warming up, or toward the end of activity. Swelling and tenderness may also occur.
For Achilles tendinopathy, it’s important to understand the pain location for effective management:
Insertional Tendinopathy
Refers to pain behind the heel.
Mid-portion Tendinopathy
Pain above the heel, often with tendon thickening and swelling.
Though these types differ, they share management similarities.
What Causes Achilles Issues?
Achilles issues often arise from load management — placing more stress on the tendon than it can handle. Several factors contribute:
Muscle Capacity
The soleus (lower calf) and gastrocnemius (upper calf) may not withstand running forces. The soleus endures 6-8 times body weight during running, while the gastrocnemius handles 2-3 times (1).
Increased Load
If running or jumping frequency increases too quickly, such as from 2 to 5 days per week without progression, the Achilles tendon can’t adapt fast enough.
Loss of Tendon Stiffness
Tendons need to be stiff to handle quick, forceful movements. As we age, tendon stiffness decreases, increasing the risk of tendinopathy.
How to Address Achilles Issues
Increase Calf Strength
Train calves in a variety of ranges and contractions.
Strengthen Hips and Knees
Strengthening these areas improves synergistic movement; for example, when the knee extends, the foot plantar flexes, reducing strain on the Achilles tendon.
Boost Calf Stiffness
Progressive plyometrics with short contact times help enhance stiffness and resilience.
Timeline for Recovery
Consistency is key. While pain can decrease by reducing strain and increasing strength, recurrence is common—up to 44% of cases (2). Achilles tendons take about 6 weeks to begin remodeling after new stress is applied. However, pain may decrease sooner by removing aggravating factors and improving strength in surrounding muscles. Full tendon recovery can take up to 1 year or more. Even after symptom resolution, a study has shown only 25% of patients regain full muscle and tendon function (3), which may explain the high recurrence rate of Achilles tendinopathy.
Isometrics for Achilles Pain Relief
Isometrics—muscle contractions without movement—are effective for reducing pain in tendinopathy cases. For Achilles tendinopathy, training in a shortened range helps alleviate strain while improving muscle contraction strength. Exercises like soleus bridges or standing plantar flexion isometrics are great options early in rehabilitation.
Achilles Tendon Remodeling Takes Time
Achilles tendon remodeling typically starts after 6 weeks of consistent stress. While pain reduction can happen sooner by reducing load and strengthening surrounding muscles, full tendon capacity and long-term change require ongoing effort.
Changes may take up to 1 year.
Other Considerations
Knee and Hip Strength
The Achilles takes on more strain if the knee or hip is unable to move or create force effectively.
Previous Injury
Previous pain, or injury in the lower limb will increase the risk of not only the achilles tendon, but also other areas, as we may have developed avoidance behaviours, and compensations around the pain/injury.
Coordination
Effective movement requires the hip to extend before the ankle plantar flexes. Training the knee, hip, and ankle together improves coordination and reduces strain on the Achilles.
Stretch-Shortening Cycle
Returning to activity requires retraining the Achilles tendon’s ability to stretch and shorten quickly under load.
Metabolic and Hormonal Factors
Factors such as metabolic disorders and hormonal changes (e.g., menopause) can increase the risk of tendinopathies. Additionally, medications like antibiotics and oral steroids, as well as alcohol consumption, can play a role.
Change in force output control
After pain and injury we see reduced cortical excitability (loss of brain to respond to a stimulus in the specific area). We not only need to address strength but to learn to contract the area with great force.
Hopping Drills for Achilles Rehabilitation
Adding hopping exercises may reduce recurrence. These drills challenge the Achilles tendon’s stretch-shortening cycle, but they should be introduced progressively at the right time to avoid overloading the tendon.
Key Takeaways
Limit Aggravation
Limit activities that worsen pain. We want to control the achilles first in order to progress. It is very hard to progress with a very angry achilles. This doesn’t mean avoiding activity all together, we just need to modify it.
Find the Right Intensity
Start at a level you can tolerate, progressively increasing intensity to match the loads your Achilles will face. We need to find the right entry point into rehab, which may need to be scaled down, or if it is a continual recurrence, the rehab may not have been intense enough to start.
Progress Gradually
Don’t rush back into full activity—your tendon needs time to adapt. At the same time we need to progress the intensity of exercises as well. Just doing bodyweight calf raises, won’t get the adaptations we need, especially for activities like running.
Meet Colin
Colin is an Osteopathic Practitioner, and a member of Osteopath BC. Using a range of manual techniques, Colin can help you reduce pain and increase range of motion with specific movements and exercises to facilitate more robust and efficient movement patterns and provide prolonged relief.
References
Muscular Strategy Shift in Human Running: Dependence of Running Speed on Hip and Ankle Muscle Performance
Tim W. Dorn, Anthony G. Schache, Marcus G. Pandy
J Exp Biol (2012) 215(11): 1944–1956.Prevalence of Achilles Tendinopathy in Physical Exercise: A Systematic Review and Meta-analysis
Yahai Wang, Huanhuan Zhou, Zhibin Nie, Sidong Cui
Sports Medicine and Health Science Volume 4, Issue 3, September 2022, Pages 152-159Full Symptomatic Recovery Does Not Ensure Full Recovery of Muscle-Tendon Function in Patients with Achilles Tendinopathy
Karin Grävare Silbernagel, Roland Thomeé, Bengt I. Eriksson, Jon Karlsson
Br J Sports Med (2007) Jan 26; 41(4): 276–280. doi: 10.1136/bjsm.2006.033464
