Managing Achilles Tendinopathy with Physical Therapy

Achilles tendinopathy is a common athletic injury caused by repetitive stress and overuse of the Achilles tendon, causing inflammation and irritation of the tendon. It most often occurs due to a sudden increase in training volume or intensity without adequate recovery time. Physical therapy exercise rehabilitation is the best intervention to address Achilles tendinopathy, restore strength and function in the lower extremity, and ensure a safe return to sports competition. Mangiarelli Rehabilitation physical therapist Bobby demonstrates 4 exercises you can do to address Achilles tendinopathy.

Anatomy of the Achilles Tendon

The Achilles tendon is the largest, strongest tendon in the body, connecting the calf muscles at the back of the lower leg to the heel bone. The Achilles tendon allows you to walk, run, jump, and raise your heel. When you push off the ground, the force is transmitted down the calf muscles through the Achilles tendon to the foot to allow you to run and jump. When you land, the Achilles tendon helps control the ankle’s position when the foot comes back to the ground.

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What is Achilles Tendinopathy?

Achilles tendinopathy involves inflammation and irritation of the Achilles tendon, most often due to repetitive stress and overuse of the tendon. Achilles tendinopathy is caused by an imbalance between the stress and load placed on the Achilles tendon and the tendon’s ability to handle the stress. This often occurs due to a sudden increase in training volume or intensity without adequate recovery time, which irritates and inflames the Achilles tendon. Among athletes who develop Achilles tendinopathy, 60 to 80% had a sudden change or increase in training intensity or duration prior to the injury. Often, Achilles tendonitis is accompanied by alterations in the structure and mechanical properties of the tendon, changes in lower extremity function, and fear of movement, which limits sports performance.

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Normally, there is a gradual onset of symptoms. Symptoms can include:

• Pain and stiffness at the back of the heel and ankle

• Tightness in the calf muscles

• Decreased strength and endurance in the calf muscles

• Stiffness in morning or after prolonged sitting

• Pain with palpation along the tendon

• Pain when running or jumping

Factors that can contribute to the development of Achilles tendinopathy include:

• Sports involving repetitive running and jumping

• Sudden increases in training duration, mileage, or intensity

• Being a weekend warrior, who exercise only on the weekends

• Lack of recovery time

• Training on uneven surfaces

• Decreased plantar-flexor strength

• Deficits in hip neuromuscular control

• Increased foot pronation

• Tight or weak calf muscles

• Bones spurs on the heel that rub the tendon

• Flat arches or overpronation (ankles that roll down and in when walking)

Physical Therapy for Achilles Tendinopathy 

Physical therapy exercise rehabilitation is the best intervention to address Achilles tendinopathy, restore strength and function in the lower extremity, and ensure a safe return to sports competition. The physical therapist conducts a thorough evaluation of the patient, assessing the strength and endurance of muscles in the calf and foot, motion of foot and ankle joints, muscle tightness, gait, and other functional movements. Full recovery from an Achilles tendinopathy injury can take between 3 to 6 months and up to a year depending on the severity of the injury; re-injury is quite common, particularly if return to sport is rushed.

Exercise rehabilitation works to provide mechanical load to the tendon to promote remodeling, decrease pain, and improve calf-muscle endurance and strength and lower leg function. Rehabilitation can include manual therapy to the calf muscle and Achilles’ tendon and mobilizations of the foot and ankle joints to decrease pain and gently restore range of motion. Exercise interventions can include eccentric exercises, which build strength in the calf muscles and Achilles tendon by putting tension on the area as the muscles and tendon lengthen.

Mangiarelli Rehabilitation physical therapist Bobby demonstrates 4 exercises to address Achilles tendinopathy and restore function in the lower leg:

4 Phases of Exercise Rehabilitation for Achilles Tendinopathy

1. Symptom management and load reduction: During the initial phase of rehabilitation, the physical therapist aims to stop constant overloading of the tendon and continued injury progression through activity modification. The patient rests from aggravating activities during this time, and instead engages in alternative exercises that place a lower load on the tendon, such as stationary biking. Modalities and manual therapy may be performed to decrease pain and gently restore range of motion in the ankle and foot. Exercises begin with heel raises.

2. Recovery: At this stage, the physical therapist works to regain strength in the patient’s calf muscles and improve the Achilles tendon’s tolerance of various loads. Exercises are progressed by increasing the number of repetitions, range of motion, and speed of movement. Heel raises are advanced to quick rebounding heel raises to increase the tendon’s tolerance to fast loads in preparation for plyometric exercises.

   • The therapist also addresses any deficits in ankle and foot strength and hip neuromuscular control. Targeting intrinsic foot muscles with strengthening exercises helps during the push off phase when running or jumping and ensuring adequate knee and hip strength and function is needed for good lower extremity biomechanics, which takes unnecessary stress off the Achilles tendon.

3. Rebuilding: During the rebuilding phase, the therapist transitions the patient to heavier strength training of the calf muscles and starts running and jumping activities. The therapist adds an external load like a weighted vest or dumbbell to the heel raise exercises to promote tendon healing and progressive adaptation of the tendon to heavier loads. The therapist begins plyometric training and specific-sport activities at this stage.

4. Return to sport: At this stage, the athlete is ready to begin the return to sport progression and assessment to prepare for full sport participation and performance. Using heel raise and jumping tests and sport-specific functional tests as well as evaluation of symptoms after training, the therapist assesses the patient’s readiness to return to the demands of their sport. The athlete is typically placed on a training schedule that combines low-to-high level activities while ensuring proper recovery time that is evaluated every 3 weeks. Once the athlete passes these activities without symptoms recurring, additional high-level activities are added to progress toward a full return to sport performance.

Achilles tendonitis can negatively affect your ability to walk, run, jump, and play your sport at the highest level. If you are experiencing pain in the Achilles tendon, consult with a physical therapist to regain function, manage pain, and return to activity safely.