Achilles Tendinopathy

2Here at Bend & Mend we see our fair share of very impressive hard working bankers who shoehorn as much marathon running/cycling/triathlons into their free time as possible. Unfortunately it doesn’t always work out. Typically endurance athletes, (that’s you) alternate periods of intensive physical training with periods of rest and recovery. An imbalance caused by overly intensive training and inadequate recovery leads to a breakdown of cell repair mechanisms and eventual tissue breakdown, usually about a week out from race day!!

Physicians have historically referred to overuse injuries of tendons as “tendinitis,” suggesting that the underlying process is inflammatory but histopathologic (looking at tendon tissue under a microscope) studies show that most overuse tendon injuries are degenerative, not inflammatory.

These tendon injuries are characterized by collagen fibre degeneration and disorganisation and an apparent “stalled” healing response. It is more accurate to use the term “tendinopathy” for these overuse injuries

The recognition that overuse tendinopathies are degenerative rather than inflammatory has important clinical implications. Any of you unfortunate enough to experience a tendinopathy will know they are SLOW to recover, they often require significant activity modification and rest, and may or may not respond favourably to non-steroidal anti-inflammatory drugs (NSAIDs) such as Voltaren, Ibruprofen or injected corticosteroids. Relative rest is a fundamental component of management.

The usual history of an Achilles tendinopathy is a gradual and insidious onset of pain in the Achilles tendon. In mild cases, symptoms may be present only during exercise, whereas in more severe cases, the pain will interfere with normal daily activities.

This can sometimes be attributed to your saddle position or foot position on the pedal, pedal stroke or running technique so it is a good idea to get your bike or your running style checked out if these problems persist.

Thankfully there is a well-documented and extensively researched treatment program and we at Bend + Mend know all about it, eccentric strengthening. Discovered by a frustrated physiotherapist/ runner who was determined to rupture his chronic Achilles tendinopathy he discovered with intensive eccentric strengthening exercises his pain levels actually decreased. Later in histological studies it was shown that eccentric strengthening actually helps to stimulate tissue repair.

The protocol he developed for treating Achilles tendinopathy consisted of high repetitions of heel drops off a step with your knee bent and repeated with your knee straight. See video on YouTube here.

As I mentioned tendinopathy problems can be slow and usually need a specific management plan so if you notice yours don’t delay, give us a call at Bend + Mend today.

2 Comments

  1. Paul Freeman
    May 13, 2013

    How many of the bent and straight knee heel drops do you need to do?

    Reply
  2. Blake van Koesveld
    May 15, 2013

    Thanks for the question Paul.

    I’ll try and give you a good idea. We’ll have to presume that you’re asking about a classic case where pain is confined to the middle portion of the tendon and did not result from a particular moment of injury, but from overuse.  
 
The shortest answer is ‘quite a lot.’ The landmark study on the effectiveness of heel-drop exercises used a total of 180 repetitions the day. This was three sets of 15 with a straight knee, then three sets of 15 with a bent knee, repeated for two sessions per day. Every day. For twelve weeks. It is a demanding programme but remember the patients all suffered from chronic pain and for them, the results were excellent.

    The other key feature of the programme is that in order to work it should bring on some of your Achilles pain. Some pain but not disabling pain. One rule of thumb is that by the end of the each session you will have some Achilles pain but it will be less than 5 out of 10 (where zero is no pain, 10 is the worst pain of your life) and also that this pain resolves within an hour. In practice, the correct number is whatever will bring on this amount of pain.  
 
Teething problems early on (such as calf muscle or foot complaints) are not uncommon and should be checked out. Depending on the examination of the patient, I sometimes recommend an altered programme to begin with to see how your tendon responds and to avoid flare-ups.

    I hope this helps and that things go smoothly for you. Please know that the real success of this programme can often be in the details so we’d love to see you for a personal assessment, even if only to confirm the diagnosis and get you started.

    Blake

    Reply

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