In the second part of the article series focusing on the Achilles tendon, physiotherapist Mark Buckingham gives advice on treating your Achilles yourself.
Mobilisation
The Achilles has to be elastic and mobile. The damaged areas become stiff and mobilisation of the whole tendon is essential. 2 minutes 4 times a day.
The sheath around the mid-tendon in long term problems can become stuck down to the tendon itself by the nerves and blood vessels previously described, even after the repair of the tendon has occurred. This generates pain and freeing it can be very beneficial. This type of mobilisation is painful. Grip the tendon tightly and move the foot up and down to slide the tendon within the sheath whilst you try to grip the sheath. 2 minutes twice a day, every other day.
The mobilisation of the tissues takes a couple of weeks to start showing changes and a couple of months to change tissues back to normal levels of flexibility. Stick with it.
Stretching
The default treatment for Achilles pain seems to be ‘Stretch it! However, tightness in the calf is not always the issue.
You can test the calf length. You should be able to flex the foot up 20 degrees beyond 90 without the foot deviating to the side (see Picture 2 for an example.) If you have good range then you join the ranks of many patients with Achilles pain where length is not a problem – so why stretch it?
If there is tightness then whilst stretching can be helpful in the classic sense it is often better in Achilles issues to use a roller – 2 minutes 4 times a day ideally. This is because the lower part of the calf to Achilles is very fibrous and does not respond that well to simple stretching but is often the cause of much of the tightness.
Strength
Alongside biomechanics and gait described in Self-Assessment of biomechanics this is the biggest issue. The calf and Achilles simply have to be strong enough to cope with the demands placed upon it. In simple terms running puts up to 5 times body weight through the tendon each step. Add in the complications of excessive load in one area from poor mechanics and not surprisingly there are issues.
A basic requirement for any runner is the ability to perform 25 single leg heel rises off the edge of a step, 3 sets in a row with a 30 second rest in between. My preferred standard is 3 x 25 heel rises plus up to 25kg on the back.
Eccentric Heel rises
The research in the past few years has shown that heel rises performed ‘up on 2, down on one’ 3 x 15 several times a day produces results. My experience with runners shows that whilst this is useful and a considerable improvement on the old advice of rest, it is simply not enough to condition the tissues to the demands of running. There is still on-going research into the possible benefits of just eccentric versus eccentric and concentric (Just lowering rather than rising and lowering).
Until we have a better idea about this I hedge my bets and ask patients to do both. A typical program would be to aim for 3 x 25 up and down followed by 3 x 25 just lowering 3 times a day, plus 25kg. You will certainly get stronger!
Smith Machine or Squat rack
The use of a squat rack to add extra load to the tendon is an excellent tool and allows load to be applied safely.
Additional Areas
Foot invertor strength – Tibialis posterior
Covered in detail in self-assessment of biomechanics. this muscle is essential to good foot mechanics and thus bears repeating here.
3 times 15 against an elastic band – has to be tough or against a pulley machine in the gym. Foot turn in or inversion needs to be isolated from whole leg turn in.
Gluteals – Especially Gluteus Medius
The strength and control required to keep the knee over the top of the foot comes from the Gluteals. Again, this is an area covered in Self-assessment of Biomechanics but the exercise below is a good place to start. Stand with the affected leg furthest from the wall, feet parallel. The wall knee pushes into the wall and the standing leg is held solid. You should feel it in the gluts after a few moments. 2 minutes building to 5 minutes.
Hopping Drills
Once you have achieved a standard of 3 x 25 heel rises with at least 15kg it is time to start hopping and lunging work as the precursor to running. These are once a day.
Hops on the Spot
These have to be barefoot and the process is 2 hops on the spot and then hold for 2 seconds, 2 hops and then hold for 2 seconds – repeated for 3 sets of at least 15.
This needs to be pain free. The emphasis is on good alignment and control of the knee over the foot. The foot should not roll inside the foot.
Backwards Lunges
Step / hop back from the unaffected foot to the affected foot, hold briefly the drive forwards back to the unaffected foot and repeat. The force should be absorbed through the foot by ensuring the foot is strong and springy. Do not let it collapse to the floor by letting your heel touch. 3 sets of at least 15 reps. This acts as a dynamic eccentric exercise.
Achilles Tendon Part 3 - Timescales For Healing, Rehab, And Returning To Running -->
