Physiotherapy - Achilles Tendinopathy

What is your Achilles tendon?

Your Achilles tendon is a strong band at the back of your ankle. It joins your calf muscles to your heel.

You need this tendon to:

• Walk
• Run
• Jump
• Stand on your tiptoes

What is Achilles tendinopathy?

Achilles tendinopathy means your tendon is:

• Sore
• Swollen
• Stiff

This happens when you use the tendon too much.

What can cause it?

You may get Achilles tendon pain if:

• You suddenly do more exercise
• You change your activity, like running faster or longer
• You change your shoes
• You put too much weight or pressure through your tendon

Some health conditions make it more likely:

• Diabetes
• High cholesterol
• Being overweight

Two types of tendinopathy

There are two places where the tendon can hurt:

1. Bottom of the tendon where it joins the heel. This is called insertional Achilles tendinopathy.
2. Middle of the tendon (a bit higher up the leg). This is called midportion Achilles tendinopathy.

Common symptoms:

• Pain at the back of the heel. The pain may spread up into your calf
• Pain is often worse in the morning or after sitting still. It may feel better once you start moving
• You may notice swelling or a small lump. This is normal and part of healing

Risk factors (things that can make it more likely)

You are more likely to get Achilles tendon problems if you have:

• Changes in activity (doing more, doing it more often, or on a different surface)
• Being overweight
• Poor diet
• High cholesterol
• Diabetes
• New or different shoes
• Past injuries
• Older age
• Flat feet or high arches (foot posture)
• Tight calf muscles
• Inflammatory (painful swelling) conditions, like arthritis
• Legs that are different lengths
• Some medicines including:
  ○    Steroid tablets or injections
  ○    Certain antibiotics (quinolones)
  ○    Statins (for cholesterol)
  ○    Aromatase inhibitors (used in some cancer treatments)

What can I do?

Resting all the time will not heal your tendon. You may need to change how you do some things. You should try to keep moving in safe ways.

What can make pain worse and what you can do instead (helps the tendon)

1. Walking barefoot, wearing flip flops, or wearing very flat shoes can make the pain worse - Instead wear supportive shoes with a back, a soft heel or a small heel lift (orthotic).
2. Walking through pain can make the pain worse - Instead try cycling or swimming (both are kinder to the tendon).
3. Sitting still for too long can make the pain worse - Instead stand up and move every 30 minutes. 

Staying active

It is important to keep moving. Being active helps to strengthen your calf muscles. Strong calf muscles take pressure off your Achilles tendon and help it heal.

Pain levels

• Some pain is normal
• You may feel pain in the morning or after exercise
• A pain level of up to 5 out of 10 is okay
• If your pain is more than 5 out of 10
  ○    Do less or
  ○    Change what you are doing

Choose your exercises by thinking about:

• How much pain you have
• What you feel able to do

When to get help

If pain is stopping you from doing your exercises, talk to your GP. They may give you pain relief to help you carry on with rehab.

Weight management

Being overweight can put extra stress on your Achilles tendon. This extra weight can make the tendon sore and slow down healing.

Having more body fat can also cause more painful swelling in the body. This can make your tissues more sensitive and take longer to get better.

If you want help with managing your weight, talk to your GP.

Exercises

Strengthening exercises are the best treatment for Achilles tendon problems.

These exercises help the tendon get stronger over time.

Healing can take:

• 3 to 12 months
• Sometimes longer

Everyone is different. Go at your own pace and move to harder exercises when you feel ready.

Flare ups

Sometimes the pain may flare up. This is normal. If it does not settle after 2 weeks, ask for more advice.

How to use the exercises

• The list starts with the easiest and goes to the hardest
• Start with the first exercise
• You can move to the next level if your pain is below 5 out of 10

Resisted seated heel raises

1. Start with your heels on the floor. Bend your knees so they are a right angle (90 degrees).
2. Press down on your legs with your hands.
3. Lift your heels slowly off the floor. Push mainly through your big toe.
4. Hold the position for 30 seconds.
5. Slowly lower your heels back down.

Repeat 4 times.

To make it harder (if you want to)

You can make this exercise harder if your pain is below 5 out of 10.

Before you lift your heels put a weight on your knee. You could use a bag filled with books or other things.

Bridge with heel lift

1. Lie flat on your back. Bend your knees and keep your feet flat on the floor or bed.
2. Push down through your heels. Lift your buttocks/hips up off the bed.
3. Shift your weight forward onto your toes. Lift your heels up. Hold this for 3 seconds.
4. Bring your hips and heels slowly back down to the bed.

Do as many as you feel able to in 2 minutes.

To make it harder (if you want to)

You can make this exercise harder if your pain is below 5 out of 10.

Before you lift your hips put a weight on your pelvis. You could put a bag filled with books or other things on your hips.

More progress

When you feel ready, you can try pushing through only your sore leg. This makes the exercise harder and builds more strength.

Seated heel raise

1. Stand with your back flat against the wall. Keep your feet on the floor, a short distance away from the wall.
2. Slowly slide your back down the wall. Stop when you are as far down as you feel able to be.
3. Push through your toes. Lift your heels off the floor.
4. Hold this position for as long as your pain stays below 5 out of 10.
5. Slowly lower your heels back down to the floor.
6. Slide your back up the wall to return to standing. Repeat for 2 minutes, doing as many as you feel able.

To make it harder (if you want to)

You can make this exercise harder:

• If you can hold this for 20 seconds and
• If your pain is below 5 out of 10

Before you lift your heels put a weight on your knees. You could use a bag filled with books or other things.

Standing double leg heel raise

1. Stand with your feet flat on the floor. Hold onto a steady surface (like a counter or chair) if you need support.
2. Keep your legs straight.
3. Push through your toes and lift your heels off the floor.
4. Hold this position for as long as your pain stays below 5 out of 10.
5. Slowly lower your heels back down to the floor. Repeat for 2 minutes, doing as many as you feel able.

To make it harder (if you want to)

You can make this exercise harder:

• If you can hold this for 20 seconds and
• If your pain is below 5 out of 10

Hold a weight - carry a bag filled with books or other things.

Standing heel raise: up with two and lower with one

1. Stand with your feet flat on the floor. Hold onto a steady surface (like a counter or chair) if you need support.
2. Keep your legs straight.
3. Push through your toes and lift your heels off the floor.
4. Stand on your sore leg. Lift your unaffected (good) leg off the floor. You should be standing on only your sore leg.
5. Slowly lower your heel back down to the floor. You should still be standing on only your sore leg.

Repeat for 2 minutes, doing as many as you feel able.

To make it harder (if you want to)

You can make the exercise harder if you can do the exercise 10 times easily.

Hold a weight - carry a bag filled with books or other things.

Often the above exercises are enough to get the tendon better over time. Talk to a physiotherapist if you want to get back into sport.

They will give you advice about the next phase of rehab.

Footwear

For now, wear trainers or shoes with a soft, cushioned heel. This can help reduce pain.

Try to avoid:

• Walking barefoot
• Flip flops
• Backless shoes
• Very flat shoes

These shoes put more stress on the tendon.

Extracorporeal Shockwave Therapy (ESWT)

This treatment uses a machine that sends sound waves to the painful area. The goal is to help the tendon heal.

Important points:

• It is not always available
• We use it together with other treatments
• We only use it when other treatments have not helped

Injection treatment

If the usual treatments do not help, we may send you to a specialist.

• We do not use steroid injections for Achilles tendon problems. They can damage the tendon
• Your specialist may talk to you about other types of injections

Surgery

• We do not often need to use surgery
• We only think about surgery when all the other treatments have not worked
• Your specialist will talk to you about this

Imaging

We do not need scans to decide if you have Achilles tendinopathy.

We may use a scan if:

• Your symptoms are different to most people
• Your pain is not getting better
• To help us find the cause
• They may guide which other treatments to use

The scan may be an Xray, an ultrasound or an MRI.

Warning signs

Get medical advice if:

• Your symptoms are new or getting worse
• You feel unwell because of the pain
• You are under 16 years old

When to get urgent help

These symptoms are very rare. If they happen, go to your Urgent Care Centre straight away:

• Sudden Achilles pain with a “pop” or snapping feeling
• You cannot put weight on your foot or ankle
• A new injury to your leg, foot or ankle
• Your calf swells up
• Your foot, ankle or calf changes colour
• Your foot ankle or calf stays hotter or colder
• •   You lose weight when you do not expect to

If your symptoms are not getting better

• Your leg should start to get better in 6-8 weeks. If it is still no better speak to your doctor. Ask to see a physiotherapist
• If your leg is getting better, even if it seems slow, keep going. It can take up to 3 months