Treating a Different Kind of Achilles Tendon Pain

By Sarah Ryerson, PT, ATC, CSCS for Athletico Physical Therapy

Calf stretching, ice and activity modification are commonly used as treatment for those who suffer from Achilles tendinosis. However, when traditional treatment fails to relieve symptoms, the problem may be in the diagnosis.

Achilles tendon pain localized in the heel (known as insertional Achilles tendinopathy), can benefit from different treatment than when Achilles pain is present in the mid-portion of the Achilles tendon (known as intertendendinous Achilles tendinopathy). Mid-portion Achilles tendinopathy is primarily a tensile loading problem involving the ability of the Achilles to resist stretching, while insertional Achilles tendinopathy is a compression issue.

When the ankle is loaded, which occurs when placing full weight on the foot during walking, the Achilles tendon is stretched and becomes compressed against its attachment site on the heel. This flat foot loaded position, placing the ankle in a position of maximal dorsiflexion, is also the position for stretching the calf. It is easy to understand why calf stretching would only compress the tendon and exacerbate the condition further. Therefore the best treatment includes avoiding stretching the Achilles. Other helpful treatment strategies include:

  • Discontinue running, especially if symptoms are provoked for more than three hours following a run
  • Avoid running uphill or extensive stair climbing
  • Avoid wearing minimalist running shoes, flat shoes such as flip-flops or walking barefoot
  • Use a heel lift in shoes, wear shoes with a heel (wide sole tennis shoe or wedge < 2″), or tape the Achilles or ankle to avoid excessive stretch on the Achilles
  • Use ice as needed to manage symptoms
  • Strengthen the calf in a protected position

Once the symptoms have resolved during general walking and stairs, calf strengthening can be initiated. Begin with calf raises in a shorted position (small book placed under heel) and progress to single leg calf raises from the floor. Avoid calf raises incorporating a heel drop off the edge of a step. Instead work to develop the amount of load the tendon can withstand by adding weight using a weighted backpack or weight vest. Pain should always be a guide with avoidance of soreness for greater than 2-3 hours following exercise.

It is important to note that these guidelines provide a basic recommendation for treatment and all conditions are unique, so always seek a comprehensive examination should self-management fail to resolve the symptoms. The entire lower extremity often contributes to the cause of the pain and the tendinopathy may return if the source of the problem is not properly addressed. Therefore, an evaluation or free injury screening by an experienced physical therapist at Athletico Physical Therapy can help you target the source of the problem and get you back on your feet and running.

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