Conservative Care For Mid-Portion Achilles Tendinopathy

Author(s): 
Kent Sweeting, B.Hlth.Sc.(Pod)(Hons)

   Activity modification and tendon loading are important concepts for both the patient and therapist to grasp. Some tendon loading activities are beneficial. Not enough or too much can be harmful. I will often tell my patients that 4 out of 10 is the “magic number” on a 0 to 10 visual analogue scale (VAS). Any pain below 4 is acceptable. If the pain goes above 4, the activity should stop.

   Tendons also require a relatively constant load so look for a sudden change in tendon loading activities in the patient history. Be aware that athletes with a history of tendinopathy who undergo off-season surgery are prone to developing the problem again. A sudden decrease in tendon load associated with the recuperation from surgery in another area will put the tendon(s) at risk. For example, if the athlete is undergoing upper limb surgery, ensure that he or she continues with the Achilles tendinopathy treatment program.

How Patients Can Benefit From Eccentric Loading Exercises

While Curwin and Stanish first identified the importance of eccentric loading exercises in the treatment of tendinopathy, Alfredson and colleagues are credited with scientifically evaluating a 12-week program of eccentric loading exercises for mid-portion Achilles tendinopathy.3,35 //There are some significant aspects of the protocol of Alfredson and co-workers that one should stress to every patient.3

   First, the protocol involves no concentric contraction of the affected side. The aim is to achieve a full eccentric range off the edge of a step with full body weight on the affected side. Ensure that patients start in a fully plantarflexed position (on tiptoes) on the affected side with no weight on the unaffected side. Patients should lower their feet down in a controlled manner until the ankle is in a fully dorsiflexed position. As soon as patients get into the fully dorsiflexed position, they return the unaffected foot to the step and remove the affected foot. Then they return to the starting position by concentrically contracting the unaffected side to return to the fully plantarflexed position.

   Applying the “no concentric contraction on the affected side” rule can obviously be more difficult when the patient has bilateral pain. In these cases, I will ask patients to do the exercises on a staircase with handrails on both sides. In using this approach, when the ankle gets down into the fully dorsiflexed position, patients can push back up to the starting position using their arms, thus avoiding any concentric calf contraction. If they are unable to find the appropriate location or lack the upper body strength to do this, a compromise must occur. In these cases I will instruct patients to distribute their weight evenly across both feet to push back up concentrically to the starting position.

   The second important factor with the eccentric loading exercise protocol is that pain is normal. As mentioned above, pain above 4 out of 10 on the VAS means the patient is loading the tendon too much. Pain below 4 out of 10 is normal and may even encourage tendon healing. The protocol that Alfredson and colleagues published was three sets of 15 repetitions of each exercise (straight and bent knee), twice daily for 12 weeks.3 One may need to adjust this for some patients in the early stages so their pain is below 4 on the visual analogue scale.

   I also enforce the “no more pain than 4 out of 10” rule to other activities and exercise. I will usually allow patients to do some walking or running as long as they do not experience pain above 4 out of 10 on the VAS both during and after their exercise (particularly the morning after). One must explicitly state this to the patient: pain above 4 out of 10 will be detrimental while pain below 4 out of 10 will be beneficial. Also ensure the patient knows that the pain may get worse before it gets better. This phenomenon may be related to the damage to the neovessels in the early stages of treatment.

Comments

crstuart's picture

Excellent explanation and recommendation on the technique of "no concentric contraction on the affected side."

I have a patient who has suffered with chronic post-static dyskinesia in the Achilles tendon mid-substance area for 2 years. He has slight discomfort before running, the pain subsides with running and then the pain returns about 1 hour after running.

X-rays show a large Os trigonum and MRI is negative for inflammatory changes around the OS, Achilles or FHL. Is it possible that this Os is just an incidental finding and that the focus should be on eccentric stretching? This large Os somewhat limits his ability to raise onto his toes and plantarflex his foot. Surgical excision of the Os may allow more plantarflextion but is it worth the risks of painful scar tissue formation, neuritis, etc.? Five weeks of physical therapy helped relieve the pain but within 3 weeks of easing back into a jogging routine, the insidious onset of pain returned.

Certainly, the patient history sounds like Achilles tendinopathy. Did the MRI or physical exam demonstrate thickening of the Achilles tendon? Is the Achilles tendon tender to palpate (see '"What to look for in the examination" section)? The os trigonum could be a red herring. Perhaps you could try the eccentric program +/- a corticosteroid injection around the os trigonum. Good luck!

Great work Kent!

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