The Achilles tendon runs behind the ankle, it connects the calf muscles to the heel bone. A common condition that affects this structure is called achilles tendinopathy (achilles tendinitis, achilles tendinosis), which refers to any pathology associated with this tendon. Pain is usually localized to the mid part of the tendon or its attachment to the heel bone. Patients often complain of pain and stiffness in the mornings or after prolonged periods of rest, generally it improves once they are warmed up and get moving. Physical activity/sport can further aggravate their symptoms and the pain can get worse 24-48 hours after exercise. There may or may not be swelling and thickening of the tendon, but pressing it will hurt. The Achilles tendon is used when you stand on your tippy toes, walk, run, jump or climb stairs so you will most likely find all these activities painful.
What’s the cause?
There are many factors that could increase the risk of getting achilles tendinopathy such as age, leg muscle weakness, ankle instability, poor foot mechanics, bad footwear, certain drug use and metabolic diseases. We are still unsure about the actual cause of tendinopathy but we know that it occurs when the tendon cannot withstand or adapt to the excessive loads placed on it. This can be from too much repetitive stress and not enough time for the tendon to repair which causes inflammation or degeneration of tendon structure.
What can I do? What are the treatment options?
We know that tendons need to be loaded so effectively managing load is crucial for recovery. Relative rest may help initially to offload the tendon and improve pain. Braces, taping, orthotics/ heel lifts, correcting footwear, changing training surfaces and cutting down training loads will also help to manage symptoms in the short term. Acute management may also include a combination of treatment modalities such as joint mobilisations, massage, stretching in conjunction with an exercise based intervention.
The use of corticosteroid injections is controversial due to conflicting studies. Although they can provide some temporary pain relief, there is no long term benefit. Additionally, there can be some adverse effects including weakening of the tendon and possible rupture.
Exercise - there is substantial evidence that shows exercise provides significant improvement in pain and function for those with Achilles tendinopathy. Traditionally, a 12 week eccentric loading program was the accepted form of treatment however research is now suggesting isometric exercises, heavy slow resistance training and combined loading programs yield positive outcomes for this condition.
How long will it take to recover?
Depending on what stage the tendon injury is in. If identified early, modifying training loads may allow the tendon to adapt and recover more quickly. This can take weeks to months taking into account the time required to properly rehab and progressively increase training loads to meet the patients physical demands. In the later stages, it can take up to 6 months or even longer, especially when symptoms are severe and the condition has persisted for a long time.
Some helpful exercises for Achilles tendinopathy:
Isometric calf holds have been shown to produce some pain relieving effects as well as maintain some muscle strength. These can be done in a few positions, try to hold for 30-45 second, repeat 5s, at least 3x/daily.
Seated calf raises:
Sit on a chair or bench and start with the feet on the floor about hip distance apart. Lift the heels as high as possible and then slowly lower the heels back down to the ground. Repeat 20 times, three times daily. If this is too easy, you can add a weight on top of the legs and adjust the repetitions accordingly.
Standing calf raises:
Stand with the feet hip width apart, you can use a table or chair to help you balance. Lift the heels up slowly for 3 seconds, lower down slowly for 3 seconds. Try to complete 20-25 reps for 3 sets, at least 2-3x/week. Once you are able to do that quite well, you want to increase 10%-15% body weight and continue progressing the weights incrementally each week.
Low back pain - what is it?
Low back pain, simply put, is something that most people will experience at least once in their life. It usually occurs when the capacity of your lower back has been exceeded and pain ensues. There are many different structures that may become irritated and cause lower back pain.
These episodes can vary in severity and duration. Generally speaking, in the majority of cases symptoms subside over a 4-6 week window, although on occasions it may take longer. This in itself is not something to be concerned about.
During episodes of lower back pain it can be hugely beneficial to understand the triggers that increase your back pain, and just as important, the things that alleviate your pain. Once these are managed well it can have a significant impact on controlling your symptoms. This in turn enables you to return to your normal activities as soon as possible.
How could a Physiotherapist help
A physiotherapist can help identify and correct predisposing factors to your back pain and hasten your recovery, using methods such as massage, mobilisation, taping and exercise prescription.
If you have had an episode of lower back pain the chances of it reoccurring are higher. This is due to weakening of the stabilising muscles of the back. A physiotherapist can guide you through a rehabilitation program aimed at preventing future episodes.
Important - Consult your physiotherapist or doctor if;
Below are three exercises that Dr Stuart McGill, a Canadian world-renowned researcher in spine biomechanics has devised to assist in increasing the capacity of your back, without putting undue stress through your spine.
These can be done during periods of pain and also on an ongoing basis. It is important that the correct regressions/progressions are prescribed by a skilled progressional to make sure the technique is correct and symptoms controlled.
The ‘Big 3’ exercises
1) The Modified Curl-Up
Set-up requires the hands (palms down) under the lumbar spine. This helps to maintain the natural curve of the spine during the exercise. Keeping one leg extended, bring the other up into a bent position, with the foot planted in line with the knee of the extended leg.
The abdominal muscles are braced and the elbows are slightly raised off the ground. Then elevate your head and shoulder blades off the floor. Imagine trying to lift from your sternum, not curling up through your neck. Movement is minimal and should only be a few centimetres. Maintain this for a few seconds and then slowly lower back.
It may not look like you’re doing much but if done properly you will feel your abdominal muscles working. Also make sure you breathe during the exercise and don’t hold your breath.
2) The Side Plank
Begin on your side with your elbow underneath your shoulder and your feet in a scissor position, with the top foot on front.
Tense your trunk muscles, then lift your hips up and forward so that your body is in a straight line. Make sure your body is not rolled forward by keeping your shoulders/chest open. Hold for a few seconds and then bring your hips back and down to the floor.
If you have shoulder problems try placing the upper hand over the shoulder and pulling the elbow down across the chest.
The side plank can be performed from the knees if you have decreased strength or an inability to engage the abdominal wall without pain.
3) The Bird Dog
Whilst kneeling in the all-4 position have your hands underneath your shoulders and your knees underneath your hips, with your spine in neutral position.
Gently tense the abdominal muscles, ensuring all the movements come through the large ball and socket joints of the hips and shoulders.
Simultaneously raise the opposite arm and leg. The aim is to hold both limbs parallel to the floor. Hold for a few seconds and then return them to the ground without losing the abdominal control.
Let us know if you have any questions/queries, or if you need guidance with managing your lower back pain.
McGill, S. (2015) Back Mechanic - the secrets to a healthy spine that your doctor isn’t telling you.
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