What Should I do for Achilles Tendonitis?
Ever been told you have tendonitis?
Maybe you were formally diagnosed, or you did some googling and settled on tendonitis… either way, there was pain in or around an area where the thick band of tissue attaches to the bone.
Let's say it actually was tendonitis. What should you do? Stretch, roll it out, ice it, strengthen it, let it rest... TOO MANY OPTIONS!
First, we have to make sure you know that a tendon is what connects the muscle to the bone.
The word tendonitis sounds a lot more complex than it really is. Basically, it means that the thick white strip of tissue (tendon) became irritated or inflamed (itis) for some reason.
Commonly, the irritation occurs when the demands of life exceed the abilities of the tendon. (ie. too much weight, too much repetition movement, too quick of a movement). Tendonitis is common in strength and conditioning settings because repetitive physical actions may to lead to overuse (1).
It is also important to mention that tendonitis is more of a “blanket term” - referring to any issue where the tendon is super sensitive and easily irritated when challenged, regardless if its new or been around for a long time (2).
So,
One of the most effective ways to address tendonitis is with time. Time under tension, that is. This means, prolonged periods of tension, done by moving your joint slowly, repetitively or holding the joint in one place for a prolonged period. Eccentrics (the “down” portion of most lifts) were the most common way to accomplished this increased time under tension, popularized after a study done in late 1990’s (3). With time, we have come to realize that we don’t need to emphasis eccentrics, as long we are loading the tissues heavy enough to create change on a mechanical/cellular level (4).
Another technique that is widely accepted as an effective way to address tendonitis is “progressive loading.” In other words, progressively increasing resistance/load on the tendon to create adaptions on a cellular level that will leave the tendon more durable and less painful. We are looking to challenge the tissue at roughly an 8/10 intensity (aka only able to do 2-3 more reps before failure), while keeping pain levels < 4/10 (2).
Here are a few example exercises using the Time and Progressive Loading techniques to address achilles tendonitis.
Prolonged Hold (Isometrics)
Calf Raises Holds
3 sets, 30 seconds each
Heavy Slow Resistance
Single Leg Calf Raises
3 sets, 15 reps/side.
3 seconds up, 3 seconds down using a weight that feels like an 8/10 difficulty while keeping pain <4/10 (5)
Reptition
Double Leg Calf Raises
3 sets, As Many Reps as Possible in 60sec. @ 1s up, 1s pause, 1s down, 1s pause tempo
_____
Each example has the potential to create a challenge for calf, ankle, and foot for an extended period of time and at an intensity that will elicit adaptions int he tendon, leading to improved function and reduced pain. I would not recommend doing all three in the same session, or even the same day. Pick one and stick with it for a few weeks, mixing it in to the routine 2-3x a week.
What about ice, heat and pain killers?
At the end of the day, it is important that you are not in so much pain that you cannot complete your required daily tasks. If you are in need of pain relief, then you may choose to use ice, heat or NSAIDs. That being said, while NSAIDs can be an effective tool for reducing pain or inflammation, they “should be used judiciously because they reduce pain by inhibiting the body’s innate inflammatory and repair responses” (6).
If you really want to see what ice can do for you, go for it! I usually tell folks, try about 15 minutes, just to blunt the spike in pain. No need to feel like you should be icing multiple times per day to assist in the recovery. As always, ensure there is a layer between skin and ice, to prevent skin injury.
Heat can be a nice way to free up the area prior to movement. So if the tendon is so tight and irritable that you cannot get moving (ie walking int he morning, working out in the gym, etc.) then consider trying about 10-15 minutes of moist heat to increase blood flow, loosen things up and reduce the pain in the area. As always, ensure there is 2 layers between skin and heat, to prevent skin injury.
Welp…. there ya have it - an INCREDIBLY BREIF guide on how I would consider addressing achilles tendonitis. It goes without saying that this is not medical advice and that the ideal approach will differ for each person. It is also important to note the the “best” way to address something is forever changing as research is published. Whenever reading articles like this, digest it with the understanding that there is rarely a “best” way, but instead a combination of of ideal/techniques from a variety of sources.
Hope this helped!
Dr. Tyler Kallasy, PT, DPT, CSCS, PPSC
Disclaimer: The information is for educational & informational purposes only. It is not intended to diagnose or treat any medical conditions, nor is it to replace a proper assessment for a qualified professional. If you are in pain, please consult with your medical professionals.
Resources
Gearity, Brian T, and Gabrielle Smith. “Reframing Inflammation in the Tendon Repair Process.” NSCA Coach, vol. 2, no. 5, Nov. 2015, https://www.nsca.com/education/articles/nsca-coach/reframing-inflammation-in-the-tendon-repair-process/. Accessed 24 Jan. 2023.
DPT, Ray Gorman PT. Retain - An Engage Movement Course.
Alfredson, H et al. “Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.” The American journal of sports medicine vol. 26,3 (1998): 360-6. doi:10.1177/03635465980260030301
Morrison, Scot, and Jill Cook. “Putting "Heavy" into Heavy Slow Resistance.” Sports medicine (Auckland, N.Z.) vol. 52,6 (2022): 1219-1222. doi:10.1007/s40279-022-01641-y
Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43:1704–1711. doi: 10.1177/0363546515584760.
Gross, MT. Chronic tendinitis: Pathomechanics of injury, factors affecting the healing response, and treatment. Journal of Orthopaedic Sports Physical Therapy 16(6): 248-261, 1992.
