The Achilles tendon is one of the coolest tendons in the body.
While many body parts are named in Latin or Ancient Greek, the Achilles tendon draws its name directly from Greek mythology.
For those who don’t know the story:
Achilles was a hero in Greek mythology and one of the main characters that participated in the Trojan War. He was also the protagonist of Homer’s epic, the Iliad.
When Achilles was born, his mother wanted to make him immortal and thus, dipped him in the river Styx. However, she did not realise that his heel, by which she held him, was not touched by the waters, and so that was the only part of his body that remained mortal. (1)
Achilles was then struck down in battle by an arrow through his heel, or more accurately, his tendon, hence we name it the Achilles tendon.
The Achilles Tendon Is Strong
The job of a tendon is to transmit the force developed by a muscle to the bone to which it attaches. The Achilles tendon is one of the thickest and strongest in the body, and allows us to walk, run and jump efficiently. It’s almost like having our own springs in our legs. In fact, when we run, the Achilles tendon deals with forces up to 12.5 times our body weight – for me, currently weighing around 87 kg, that is 1087.5 kg!
But It Still Gets Injured
One of the most common forms of injury to the Achilles tendon is to develop an “overuse tendinopathy”.
An overuse tendinopathy, or more accurately, an overload tendinopathy, occurs when the loading on the tendon causes an increased rate of tissue breakdown, beyond which the body can keep up with. This results in inflammation, swelling and pain localised to the tendon.
Side note: all tissues in the body are in a constant state of breakdown and building, it’s when the rate of breakdown is increased beyond the body’s repair capacity, or the body’s repair capacity is impaired, that we see problems.
We Don’t Know Exactly Why
Researchers haven’t been able to isolate a single variable that causes Achilles tendinopathy (surprising eh?), but the following are implicated:
- Running (recreationally and competitively)
- Participation in other sports like track and field, racquet sports, volleyball and soccer
- Use of certain antibiotics (fluoriquines)
- Biomechanical issues at the feet
- Age, gender, height and weight
- Injury history, like previous ankle sprains
What we don’t know, is exactly what happens that makes the tendon painful.
We Don’t Even Know Why They Get Better
With Achilles tendinopathy, we will often see symptoms that correlate with structural changes early on in the clinical history, but as the condition progresses and goes on for longer, this correlation becomes weaker and weaker.
In fact, in many cases, it has been shown that diminished or even absent pain is accompanied by little to no structural change to the tendon!
We Do Know What NOT To Do
You’d think that simple rest would therefore be best for an Achilles tendinopathy, however, that’s not the case. Too much rest and we lose conditioning of the tissues, and thus our capacity is reduced, leading to recurrence, only this time it takes less and less loading to aggravate.
We also know that taking anti-inflammatory drugs is not the best approach either. Firstly, there isn’t strong evidence to suggest inflammation is the primary cause of pain. Secondly, anti-inflammatory drugs have side effects. Thirdly, anti-inflammatory drugs can impair healing.
Stretching tendons also gets a bad rap, though I’m not sure why this is a blanket no. Some tendon injuries respond to being stretched (it’s simply a form of load), while others do not. You’ll see why below.
We Also Know What Works
In the physiotherapy world, where much of the research on tendinopathies is done, load management strategies combined with targeted exercises are currently the treatment with the best supporting evidence.
The actual type and dosing of the exercises has not been fully established, though we do know that you can push the loading higher than you would expect, even if it is painful.
You can use different types of exercises:
- Eccentric where you load the lengthening portion of movement
- Isometric: where you load the tendon without lengthening or shortening it
- Concentric/Eccentric: where you load the tendon in a full range of motion (lengthening and shortening)
To my knowledge, the best approach has not been established in research, and in my experience, different people respond better to different approaches.
This might have something to do with some recent research that suggests there are different types of tendinopathy: compressive, shear and friction, and tensile.
As the names suggest, these imply that the tendinopathy occurs as a result of different types of tendon loading, which makes sense to me. It also makes sense that if there are different aggravating loads, the exercises which have the most benefit will also differ.
The evidence suggests avoid those loading mechanisms which are aggravating (load management), whilst stimulating the tendon with loads that don’t aggravate it.
For most people, isometrics are a good, neutral, place to start.
You can do these in a variety of ways, but one of the most accessible is to sit with your thighs under a table and feet on a block, then press your thighs into the table by raising your heels. You want to be about 70% of your maximum contraction, at least to begin with. Hold that contraction for up to 45 seconds (though I will often break it down to 3×15 second holds per set). Over time you can increase the intensity of the contraction and then progress to dynamic loading.
Sometimes exercises will hurt while you do them. That’s okay. As long as your pain doesn’t spike, or get really bad afterwards, you are stressing the tissues in a positive way.
Hands On Treatment?
This is something I learnt from my colleague, osteopath Cameron Kealy who runs Recharge Osteopathy in Melbourne, along with teaching at Victoria University.
There aren’t any studies (to my knowledge on this), just clinical observations.
Cameron will treat Achilles tendinopathy with a localised technique. He will grasp the tendon and find a position where tension is relieved and hold it – often for 5-10 mins – waiting for a tissue texture change. He will then check and treat the pelvis and upper neck. Another osteopath, Walter McKone, has also suggested the key to relieving Achilles tendinopathy is optimising blood flow by treating the pelvis.
Success leaves clues, even when there aren’t studies.
Now, we know that manual therapy doesn’t change the structure of tissues.
What is happening is likely an effect of working with the sensory nerves around the tendon.
But if a person’s pain decreases, allowing them to load again and return to activity, I’m all for it.
This Makes It Work Even Better!
At the moment, one thing that all this focus on localised exercise for tendinopathy is doing, is forgetting that the injured and painful tendon is part of the body, which is considered a whole.
After all, the blood that supplies our tendons also supplies everything else.
The nervous system that perceives the tendon also perceives everything else.
The nutrients delivered to the tendon are, you guessed it, also the nutrients delivered to everything else.
Once we have labelled the tendinopathy, the more important thing to do is to look at the health of the person.
In fact, this is the premise of osteopathy: find the health within the person, and remove the barriers to that health being expressed.
After all, it isn’t lack of exercises that cause a tendinopathy, it is lack of capacity. Exercise can increase physical capacity, no doubt about it.
However, lack of capacity can be cause by sub-optimal physiological function, and not just poor load tolerance. For example, impaired blood flow.
And, as I have discussed before, it is often easier and more efficient to “remove the handbrakes” to performance/health, than it is trying to force adaptations.
Enter The ANS
The autonomic nervous system (ANS) regulates physiological function in our bodies.
It is controlled by lower brain centres – that means we don’t have direct conscious control over it. This is a good thing, as regulating all the systems in our body is a lot of work.
Having a balanced ANS is important for health. When the ANS is over or understimulated, so that it skews towards one state too much, health is affected.
This is where it gets really interesting.
The School Of Physiotherapy at The University of Otago has been doing some interesting research (and research that should be done by osteopathic schools, but that’s another issue altogether) on the effects of manual therapy and the ANS.
Recently, one of their PhD students looked at whether spinal manipulation, delivered to the thoracic spine (which is where many important ANS centres are located) would have any effect on recovery from Achilles tendinopathy.
First, they did a review on the effects of manipulation and the ANS. That is, they looked at all the research on the topic to see if manipulation affected ANS function in any way. They found a positive relationship.
Then, to look at whether this would affect recovery from Achilles tendinopathy, the researchers created two groups: a control, which received usual care for Achilles tendinopathy (read: exercises) and the intervention group, which received usual care plus spinal manipulation.
The group receiving the spinal manipulation made better improvements in both pain and function compared to the usual care group.
Whilst only a pilot study, this is promising. It suggests that improving whole body, or rather whole person, health and function, is the most optimal way to treat Achilles tendinopathy.
Future studies will need to look at whether this was a specific effect of spinal manipulation, or a general effect of manual therapy, however, my gut feeling is that the researchers are onto something.
Don’t Forget The One Percenters
Finally, when we are really seeking above average results, we can add the extras, which can help take things from good to great.
These extras wouldn’t be classed as treatment on their own, but they enhance what you are doing already.
In my opinion, these extras are what should define private healthcare. This is what you are paying for. Not just “usual care”, which is offered by the public health system, but exceptional care, with exceptional results to match.
Some of these “one percenters” can include:
- A tailored, not generic exercise plan
- Specific nutritional strategies, including supplementation advice
- Behavioural and mindset coaching (we know that mindset is an important factor in recovery from injury)
These are not specific to Achilles tendinopathy, but they can definitely play a role in addition to the treatments mentioned above.
If you are suffering from Achilles tendinopathy, the two most important things you can do to manage/treat it are:
- Load management: avoiding/reducing aggravating movements initially
- Build capacity: use loading/exercise strategies to build capacity in the tissue and inhibit pain
However, while these strategies would give you the majority of benefits, if you are looking to optimise your recovery, then there are more options available.
I’ve outlined some of these options, which you give you a clue as to how you can really enhance your recovery from an Achilles tendinopathy injury.
As with everything, it comes down to you.
The two big questions any osteopath worth their salt should ask are: what do you want, and what can you do to achieve it?
Some interventions are not realistic because of cost, availability or other reasons. Whatever your situation, your treatment approach should be optimised for you.
That means treatment for Achilles tendinopathy should have a whole person focus, and not just a tendon focus.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.