Ankle Injuries

Training errors often leads to Achilles Tendinopathy.

Jun 23, 2022

The Achilles is the largest and strongest tendon in the body, it can resist large tensile forces.

However, it’s one of the most common overuse injuries, particularly in runners.

Often, this is due to training errors, suddenly overloading the tendon. The sudden overload causes repetitive energy storage and release with excessive compression. We know in the healthy person, our peak force of the calf comes in full dorsiflexion, but with tendinopathy patients the peak torque is 5-10 degrees off dorsiflexion, thus the tendons ability to shock absorb is reduced. The site of pain is localised to the tendon, either mid portion, so between 2-6cm from the insertion or at the insertion of the tendon. Pain will be experienced with loading either during, often referred to as the ’warm up effect’, it comes and goes, but may progress giving pain afterwards. We can accurately diagnose Achilles tendinopathy with the subjective tests and a couple of physical tests, which include the London Hospital and Painful Arc Test. Once confirmed we assess your function further and pain response.

Do I need a scan ?

Imaging and scans can be useful to exclude other pathologies when we suspect there is a partial or longitudinal tear of the tendon. However, it is often not helpful when we suspect a tendinopathy as positive signs are often observed on imaging, yet a person may not be experiencing any current symptoms. Thus, you can have structural changes on imaging suggestive of tendinopathy, but be symptomatic or asymptomatic. Incidentally, a positive scan increases the likelihood of developing symptoms under the right set or circumstances. For instance, if you overload the tendon and/or have biomechanical issues the tendon is more likely to become symptomatic.

How do we rehabiliate and manage an achilles tendinopathy?

Emerging research by a Consultant Physiotherapist, Professor Seth O’Neil and his team found that patients with Achilles Tendinopathy are weak in plantar flexion and that heavy isokinetic exercises improves calf power, positively influencing pain and the tendons ability to tolerate load. The calf raise is prescribed with the knee flexed, as this replicates the running position where the peak torque of the calf is usually generated. Initially, this may be using the person’s body weight pending symptom response, progressing to heavier loads. The rehab program is individualised to that person’s pain response and load tolerance working towards heavy resistance adding external load for tissue adaptations and strength gains.

Consider your pain scale when loading your tendon, monitoring its response. A  traffic light system can be useful. On a Visual Analogue Pain Scale 0-4 = GREEN; 4-7 = AMBER ; 7-10 = RED. Thus, depending how the tendon reacts, determines how we progress the loading. For instance, if you pain levels fell within the red zone in response to a loading/activity we would advise you to reduce the load or level or activity. Similarly, we will monitor the time it takes for the tendon to settle following the loading activity, which may also determine the loading progressions.  As your tendon gains strength and responds to the gradual loading ultimately, we would recommend high resistance training to low reps, high sets 3-4 times per week with rest days for tissue adaptation.

Should I stretch my calf ?

The simple answer based on current research, is there is no need. Following a calf loading program will result in sacromerogenesis, improved tissue extensibility in response to tensile forces. Thus the calf will feel less tight as it gains strenght!

Should I strengthen my gluts?

Yes, there is some evidence to suggest that runners with Achilles Tendinopathy have altered control around their gluteal. Thus, rehabilitation directed at these can be beneficial along a calf loading program.


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