Achilles tendinopathy management: Expert rehab tips you need to know

Achilles tendinopathy management is notoriously challenging, whether this is due to tough competition schedules or the decrease in capacity that inherently occurs with chronic tendinopathy, patients can find themselves significantly limited by the condition. Providing our patients with the right tools and strategies in their rehab journey sets them up to recover quickly and come back even stronger. In this blog, I’ll outline expert physio Dr. Ebonie Rio’s approach to Achilles tendinopathy rehab and management, based on her excellent Practical.

If you’d like to learn how expert physio Dr Ebonie Rio manages Achilles tendinopathy, watch her full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

Where do we start?

A thorough assessment will help to get a baseline of your patient’s function and irritability, as well as ensuring you are actually dealing with a true Achilles tendinopathy and not another cause of posterior ankle pain (see my blog on Achilles tendinopathy assessment). The next step is to decide whether we are managing or rehabilitating the tendinopathy. The management-based approach is for athletes (or workers in certain occupations) who regularly expose their Achilles to high loads and have minimal control over their schedule. For example, an in-season collegiate basketball player’s game schedule is basically set; with such athletes, our aim is just to keep symptoms “low and stable” and not aggravate their tendinopathy further. On the other hand, a rehabilitation-based strategy is for patients with significant control over their physical activity and load, so we can dose them with a progressive exercise program.

Tendinopathy rehab starts with minimal tendon loading, and progresses to maximal tendon loading as the athlete prepares to return to sport. We’ll go through four phases, with progression through each phase determined by the athlete’s response to exercise and ability to demonstrate sufficient fitness at each phase. The four phases are:

1. Isometric
2. Isotonic
3. Energy storage
4. Energy storage-and-release

Note that passive approaches, such as corticosteroid injections, are not emphasised. There is little evidence for their efficacy, and they are often paired with downtime which further reduces the patient’s capacity, resulting in more difficulty loading the Achilles later on.

Management-based approach

For our in-season management approach, we strive to keep symptoms “low and stable”, until there is a break where we can take the athlete through a full rehab program. No pain after activity may not be realistic, but we need to limit loads so the patient has minimal tendon pain 24 hours after activity.

The first step to manage an in-season athlete is to understand their loading schedule. How often are they competing and training? Are they training in the gym? We need to get specifics of these activities, because an activity the patient may not perceive as aggravating could be contributing to increased tendon loading. After understanding their activity schedule, we have several interventions to employ:

• Reduce volume and/or intensity of aggravating activities where possible
• Increase recovery time between high tendon load days (e.g., allow for 1-2 days of rest between high tendon load days)
• Introduce Phase 1 and 2 rehab exercises (isometrics and isotonics)

The athlete should be able to perform Phase 1 and 2 exercises without aggravation – as Dr. Rio says, tendons “don’t care about heavy, tendons care about speed”. Once the athlete has a sufficient break in activity, we can progress them through the other phases of tendon rehab.

Rehabilitation-based approach

When rehabilitating, we are addressing deficits and aiming to get the patient ready for activity. Note that because we have a lot of control over loading and recovery, we want to minimise pain following rehab exercises. If the patient is an athlete, they likely had significant tendon aggravation in-season, so we are aiming for minimal pain the day after rehab exercises. Also, while the principles of each phase are universal, the exact exercises chosen should be unique to the patient in front of you. For example, developing multiplanar strength is more important to a field hockey athlete than a marathon runner. Now, let’s get into the phases.

Phase 1: Isometrics

Isometrics serve as an excellent starting point for rehab because they reduce pain and modify cortical changes that occur with chronic tendinopathy (e.g., cortical inhibition of the muscle related to that tendon). Phase 1 begins with exercises that are relatively challenging for the patient. These isometrics are variations of heel raises, where the patient holds the contraction for 30-45 seconds x 5 repetitions. The load should be sufficiently challenging so that they near muscular failure at the end of each repetition. Isometrics can be performed daily, as they should not aggravate the Achilles tendon and will not generate significant fatigue. The video below shows an example isometric exercise taken from Dr. Rio’s Practical:

Other example isometric exercises include the seated heel raise, if the patient lacks the strength to perform them in standing. Alternatively, stronger athletes may need external loading, even for the isometric single leg heel raise. Patients should spend minimal time in this phase. Often a few sessions is enough to get them to the next phase – isotonic training.

Phase 2: Isotonics

During this phase, we increase intensity and introduce full range of motion heel raise variations in both standing and seated. We are aiming to develop strength and strength-endurance. To develop strength, the patient performs 4 sets of 6-8 reps. To develop strength-endurance, the athlete performs higher rep sets (from 10-30 reps). The tempo should be controlled, as a rapid transition from eccentric to concentric contraction can aggravate the tendon. These isotonic training days should be separated by at least one day of recovery. In the below snippet from her Practical, Dr. Rio takes us through an example exercise for this phase:

In addition to isotonic heel raise variations, we need to build foot intrinsic strength and gross lower extremity strength. Note that for insertional tendinopathy we may need to modify exercises (e.g., squats), as loaded end-range dorsiflexion may aggravate these patients.

The patient is ready for the next phase of rehab once they meet these fitness standards:

• 30-35 unilateral heel raises for athletes, 20-25 unilateral heel raises for non-athletes
• 4-6 reps of 1x bodyweight standing unilateral heel raise
• 4-6 reps of 75% of bodyweight seated unilateral heel raise
• 4-6 reps of 1-1.5x bodyweight unilateral leg press

Of course, as we progress into the Phases 3 and 4 of rehab, we continue these isotonic exercises to maintain and further develop the athlete’s fitness.

Phase 3: Energy storage

This represents a stepping stone to full plyometric activity. Exercises in this phase include introductory plyometric drills, where the athlete is building a tolerance to energy storage (i.e., landing), with less emphasis on the concentric component. When performing Phase 3 drills, the goal is not to maximise height or distance, but rather to gradually expose the Achilles to the demands of landing. Some example Phase 3 exercises include hops in place, jumping rope, and introductory deceleration drills. These Phase 3 exercises blend into Phase 4 as we progress the following variables:

• Performing continuous reps (e.g., single hop in place versus continuous hops in place)
• Increasing the height of the plyometric
• Adding new planes of loading (e.g., lateral hops)
• Adding alternating/single leg maneuvers

Note that in each session only a single variable should be changed, so that we don’t aggravate the tendon and can identify what changes the patient can tolerate. Like with in-season management, we want to monitor pain in the 24 hours following loading. If a progression turns out to provoke too much pain, we can regress the exercise or modify volume and/or intensity. After the athlete has mastered landing in Phase 3, we can progress them to high intensity plyometric drills in the last phase of rehab.

Phase 4: Energy storage-and-release

This last phase includes exercises where the patient jumps, lands, and runs with maximal speed and/or intensity. Exercises may include continuous bunny hops (moving forward), skipping for height and/or distance, and change-of-direction drills. Dr. Rio emphasises the importance of exposing the Achilles to a variety of stimuli, see her demonstrate this in the below video from her Practical:

Phase 4 exercises become even more specific to the athlete, where we seek to replicate the demands of sport. Of course, as in P hase 3, we listen to the athlete’s 24 hour response and modify exercises as needed.

Wrapping up

Rehab and management of the Achilles requires an understanding of the athlete’s activity schedule, current capacity, and goals. For in-season athletes, we focus on keeping symptoms low through the use of isometric and isotonic training, as well as modifying aggravating activities where possible. Once athletes have a break, we go beyond isotonic training with progressive plyometric drills that aim to build them back up for sport. This whole process requires an intimate understanding of your athlete’s activity and close monitoring of feedback from high tendon load activities. These same practical principles can be applied with any non-athletic populations experiencing Achilles tendinopathy.

For a full rundown on how to master your rehab and management of Achilles tendinopathy, check out Dr. Rio’s Practical HERE.