Some people will choose to manage their ankle pain with pain relief, whilst some may choose to avoid medication. Applying something cold to your ankle may also be useful in helping with some of the pain (do remember to wrap your frozen peas in a towel before applying them to your skin to avoid cold burns).
Achilles Tendinopathy
This page has been designed to provide you with the right information about Achilles tendinopathy and the rehabilitation that may help you in your recovery.
What is Achilles tendinopathy?
Firstly, Achilles tendinopathy is not a dangerous issue. It normally relates to pain around the back of the ankle.
Pain around the back of the ankle can be caused by a number of things, but Achilles tendon issues tend to be one of the most common causes.
You haven’t explained what it is yet!
You’re right, we haven’t!
Achilles tendinopathy refers to an irritation of the tendon (which attach muscle to bone), from your calf muscles (lower leg muscles), to your heel bone.
What is a tendon and why are mine irritated?
A tendon is a normal part of your anatomy. Their main job is to connect muscle to bone so that when your muscle contracts (works), it passes the force (or energy) to the tendon and then to the bone, which creates movement.
Tendons are incredibly strong and robust things. This means they are designed to work and sometimes works hard, and they normally do this without any issues. Just like any other body part, they can be trained to work harder if you need them to (i.e. by lifting weights or doing your job), but equally, they can become less efficient at doing their job if you don’t use them.
Tendon irritation can be caused by many things, but in a lot of cases it is normally caused by one of the following:
OK, so what happens to the tendon?
If you think of your tendons as being really good at doing their job (passing the energy from the muscle to bone to create movement), it means they can put up with a lot of work when they need to. If you find yourself doing more than you are used to, doing something you are not used to doing or more importantly, having a period of doing less activity before, you can push your tendon’s ability to cope. Most of the time you notice very little, maybe a bit of an ache here and there, but sometimes your tendons can react and say “I’m struggling”.
If this happens, you will normally notice some discomfort and may find that moving can be uncomfortable. Think of this as your tendon being an ‘unhappy worker’, now struggling to do its normal day job and complaining about the work it has to do. Most of the time the soreness will settle with time, but sometimes it can last a bit longer, maybe into weeks or months.
So, what are the common symptoms of Achilles tendinopathy?
In most cases, Achilles tendinopathy results in discomfort around the back of the ankle, near the heel. This discomfort can sometimes spread up or down your leg, occasionally into the calf or even to the foot.
People with Achilles tendinopathy often find that standing or putting weight on their foot, especially first thing in the morning or after rest, will make their pain worse. Sometimes walking either further or faster will hurt and on occasions, the heel cup of certain shoes can cause discomfort.
Ok, I think I might have Achilles tendinopathy but what can I do about it?
Firstly, you can feel better. Sometimes, these issues can be really quite sore and can get in the way of things that you would normally take for granted and can make you feel like you’ll never get better. However, if it hasn’t settled by itself, physiotherapy can help.
Understanding the issue is often the best place to start. Reading the information above can help you better understand that Achilles tendinopathy is not a damaging or dangerous problem and that it can get better.
Secondly, there are two important things that can help you on your recovery:
What does ‘calm the problem down’ mean?
If you think back to the idea that your irritated tendon is an unhappy worker, then if you keep asking your tendon to do the same job, in the same way that it always has, the tendon will keep being sore. In other words, when something is sore, think of it like your tendons saying “I can’t do that as easily as I used to at the moment”. Making some changes to the things that are sore may help calm the issue down to allow you to move on with your recovery. Think of it as putting the tendon on lighter or amended duties whilst it’s sore.
We have written a whole page on ‘calming things down’ and called it ‘load management. You can find it here, along with some homework to try to help your leg’s recovery: Load Management.
Can you give some examples of what you mean?
Sure, but remember everyone is different and you will have to do some thinking yourself around how your ankle is affecting you and some of the changes you might need to make.
|
Things that are sore |
Why is it sore? |
Possible solution |
|
Standing for a long time |
Sore tendons will tire more quickly |
Try to take more breaks or shift your weight to the unaffected side from time to time |
|
Walking (especially uphill or fast) |
Sore tendons will tire more quickly and they don’t like too much stretch or work |
Reduce how far you walk or take more breaks, choose a different route or shorter strides |
|
Putting weight on it first thing in the morning |
Sore tendons sometimes take time to ‘wake up’
|
Try some ankle movements before getting out of bed/following rest |
|
Being barefoot |
Sore tendons don’t like too much stretch |
Don’t walk barefoot! |
How long should I work on ‘calming things down’?
This is a little tricky to be specific about and it is probably best to think about what your ankle is saying. If you have been good at adjusting, modifying and looking at the things that make your ankle sore, then you should notice some changes within a few short weeks.
Ok, what do I do once it feels calmer?
Firstly, well done! Often ‘calming it down’ is the hardest part of your recovery.
Now that your ankle feels somewhat calmer, the temptation might be to start going back to your normal activities in the same way you did before your ankle issue. Sometimes this can be ok, but equally, sometimes you might find that your ankle is not quite ready to return to normal just yet and may get irritated again. It might be best to think that your ankle needs to get fit and strong again in order to get back to doing normal things in normal ways.
As we’ve said before, if you consider your sore ankle as an unhappy worker, then you’ve adjusted and modified things (put it on ‘lighter duties’) to help calm it down. Now you’ve got to start a gradual or phased return to work (or normal). Jumping in at the deep end and going back to normal might result in your ankle becoming grumpy and sore again.
OK, I know I’ve got to build it up and understand it’s got to be done in the right way, but how?
Understanding that it might take some time and that your ankle will be more likely to cope better if you do things in a gradual way, is very important as the temptation will be to rush in, especially if it’s less sore than before.
No one is the same, just like no ankle problem is the same as the next, therefore there are no ‘formulas' that will be right for everyone. However, we have provided (below) an exercise programme that, if followed, can be effective to helping you move forwards with your ankle complaint.
Before I start, I’d like to know what the exercises are trying to do.
Excellent point - it’s often useful to know what you’re aiming to do before you start.
Firstly, the exercises are aiming to introduce a little bit of work into the tendon by asking the muscles to do some work. The aim is to start with only a little bit of work (within what is comfortable) and not much movement.
As you move through the exercises (as your ankle allows), you will notice that the amount of work/effort and the amount of movement increases.
Lastly, one of the most important things about all of these exercises, is that they are trying to help you regain some trust in your ankle. If your ankle has been sore for some time, it is only normal to be a little cautious when you start to move back into doing things that caused you pain before. This is why the exercises are done gradually and shouldn’t be rushed too much.
What should I expect with these exercises? Will they be painful?
This is a very important question.
If your ankle has been sore for some time, it would be a bit unrealistic to expect that it will be pain-free when doing these exercises. However, it is important that you don’t do too much to then upset the problem all over again.
A good marker for how hard to work is that you should feel some discomfort (not too much though), but it should settle within 24 hours. If you are still obviously sore the following day, you may have done too much/pushed too hard, therefore next time you do the exercises, reduce the effort a bit.
Will this get better with just adjusting the things that are sore, and exercises?
Although it is impossible to predict how each and every person will respond to rehabilitation, advice and exercises similar to that laid out on this page is considered the most effective way of managing Achilles tendinopathy (Silbernagal et al. 2020).
Apart from these exercises, is there anything else I can be doing to help myself?
Yes there is - here are just a couple of the most important things.
Frequently asked questions
Q: I’m worried I might have torn my Achilles, have I?
A: A torn Achilles (tendon rupture) is rare as your tendon is incredibly strong. However, a possible tendon tear is something that should be reviewed by a healthcare practitioner i.e. it needs to be investigated properly and might need a different approach to treatment. If you have felt a pop in your Achilles tendon region, can feel a dip in the tendon itself and cannot tiptoe raise on that side, you should get this checked out by your GP or physio, or go to A&E.
Q: Would an injection help my ankle?
A: A steroid injection for Achilles tendinopathy is an option, however, like most drugs, steroids come with side effects and some of these can cause problems in the future for your ankle (particularly the tendons). Often, injections only help in the short-term and exercise and advice remains the most effective option for most people (Silbernagal et al. 2020).
A: Scans (MRIs or ultrasound scans) are very useful in a lot of cases. However, they are not normally needed for the assessment or management of Achilles tendinopathy. If your GP or physio decides they would like to arrange a scan for you, it is likely they are checking for something in particular, but the treatment (outlined above) remains the same and the most effective way of managing Achilles tendinopathy.
Q: When can I go back to sport?
A: This is something that your Achilles tendon will dictate. If you have reached a stage in your recovery where the pain is settling and things that used to hurt are less sore, you might want to try some gentle training-type exercises (see phase 6). It is strongly advised that any return to sport is done gradually to allow you the best chance of success.
Q: I’ve tried the exercises and nothing works, why?
A: Firstly, ask yourself if you tried the ‘calm it down’ approach first. If you didn’t, then that might be the reason why you haven’t moved forwards. If you have, ask yourself if you did everything you could do and really commit yourself to adjusting/modifying all the things your ankle was telling you it was struggling with.
Q: What if I’ve done everything that I should do, but I’m still no better?
A: Often, these types of problems take a long time (weeks into months) to settle, so be patient with yourself. If you have been dedicated to the ‘calm it down’ work and the exercises, as well as being patient and giving it time and still you feel no better, do discuss this with your physio as they may be able to discuss other options with you.
Exercises
Phase one:
Whilst sitting, raise your heels off the floor and hold this position for 45-60 seconds, before slowly lowering your heels back down.
Phase two:
Exercise tip: You only have to pick one of these exercises. Concentrate on making the movement (particularly the lowering down part) nice and slow (about 3-5 seconds) and repeat 5-10 times for 2-3 sets. Aim to complete this exercise every other day.
Move onto the next phase when these exercises start becoming too easy.
Phase three:
Exercise tip: You only have to pick one of these exercises. Concentrate on making the movement (particularly the lowering down part) nice and slow (about 3-5 seconds) and repeat 12-15 times for 3 sets. Aim to complete this exercise every other day.
Move onto the next phase when these exercises start becoming too easy.
Phase four:
Exercise tip: You only have to pick one of these exercises, but a variety is good. With this phase, you can start to play around with speed. This section is important to help your ankle regain its ability to tolerate high level fast movements.
Phase five:
Exercise tip: Hold the wrist position for 15-30 seconds and repeat 2-3 times. Have a rest for about 1-2 minutes, then repeat again, aiming for a total of 2-3 sets overall. Aim to complete this exercise every other day.
Move onto the next phase when these exercises start becoming too easy.
References:
Silbermagel, K.G., Hanlon, S & Sprague, A. (2020). Current clinical concepts: Conservative management of Achilles Tendinopathy. Journal of Athletic Training, 55(5): 438-447. https://doi.org/10.4085/1062-6050-356-19 (accessed 13/01/2021).
Tashani, O.A., Astita, R., Sharp, D. & Jonhson, M.I. (2017). Body mass index and distribution of fat can influence sensory detection and pain sensitivity. European Journal of Pain. 21(7):1186-1196.
doi: 10.1002/ejp.1019 (accessed 16/12/2020).