Achilles tendon

rehabilitation
HMO7004

Victoria University CRICOS Provider No. 00124K (Melbourne)

CRICOS Provider No. 02475D (Sydney)
RTO Code: 3113

Updated: 1 February 2021

Acknowledgement of Country – Melbourne

We acknowledge the Ancestors, Elders and families of the Kulin Nation who are the Traditional Owners
of University land. We also acknowledge all Traditional Owners of Country throughout Victoria and pay
our respect to their culture, and their Elders past, present and future.
As we share our own knowledge practices within the University may we pay respect to the deep
knowledge embedded within the Aboriginal community and their ownership of Country.
We acknowledge that the land on which we meet is a place of age old ceremonies of celebration,
initiation and renewal and that the Kulin people’s living culture has a unique role in the life of this region.

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Achilles tendinopathy

• Localised pain at mid portion or insertional

regions
• Common in sports that include running, hopping
or jumping
• Morning stiffness and pain- localized
• Classic pattern: warms up with activity but often
worse next day
• Full recovery of symptoms does not correlate
with recovery of tendon structure eg remains
thickened

(Silbernagel et al., 2020;

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Achilles tendon pain map

Zwerver Brink, & Cook, 2021

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Achilles tendon loads

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Understanding achilles tendon loads
• Tensile- spring (energy storage and release, fast)- highest tendon load
• Compressive- eg. pushed against bone
• Shear/friction- irritates structures outside the tendon, low load repetition
• Combination- compressive and tensile loads- most provocative

(Cook & Purdam, 2016)

Remember- these are normal loads and forces- it is the tendons ability to
cope with them that is the issue!

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(Baxter et al., 2021; Zwerver Brink, & Cook, 2021)

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During gait

(Angin & Simsek, 2020)

• For a majority of the gait cycle the calf complex is working eccentrically
• This means the tendon is storing elastic energy during terminal stance to the swing phase to be using
during concentric release during from mid stance to toe off

• If you need to review the gait cycle see: https://www.youtube.com/watch?v=WuG87mRiY-8&t=2s

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(Baxter, 2020)

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(Baxter, 2020)
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(Baxter, 2020)

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 Tendon stiffness
• Tendons are stiffer at their osseous (bony) insertion and more compliant/stretchy at the
muscle end
• Stiffer tendons give faster transmission of force from the muscle. But this requires a
balance between tendon and muscle capacity or can be a risk factor for injury
• Heavy load, slow exercises (weighted calf raises) decrease stiffness in the tendon
• Plyometric exercises (light load & fast) increase stiffness

• (Baar, 2017)

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HMO7004 Achilles tendon rehab 13
Examination &
management

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 Examination- Identify impairments
Irritability to load
Functional impairments to measure:
• Ankle DF ROM
• Calf muscle endurance (SL)
• Calf muscle strength:
•Straight knee: Isokinetic dynamometry or 6RM (estimate of max isotonic force)
•Seated heel raise 6RM

• Hip & knee strength: Hip abduction & extension, knee flexion
• Hop/Jump testing
• Drop jumps (reactive strength index-RSI) and single leg hurdle jumps (horizontal distance)
• Consider required abilities for RTP

(Griffin et al., 2021; Silbernagel et al., 2020;

Sancho et al., 2022)
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PROMs

• Victorian Institute of Sport- Achilles (VISA-A) questionnaire: valid and

reliable
• Short version of Tampa Scale for Kinesiophobia- (TSK-11)

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Management strategies
• Education
• Pain relief
• Icing, medication, manual therapy
• Load management
• Complete rest is rarely indicated
• Need to understand their ADL’s, physical activity, training etc and their pain pattern (daily or
related to activity)
• Decrease running, hopping
• Decrease any activities with repetitive loading/compression into ankle dorsiflexion
• Rehabilitation program
• Based on impairments identified in the physical examination – local tissue capacity and kinetic
chain
• Gait analysis/training

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Progressive Achilles tendon loading

(Baxter et al., 2021; Zwerver Brink, & Cook, 2021)

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 Choosing exercises and parameters
• Slow exercises, even with weights, are not high tendon load and can be used early in
rehabilitation
• Exercises where the tendon acts as a spring eg jumping, change of direction, are high load
and usually should be avoided early and slowly introduced later
• Exercises where the muscle is in a lengthened position (eg eccentric exercises or stretching)
compress the tendon insertion and should be avoided early, then slowly introduced eg calf
raises off a step

• In the early stages you might not be able to examine for strength/endurance etc because the
tendon is too irritated. You can still consider:
• Do any exercises eg isometrics reduce the patients’ pain?
• Exercises to address impairments above and below
• General activity/cross training

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Pain during rehabilitation

• Remember that some pain is ok during

• Monitor the response the day after
• Build in low and high load days as appropriate and
if exercises such as isometrics provide relief for
the patient, use these to your advantage

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Protocols

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Rehabilitation protocols
Many different protocols exist
• Use these as a starting point/guide and consider your individual patient’s needs
• Not all patients need to progress all the way through a program OR you may need to extend the
protocol to include further consideration of the patient’s specific functional/activity requirements

Remember to think about your individual patient and progress them based on:
• Their symptom levels/load tolerance
• Examination findings & capacity testing

• Consider the patient and what a rehab program looks like for them
• Amount of time they have for the program
• Level of yellow flags eg sleep disturbance, fear avoidance etc

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(Sancho et al., 2019)

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(Sancho et al., 2019)

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(Sancho et al., 2019)

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(Griffin et al., 2021)

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 References
• Agergaard, A. S., Svensson, R. B., Malmgaard-Clausen, N. M., Couppé, C., Hjortshoej, M. H., Doessing, S., ... & Magnusson, S. P. (2021). Clinical outcomes, structure, and function improve with
both heavy and moderate loads in the treatment of Patellar tendinopathy: a randomized clinical trial. The American Journal of Sports Medicine, 49(4), 982-993.

• Ahmad, Z., Parkar, A., Shepherd, J., & Rushton, N. (2020). Revolving doors of tendinopathy: definition, pathogenesis and treatment. Postgraduate medical journal, 96(1132), 94-101.

• Angin, S., & Simsek, I. (Eds.). (2020). Comparative kinesiology of the human body: normal and pathological conditions. Academic Press.

• Baar, K. (2017). Minimizing injury and maximizing return to play: Lessons from engineered ligaments. Sports Medicine, 47(1), 5-11.

• Baxter, J. R., Corrigan, P., Hullfish, T. J., O'Rourke, P., & Silbernagel, K. G. (2020). Exercise Progression to Incrementally Load the Achilles Tendon. Medicine and Science in Sports and Exercise.

• Breda, S. J., Oei, E. H., Zwerver, J., Visser, E., Waarsing, E., Krestin, G. P., & de Vos, R. J. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy:
a randomised clinical trial. British journal of sports medicine, 55(9), 501-509.

• Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?. British journal of sports
medicine, 50(19), 1187-1191.

• Goom, T. S., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical
therapy, 46(6), 483-493.

• Hernandez-Sanchez, S., Hidalgo, M. D., & Gomez, A. (2014). Responsiveness of the VISA-P scale for patellar tendinopathy in athletes. British journal of sports medicine, 48(6), 453-457.

• Magnusson, S. P., Langberg, H., & Kjaer, M. (2010). The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology, 6(5), 262-268.

• Marigi, E. M., Buckley, P., Razi, F., Abbas, M. J., Jildeh, T. R., Camp, C. L., ... & Okoroha, K. R. (2022). Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments. JBJS
reviews, 10(3), e21.

• Mascaró, A., Cos, M. À., Morral, A., Roig, A., Purdam, C., & Cook, J. (2018). Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina
de l'Esport, 53(197), 19-27.

• Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., ... & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on
global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. bmj, 361.

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References

• Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., ... & Rodeo, S. A. (2021).
Tendinopathy. Nature reviews Disease primers, 7(1), 1-21.
• Nasser, A. M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E., & Semciw, A. I. (2021). Proximal hamstring tendinopathy; expert
physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, 67-75.
• Padua, D. A., Boling, M. C., DiStefano, L. J., Onate, J. A., Beutler, A. I., & Marshall, S. W. (2011). Reliability of the landing error
scoring system-real time, a clinical assessment tool of jump-landing biomechanics. Journal of sport rehabilitation, 20(2), 145-156.
• Sancho, I., Morrissey, D., Willy, R. W., Barton, C., & Malliaras, P. (2019). Education and exercise supplemented by a pain-guided
hopping intervention for male recreational runners with midportion Achilles tendinopathy: a single cohort feasibility study. Physical
Therapy in Sport, 40, 107-116.
• Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., ... & Zwerver, J. (2020). Icon 2019: international scientific
tendinopathy symposium consensus: clinical terminology. British journal of sports medicine, 54(5), 260-262.
• Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current clinical concepts: conservative management of Achilles
tendinopathy. Journal of athletic training, 55(5), 438-447.
• Tayfur, A., Haque, A., Salles, J. I., Malliaras, P., Screen, H., & Morrissey, D. (2021). Are Landing Patterns in Jumping Athletes
Associated with Patellar Tendinopathy? A Systematic Review with Evidence Gap Map and Meta-analysis. Sports Medicine, 1-15.
• Zwerver, J., Brink, M., & Cook, J. (2021). Tendon injuries in football players: FC Barcelona 2021 Tendon Guide.

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