| The keys to successful rehabilitation of Achilles tendinopathy are early diagnosis and RICE treatment to prevent additional collagen damage, an eccentric strengthening program, correction of predisposing factors such as muscle tightness and abnormal biomechanics, and appropriate progression to functional activities and sport-specific rehabilitation.
Initial treatment of Achilles tendinopathy seeks to settle pain with the use of ice and electrotherapeutic modalities.(15) A heel raise should be used (in both shoes) to reduce the load on the tendon. Soft tissue massage using grade I (below pain) transverse mobilization (Fig. 28.8) of the Achilles tendon may be performed in the acute stage. The role of NSAIDs is controversial.(16) Astrom and Westlin found no benefit of piroxicam in a randomized controlled trial of 70 patients with Achilles tendinopathy.(17) Self-stretching programs are important to maintain muscle and tendon length (Fig. 28.2d, 28.2e).
Strengthening program
Although randomized controlled trials of strengthening are rare,(14) we provide the current standard of care from both clinical experience and published papers (Table 28.3).(14) (18)
Eccentric exercises have the potential to cause damage if performed inappropriately or excessively. The exercises should be preceded by an adequate warm-up and stretch and commenced cautiously. The patient should expect pain when beginning the strengthening program (18) and at each new load. The patient should only progress to the next exercise when the previous activity is pain-free during and following the activity.
The standard exercise used in the rehabilitation of Achilles tendon injuries is the heel drop (Fig. 28.9). Heel lowering requires an eccentric (muscle lengthening) contraction. The patient should perform this heel drop exercise with both the knee extended (to strengthen gastrocnemius) (Fig. 28.9 b, 28.9c) and flexed (to strengthen soleus) (Figs 28.9d, 28.10). Here is an example of exercise progression:
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Bilateral heel drop while standing on step with heels over the edge (Fig. 28.9a): lower heels below the level of the step.
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Increase the percentage of weight through the injured leg.
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Single leg heel drop (Fig. 28.9b).
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Add weights (Figs 28.9c, 28.10).
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Ice should be applied following exercise.
Correction of predisposing factors
As with any overuse injury, it is important that the predisposing factors are corrected. Generalized tightness of the calf muscles predisposes athletes to the development of Achilles tendon injuries and needs to be corrected with a structured stretching program (Fig. 28.2d, 28.2e) and soft tissue massage, including sustained myofascial tension (Fig. 28.11) and grade III transverse friction. It is often necessary to treat associated tissue thickening in the belly of the soleus muscle. Reduced range of motion in the ankle or subtalar joints places increased load on the Achilles tendon and should be treated with manual mobilization (Fig. 28.12).
Because abnormal foot biomechanics, particularly excessive pronation (Fig. 28.7), is a major predisposing factor to Achilles tendon injuries, (13) biomechanical assessment is essential (Chapter 5). The practitioner should assess footwear as running shoes may lack rear foot control. Treatment with orthoses may be indicated .
Return to activity
Return to activity should be gradual. Activity may be resumed when local tenderness has settled. On return to activity, a heel raise should be used to reduce the load on the Achilles tendon (both shoes).
Jogging should be commenced and gradually increased provided that there is no pain during or after exercise. When the patient is able to jog comfortably for 30–45 minutes, speed can be gradually increased. Later, sprint work and hill running may be slowly introduced. The athlete should be particularly wary of doing track work in spikes with their lowered heels. Consideration should be given to building up spikes with a heel lift on return to sport (Chapter 6).
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Early treatment and long-term rehabilitation 1
