Achilles tendinopathy is really just pain that has been present for months. It’s more complex then that from a pathology perspective but treatment does not need to be complicated.
Tendinopathy is more common than OA. In the US 26million have OA and 35 million have had a tendinopathy.
We know that load and compression forces are a risk factor and that metabolic factors such as diabetes, obesity and infection can be important. However, debate is still ongoing in the literature as to whether the pain originates from chronic inflammation, neuropeptides, tenocytes, peripheral sensitisation, central modulation or a neurovascular ingrowth. All this terminology makes it very confusing for the patient.
We do know that 75% of these patients can get better when managed properly and that rehab is king when it comes to treatment and evidence.
We know eccentrics work but we also know that heavy resistance training also works. So do both. However, less is more here. Load into pain is possible but pay attention to the 24hr reaction. You need to go heavy and train for strength gains. Soleus strengthening is especially important in Achilles tendinopathy. Aim for rehab at a heavy intensity 2-3 times per week – no more. Recovery needs to be included in the programme if the intensity is right.
So what about the other 25%? Well if the strength has increased but no change in pain, then is the diagnosis accurate? Did you load heavy enough? Have you trained for long enough (3months)? Consistently? Really?
What about injections? Well more evidence is needed on PRP injections but please don’t inject corticosteroid as this has no evidence to show long term benefit and can make you worse.
Additionally, if you have medial mid portion Achilles tendinopathy and you haven’t responded then your therapist should also be considering the role of plantaris. In these patients surgery may be a successful option.
See you in the gym! 💪🏻