Many Achilles tendons reared their heads through our series of 2020 lockdowns and consequent daily walks or peer-pressured and boredom inspired charity runs. The most common issue is known as tendinopathy, a maladaptive response by tendons to exercise, which can be problematic in both the limitations it causes and persistence for months if action isn’t taken.
Well-functioning tendons are a highly organised connective tissue which transfer force generated by muscles onto bones, thereby allowing, controlling and facilitating movement. In the case of the Achilles tendon, this means controlling the movement of your knee over your toes as you land and pulling the heel through as you push off when running and walking. They are composed of aligned collagen fibres amongst a matrix of tendon cells, proteins and water which allows minimal and reversible stretch even under very high loads. This makes tendons very effective at storing and transferring energy during relatively quick tasks such as running and walking – they lengthen and shorten under what is called a stretch-shortening cycle, much like an elastic band. Muscles can’t contract quickly or effectively enough to match this and so maintain a similar length to provide a base for tendons to work off.
Whilst a blessing for our movement efficiency, this explains why extra running, walking or new exercise classes with skipping or jumping can cause trouble. Tendon cells respond to exercise by releasing new collagen to replace the old and be arranged appropriately to handle what it needs to. Tendons which are regularly exercised respond and recover well, particularly when around 72 hours are left between large bouts. However the loads associated with running and even walking are quite high, being measured at far beyond bodyweight, and much of the pressure falls on our Achilles tendons to absorb energy and then propel us to our next step. Tendons require time to adapt and more so to larger forces or amounts of exercise, meaning walking or running further, faster or more frequently than you’re used to can affect their ability to produce and organise collagen effectively. When this is compromised we start to see areas of poorly organised collagen on imaging and your Achilles tendon can become less effective at lengthening and shortening to transfer energy and be painful when doing so. Certain medications and medical conditions can make you more sensitive to this process.
Achilles tendons can become painful of one-off extreme exercise and this should settle quickly by resting and allowing your body to get on top of its response to what you did. However most patients with Achilles tendinopathy we treat at West London Physiotherapy have been having issues for some time. They experience pain running or walking and particularly first thing in the morning or after an active day. As a result they are surprised when we suggest specific exercise to target the affect Achilles tendon and calf muscles. This benefits the tendon by stimulating tendon cells to release and organise collagen in a controlled fashion, particularly when exercise is performed slowly and quite pain free, even with heavy resistance. Heavy resistance better stimulates the tendon to adapt and better prepared for the forces of running and walking whilst building the capacity of the calf muscles, which provide a base for the Achilles tendon to work and also protect it. Tendons take time to respond to load but gradual, progressive loading can make a big difference to their structure and function over several weeks to months. Low-level and controlled pain is not necessarily negative either and can indicate the exercise focussed on the right spot, so to speak.
As our patient’s improve they may require different, faster exercises or those targeted to other areas around their hip, knee and ankle but a mainstay of Achilles tendinopathy should be specific loading for the affected tendon and calf. It stimulates the tendon to handle future loads better and will see you back to walking, running or what you need to do most effectively. Not all patients and Achilles tendons are the same and so if you’re struggling to walk, run or exercise due to pain in that area, reach out to get assessed and onto the right exercises.
If you have any questions or would like some help with your tendon recovery, feel free to get in touch.
Liam McCloskey
Specialist Sports and Musculoskeletal Physiotherapist
