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Achilles tendonitis rehab – Going beyond the scan results to figure out the best approach

Updated: May 27, 2023

A research study recently identified three types of Achilles tendonitis rehab patient, and the authors recommend a different approach for each. They wanted to figure out why 40% of Achilles tendonitis cases they treated with the standard rehab protocol of strengthening exercises weren't resolved. Knowing which group you belong to could be useful for choosing the best Achilles tendonitis rehab approach for you. This should include factors such as pain levels (which often do not correlate with scan results), fear of exercise that may increase pain, and physiological factors. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

Scan results don't impact Achilles rehab outcomes

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

In this article:

We've also made a video about this:

This article is a follow-up on an article I wrote about how understanding the psychological nature of pain can help us to get rid of chronic Achilles pain, based on an interview I did with sports psychologist and pain specialist Dr Caroline Marlow. That article mentions that the severity of the pain you experience from your Achilles injury does not necessarily equal the amount of physical damage to your tendon. This article explores the topic in more detail.

What do scans tell us about Achilles injuries?

Scans are very useful for indicating the amount of structural (physical) damage an injured Achilles tendon has. This should be an MRI or an ultrasound scan; X-rays show only bone, whereas the others also show ligaments, tendons, muscles, and other structures.

They can tell us things like whether there is any inflammation, whether there are any signs of a thickening of the tendon, whether the structure of the collagen fibres that make up most of your Achilles tendon has changed, and also the amount of water in the tendon. However, there are some things about an Achilles injury that a scan cannot tell us.

Here is a holiday snap of me and my husband and our kids. We’re smiling, waving, and holding hands against an idyllic backdrop. Everything looks hunky-dory.

Our lovely holiday pic!
Our lovely holiday pic!

But what if I told you that, just before the pic was taken, one of my kids had thrown a massive tantrum, the other had fallen and hurt themself, that my husband and I had had words, and that we had had horrendous weather for the past two days, confining us to our hotel room? You would know none of this by just looking at the picture.

...but in reality we spent about 90% of the time like this! Fighting and crying and not happy.
...but in reality we spent about 90% of the time like this!

It’s the same with a scan of an Achilles injury. It can show structural changes, but it can’t indicate what sensations we're getting from those structural changes. And those structural changes might not relate to a pain driver at all; they might not be involved in what is happening when you're experiencing a certain sensation.

Despite this, many Achilles injury treatment programmes are targeted at dealing only with the structural change in the tendon. Those sorts of treatments, particularly back in the day, were typically hands-on, massage-based therapies. Sometimes it would also include ultrasound or laser machines. Or they might really target the structures involved, e.g. injection therapy or surgery.

All of those sorts of things are treating the physical aspects of the injury and they don’t take into account the wider situation.

When we assess somebody at Treat My Achilles, we need to know lots of information. How do you use your tendon normally? What would you like to do with it in the future? How is it affecting you now and what kinds of symptoms are you feeling? Scan results are not necessary, but if you do have them, of course we’ll look at those as well, but only as one element of creating a bigger picture.

This is because we really do know that what is shown on the scan doesn't relate to pain. And we also have quite a few patients who have had scans, because their pain has been going on for quite a long time, and there hasn't been any sign of an Achilles tendinopathy on the scan. So, why on earth are they getting Achilles pain?

The three sub-groups of Achilles patients

This is something that Shawn Hanlon and his colleagues at the University of Delaware investigated, and they published their findings in a research paper in 2021.

They took 145 people with Achilles tendinopathy and did scans of their injured tendons to assess the amount of physical damage. They also got the people to do tests to see how well their Achilles tendons functioned in strength and movement tests. Then they added other variables such as the patients’ age, sex, and body mass index, as well as indicators of the amount of pain the patients experienced and how they experienced their injury on a psychological level.

Overall, they ran 14 variables for each person through a statistical model and were able to classify the 145 people into three groups: activity dominant, biopsychosocial dominant, and structure dominant.

The activity-dominant group

A total of 67 people were in this group. They tended to do well in their tendon function tests, reported a good quality of life on a psychological level, their tendon pain was mild, and they had low levels of kinesiophobia, so they weren’t afraid of injuring their tendon further through movement. They tended to be younger and not obese, and their tendons showed relatively minor damage on the scans.

The researchers speculated that a lack of fear of re-injuring their tendons through movement may contribute to their good quality-of-life scores and high activity levels, or vice versa. They also concluded that this group of people had the highest likelihood of successful Achilles rehab with a standard 12-week exercise programme to strengthen their tendons.

1. The activity-dominant group showed minor damage on scans, and reported low levels of pain and good function.

The biopsychosocial-dominant group

This second-biggest group of 56 people had the same amount of tendon damage as the activity-dominant group, but they reported much higher pain levels and their fear of movement was bigger. They also did worse in the tendon function tests and reported poor quality of life. They tended to be older, obese, and female.

The researchers wrote that this group’s fear of moving in case they injured their Achilles tendon further and increased their pain may have caused them to do worse in the tendon function tests. It may also contribute to their tendons not getting better, because they’re afraid of doing the necessary exercises.

2. The biopsychosocial-dominant group showed minor damage on scans, and reported high levels of pain and poor function.

The structure-dominant group

The remaining 22 people comprised this group. They were mainly older and male, and 86% of them were obese. Their tendon scans showed the most damage of the three groups, and they fared the worst in the tests of how well their tendons function. However, they reported low levels of pain and were less fearful of re-injuring their tendons and reported a higher quality of life than the biopsychosocial-dominant group.

The researchers point out that other health-related factors, such as metabolic problems related to obesity, and the menopause, may negatively affect tendon healing and lengthen the recovery times for members of this group.

3. The structure-dominant group showed quite a lot of damage on scans, but reported low levels of pain and had very poor function.

A well-rounded Achilles tendonitis rehab plan looks beyond structural damage

Physiological factors

Obesity was a factor in two of the three groups, and those were the groups least likely to benefit from a standard, exercise-based rehab programme for Achilles tendinopathy.

Obesity is a tricky thing, because it isn't just about how much weight is going through your tendons when you're walking; it's also about the system change that we have if we are carrying extra weight. It can make us a bit more pro-inflammatory, and it tends to be related to rises in cholesterol or high blood pressure. And we know that these have an effect on our tendon health.

So, physiological issues outside of the structural diagnosis of your tendon, such as obesity, diabetes, or the menopause, can have an influence on our tendon health.

Psychological factors

And then, of course, there are the psychological factors, as the research has clearly demonstrated. It's all well and good telling people to go and do exercise. But if it hurts when you do exercise or you are frightened that you may cause more damage, how can you possibly go and do it and stick to your programme? It's not going to help you to recover from your tendon injury.

We all have a different mix of factors that contribute to our tendon pain.
We all have a different mix of factors that contribute to our tendon pain.

The bigger picture

So, if you’re among the 40% of people for whom the standard rehab programme for Achilles tendinopathy isn’t working, it may be worth your while to get professional support from either a GP, a nutritionist, a dietician, a physiotherapist, or a pain psychologists like Dr. Marlow or other counsellors to work together to help manage those bigger issues.

Many of our health services don't tend to look at the bigger picture. We get sent off to the specialist of this and the specialist of that, and nobody looks at that bigger picture, and it's important that we start to do that.

At Treat My Achilles, we don’t just zoom in on the tendon with an attitude of “Well, I'm only the tendon physio.” For instance, with patients in the biopsychosocial group, who are fearful of aggravating their pain with exercises, we would work on going much slower, rather doing fewer exercises and more often than going for big, strenuous sessions.

We would focus on things like "How does this pain impact you? What can't you do? Why do you think this is happening? How can we help you build more confidence in what's going on?"

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

Meet the TMA physios

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

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About the Author

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.



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