My Achilles hurts so much? What shall I do?

After a sudden change in activity (load) or direct trauma an Achilles tendon may become very painful, so much so that exercise and sometimes even walking can be very sore and difficult to do. In this article we explore why this might be the case, what does the pain mean and what we can do about it.



In this article:

  • Why has this happened?

  • What does having this amount of pain mean?

  • What can I do to help my tendon?


Why has this happened?


Sometimes when an Achilles tendon has experienced a sudden change in activity (load) or maybe suffered a direct blow / trauma to the tendon, it can react and cause very acute and intense pain. If this occurs this can be known as a reactive tendinopathy.


Researchers have studied what happens inside your tendon when this reaction occurs. A healthy tendon is made up of lots of fibres of collagen organized in straight lines (think one strand of dried spaghetti). These fibres are then organized in bundles (think a handful of dried spaghetti). There are many bundles of collagen fibres in one tendon (think multiple handfuls of spaghetti next to each other).


If you were to look at a reactive tendinopathy under a scan it would have very minimal change to the fibres or bundles of collagen, the main change would be the movement of water in and amongst the tendon fibres. This is thought to be a reversible process.


If you have a longstanding Achilles problem or indeed changes to the fibres of the tendon that you may have seen on a scan, you can still get a reactive tendinopathy in part of your tendon. This can therefore create an acute reaction (reactive tendinopathy) on top of an old injury.


What does having this amount of pain mean?


The amount of pain and symptoms you have doesn't tell you anything about the severity of the injury. Pain is part of an alarm system in your body and what you feel depends on how sensitive your alarm system is.

When you stop training and rest, it just calms the alarm system down - it doesn’t rehabilitate or make your tendon more robust to withstand the load (amount of activity) you want to do.


So pain does NOT equal harm or damage.



What can I do to help my tendon?


In a nutshell: The treatment consists of activity / load management, exercise and possibly anti-inflammatory drugs.


Activity / Load management


This is where knowledge about your job, your sport and activities of your day to day life is important, as well as information on how much, how often and how intense you do them.

Our tendons are designed to withstand all the forces we need them to take in our lives. This includes the load we put through them when we walk, run, jump, dance or whatever activity we choose to do that contracts our calf muscles or resists a stretching force to the calf muscles. This is known as tensile load.


When you have a reactive tendinopathy, reducing this tensile load is important – for example decreasing how fast you run, or for how long you do an activity. This is not the same as stopping completely – tendons do not get more robust to handle the activity you want to do by resting.


This means modifying your activity is paramount. Pain can settle quite quickly when you decrease activity (in as little as 5-10 days) but if you then increase the activity again before the tendon is robust enough to handle it, it can increase the symptoms again.


A general guide to help with this is that you should first be comfortable at rest and with normal walking before restarting your sporting activity. Then to monitor your symptoms for 24 hours after you have done something. Typically with tendons they are more sore later that day or the next day than they are at the time of exercising. It’s usually OK if you experience a niggle level of pain (0-3/10) over the next 24 hours. If it goes above this level it may mean that the activity was too intense for what your tendon currently wants.


You can keep your fitness levels up by cross training. This means choosing an exercise that does not flare your pain up such as swimming or cycling. If you are unsure or can’t get this fine balance right with the demands of your day to day life / sport and training, please get advice. This is something that we can also help you with.


Strengthening exercises


Strengthening exercises help to increase the robustness of the tendon, but there is no one-size-fits-all. What strength training exercise programme will work for you depends on you, your fitness levels, pain levels and training – it’s really worth seeking guidance from a professional.


Traditionally isometric exercises (a contraction without movement) have been advocated for reactive tendinopathies. An example of an isometric exercise for your gluteal muscles is to clench your bottom muscles whilst you are sitting. These type of exercises for your calf muscles can be a useful starting point for people who cannot, because of pain, start with exercises with movement, e.g. calf raises.


Reactive tendinopathies may not like a compressive force either e.g. stretching your foot off a step – this position anatomically brings your Achilles tendon closer to the heel bone, causing it to compress there. This is not a problem for healthy tendons but can irritate your tendon when it is injured. Therefore, avoiding calf stretches may be a good idea in the short term. Stretching can be resumed, with advice, once things settle.


Medication


Inflammation has not been shown to occur in a reactive tendinopathy. Despite this, anti-inflammatory medication is thought to be helpful – the theory being that it inhibits the production of proteins responsible for tendon swelling. Please remember always speak to a GP or pharmacist before taking any medication.


The solution to getting rid of a really painful tendon lies in combining all the advice above in a treatment plan that is individualised to you. That’s why we always start our online treatment process by doing a thorough assessment of you to find your ideal starting point. For example: what you can do without flaring any symptoms, what you would like to be able to do in the future and how strong you are right now. Based on your current strength and capability we then design a rehabilitation and load management programme that suits you and your lifestyle.


Let me know if you have any questions. Need more help with your Achilles injury? You’re welcome to consult us online via video call for an assessment of your injury and tailored treatment plan.

Best wishes

Alison


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 or Twitter.




References

  1. Cook, J.L. and Purdam, C.R., 2009. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), pp.409-416.

  2. Cook, J.L. and Purdam, C., 2012. Is compressive load a factor in the development of tendinopathy?. Br J Sports Med, 46(3), pp.163-168.

  3. Cook JL, Rio E, Purdam CR, et al Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine 2016;50:1187-1191.




Subscribe to our mailing list!

For weekly Achilles tendinopathy updates

Contact

Email:

contact@treatmyachilles.com

Phone:

Legal Stuff

Treatmyachilles.com is owned by ML Physio Ltd. (England No. 7434251) trading as Treat My Achilles. Registered office: 4 Frederick Terrace, Frederick Place, Brighton, East Sussex, BN1 1AX

© 2018 by ML Physio Ltd.