Updated: Oct 1, 2020
There is nothing worse than feeling like you are making progress with your Achilles problem or even starting to get back into activity when boom, your pain rears its head again. It’s a sure way to lose motivation or maybe even give up on the rehabilitation process all together. In this blog post I explore why a flare may in fact not be a bad thing and can help you manage your Achilles problem in the future.
In this article:
What is a flare-up?
Common reasons why a flare-up happens
What can you learn from a flare-up?
I've also discussed it in this video:
What is a flare-up?
A flare-up of Achilles symptoms is normally just that – the symptoms have increased but the pathology or the underlying nature of the condition has not changed. Symptoms normally relate to pain, a stiff or sore feeling first thing in the morning or indeed whilst exercising, which in turn can then limit your activity. It is important to remember that these symptoms are a response from your body’s alarm system and not an indication of the severity, deterioration, or a change in the diagnosis.
Even when we have had an Achilles tendinopathy for a long time, we can still get flares of symptoms that feel like acute pain or re-injury. If this is the case it can be said that the old problem has had a reaction to the stimulus (normally a change in lifestyle or activity). This is termed a reactive tendinopathy.
Flare-ups of symptoms do settle down again, especially if attention is given to activity management. The tendon may be sensitive to increased load for a while after this flare so it is important that the return to activity is careful and gradual, and professional advice will help with this.
Common reasons why flare-ups happen
Load changes: Sudden increases in load on the Achilles tendon can cause flare-ups when the tendon’s not robust enough to cope with this change in demand. Examples include a quick change in activity level, change in terrain (hills vs. flat), a change in footwear (e.g. flip flops), period of less activity (such as holidays or illnesses) before returning to our usual levels.
Solution: The good news is that returning to a phased activity management and exercise programme can allow the tendon to calm down and help restore activity levels back to normal.
Stopping or decreasing rehabilitation exercises: Let’s face it, doing the same old exercises over a long period of time and looking into the future and seeing this still happening isn’t always motivating. Lifestyle stressors or activities such as illnesses, holidays, special occasions also happen which cause changes in our lifestyle and can throw us out of our rehab routine.
Solution: A good way to help with the on-going nature of these exercises is to create a habit. Sometimes attaching them to an existing thing you do can keep you on track. For example, doing the exercises whilst the kettle is boiling and the tea is brewing (you can tell I’m English!).
The exercises were not progressed: Doing an internet search for “exercises for Achilles tendinopathy” gives you many options and many variations of an exercise to choose from. To rehabilitate an Achilles tendon and make it robust enough to do the activity we want it to do, we need to strengthen it. This not only takes time, but the exercises also need to be made more difficult as we get stronger. The Achilles takes the equivalent load of several times of our bodyweight when we do sport, therefore progressing the exercises over time by adding more load is important. There is evidence to support that jumping and hopping training is also necessary to help with rehabilitation.
Solution: Ensure that your tendon is robust enough to withstand activity and reduce the likelihood of flares through progressing your rehab over time. If your symptoms or lack of ability to return to your activity persists, it may be worth seeking professional rehab advice to ensure that your strength exercises have been progressed to an adequate level and that you’ve included the necessary plyometric training.
What can you learn from a flare-up?
In a nutshell, it can help you work out how to better manage the load through the tendon or the amount/ intensity / frequency of activity you do.
Alongside the exercises, activity or load management is very important. Using pain as a guide to help keep you in your acceptable baseline of activity can help and I’ve discussed this in more detail in the video below.
When you experience a flare-up, it can be useful to go back over the last few weeks or months and look for possible causes e.g. load changes, what’s happened with the rehab exercises, alongside other factors that can influence pain like lifestyle stressors, general health, sleep levels and major events? This information can then help to inform you about where you are at the moment and how to plan for the next few weeks in regards to Volume, Intensity and Frequency. You Achilles exercises may need to be altered to help reduce pain levels in the short term and then progressed back to previous levels before progressing further.
You should also look at sleep and recovery and if these are optimal – our treatment plans often include suggestions for our patients on how to improve this.
This information can then help plan for the future so that the same circumstances don’t arise again or if they are out of your control, we can then adjust the rehab and training programme to fit with this change.
Summary of useful info about flare-ups
A flare-up of Achilles symptoms is normally just that the symptoms have increased, but the pathology or the underlying nature of the condition has not changed.
A flare-up helps us examine what has happened recently with regards to activity, lifestyle and rehab exercises.
This information can then be used to learn from and to manage or avoid these situations that lead to the flare by adjusting your training and exercise programme.
About the Author:
Sancho, I., Morrissey, D., Willy, R. W., Barton, C., & Malliaras, P. (2019). Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study. Physical Therapy in Sport, 40, 107-116.