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Rehab for Chronic Achilles Tendinitis

The syndrome of chronic Achilles tendinitis is one of the commonest problems encountered in the sport medicine clinic.

The clinical presentation is increasing pain, swelling in the tendon, associated with activities such as running.

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This demonstrates the tender nodule in the avascular area of the tendon.

The program of treatment should be based around eccentric exercises for the tendon. There was a recent paper in the American Journal of Sports Medicine that supported the use of eccentric exercise for Achilles tendinitis. Here is the abstract of the article.

Am J Sports Med 1998 May;26(3):360-366

Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.Alfredson H, Pietila T, Jonsson P, Lorentzon R

Department of Orthopaedic Surgery, University Hospital of Northern Sweden, Umea, Sweden.

We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 +/-7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional nonsurgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side. After the 12-week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal antiinflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their earlyforties.

The traditional treatments of icing, stretching, and other modalities are the mainstay of the treatment, however the progressive eccentric loading exercises are what will allow the athlete to return to competition. Remember to use a heel lift during the acute phase.

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Concentric exercise is done by toe raises with progressive weights. The use of the blocks allows the patient to do both strengthening and stretching exercises.

Warm up exercise

This should consist of moderately vigorous exercise such as on the exercise bike.

Stretching Exercise and Icing

Standard stretches are performed by leaning against a wall with the heel on the floor.

Eccentric Exercise

Next, 3 sets of 10 repetitions of eccentric exercise on the ankle boards are done. The severity of the initial symptoms dictates the starting resistance of the program.

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The heel is dropped below the level of the step. The Aircast pump helps to massage the avascular area of the tendon and aids in healing by increasing the vascularity. The use of a ice pack during and immediately after this exercise controls the pain and swelling.

Increasing the speed of movement or increasing resistance allows for progression:

The symptoms will gradually disappear and allow the athlete to return to sports.


Week Day               Exercise                                        Activity Level


1         1-3                 Slow drop, bilateral weight support               No Sports

    1.                   Moderate speed, bilateral support
    1.                  Fast drop, bilateral support

2        1-3           Slow increase in weight on symptomatic leg

    1.                  Moderate increased weight
    1.                Fast, increased weight

3       1-3            Slow weight supported on symptomatic leg       Pain during drop but active in limited sports

    1.                moderate weight on one leg
    1.                Fast speed


4      1-3              Slow add 10% body weight                          Pain with vigorous activity

    1.              Moderate, same weight
    1.              fast speed


5       1-3            slow, increase by 5-10# Pain during exertion

    1.              moderate speed
    1.             fast speed

6      1-3           slow, increase by 5-10#                                   Rarely experience pain

    1.            moderate speed

         7              fast speed