So what should you do if you have Achilles tendinopathy?
Lets start with the research trend of the year, eccentric, eccentric-concentric, isometric, heavy, slow loading ………
So if you are truly an evidenced based practitioner then you would have to change your approach anytime a new paper came out!
I think the biggest problem is taking the research literally, rather than taking the underlying physiological principle. All the research generally shows that tendons like to be loaded in some shape or form and that rest does not really resolve the problem!
The paper will have tested one protocol against another, but in theory there are limitless protocols if we manipulate repetitions, load, frequency, position. So don’t just stick to the protocol because one study says so!
Eccentric training protocol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527202/
Isometric loading
https://www.ncbi.nlm.nih.gov/pubmed/29974171
Heavy slow loading
https://www.ncbi.nlm.nih.gov/pubmed/26018970
One thing I do not understand is why all the programs studied look at vertical loading when most problems occur with horizontal loading/motion? Ease of loading the calf muscles is probably the most obvious answer, but can we be more specific?
Of course we can, once we understand the basic function of the calf muscles and the foot. If we say that the foot (very basically) does two things 1) Pronation – deceleration, 2) Supination – acceleration, then the calf muscles are working to help the foot. Pronation will eccentrically load the calf (soleus>gastroc) in all planes of motion due to the oblique pennation angle of the muscle and tendon. This will lead to the concentric action of the soleus helping to create supination and the gastroc causing knee extension then plantar-flexion with supination.
If we have a problem with sequencing these actions we can see how the Achilles will be put under undue stress. A common pattern is impact occurring without pronation then late pronation/medial heel whip in the acceleration phase. This pattern will put more stress on the medial aspect of the Achilles – unsurprisingly the area that nearly all Achilles pain occurs.
One easy way to work on this sequence is by using a rower as a movement platform https://www.instagram.com/p/BpHLoTolErT/. This provides ecc/conc/isometric loading to the calf whilst working on the specific pattern that the patient may be struggling with. Working these specific patterns can result in quicker changes in pain and function of the Achilles and return to running.
Mark Leyland MCSP BScH CSCS
www.momentum-physio.co.uk
