Achilles Tendon Pain in Runners | E17 with Myles Murphy, Physiotherapist

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Achilles tendon pain is one of the most common and persistent running injuries. Many runners experience Achilles tendon pain after particularly long or hard runs. It usually hurts as you start running and then warms up and starts to feel better, only to feel more painful the next day. Achilles pain can often persist for years and years. In response, many runners gradually reduce their running volume or switch to shorter races to “avoid damaging their tendon”.

Myles Murphy is a Sports Physiotherapist and Ph.D. candidate at The University of Notre Dame, Australia. His Ph.D. focus is investigating rehabilitation strategies for Achilles tendon pain (aka Achilles Tendinopathy or Achilles Tendonitis). Myles has done a lot of work reviewing the current evidence on Achilles tendon rehabilitation. He joins me on the show today to help shed some light on the current best-practice for Achilles tendinopathy rehabilitation. This episode is packed full of practical advice for runners suffering from Achilles problems.

Follow Myles:

• Twitter @myles_physio
• ResearchGate

Cool Stuff Mentioned in the show:

• La Trobe Sport & Exercise Medicine Research Centre (LASEM) on Facebook @latrobesemrc and Twitter @LaTrobeSEM

Here are a couple of posts in which I demonstrate some of the exercises we discussed in the show…

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A post shared by Matthew Boyd (@matthewboydphysio)

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A post shared by Matthew Boyd (@matthewboydphysio)

Discussed in the show…

• Eccentric exercises don’t fully resolve Achilles pain
• Less running doesn’t help Achilles pain
• Rest days improve Achilles pain with running
• Ultrasound scans showing Achilles tendon changes don’t dictate symptoms
• How to fix Achilles tendon pain

[su_accordion class=””]   [su_spoiler title=”Transcript” open=”no” style=”default” icon=”plus” anchor=”” anchor_in_url=”no” class=””] f you compare a healthy non-thickened achilles versus someone with tendinopathic change the actual quantities of good aligned fibrillar structure are exactly the same i didn’t know that that’s interesting yeah so that’s something that can be reassuring for patients because they they look at the skin and go oh i’ve got this big grotty foul looking tendon and you know i’ve had it explained to me and it’s going to rupture whereas you can actually reassure patients that that’s a physiological response based on the fact that you’re running or loading and that the amount of good tenant structure within your tendon even though it’s got that tendinopathic change is going to be comparable to someone that hasn’t had tendinopathy so you don’t have to freak out much about the scan right and the other the other thing we know is that what kind of things are you researching and what got you interested in that in the first place yeah so a lot of my research today in relation to the achilles has been about challenging some of the long-held assumptions that we have in the management of people with achilles tendon pain so wanting to look at some really basic information about what mechanisms might be responsible for improvements in pain and function with people when they’re doing rehab for achilles tendon pain and having a look at what we think we know and then what we need to get to in order to actually improve outcomes for our patients so to start with what do we think we know well the thing that’s quite commonly referred to in the literature is that exercise is the gold standard with a high level of evidence supporting its use for people with achilles tendon pain so i’d say that’s probably our number one assumption and then the second assumption i think that we have is that it’s a sort of a a load or dose response so we tend to think that you know the more you do or the better you are with your rehab programming the better your outcomes are um but from what i’ve done that doesn’t seem to be the case yeah and i think um that’s certainly my like as a clinician um that has been my perception right it’s like someone has achilles tendon pin when they run we need to do loading exercises so like coffers is getting progressively heavier and harder and then working on hopping and then in you know six to 12 weeks it’ll all be fine and dandy and they’ll be back to running so is that is that not the case is that um is that that we’re oversimplifying it a little bit yeah based on the research that’s definitely not the case these tend to take a lot longer um but the other thing to note in the research is they don’t tend to study fresh achilles episodes and then as a clinician you might be more inclined to see someone that has one or two weeks of achilles pain that’s starting to interfere with their running capacity whereas a lot of the studies are done on people that have had it for over three months varying from you know three months to three years of tendon pain before they present for a study so they’re obviously you would think going to take a little bit longer given that they’ve had the presentation a little bit longer than your your fresh achilles patients but definitely from the work we’ve done it doesn’t appear that it’s a straightforward recovery and there’s been some previous work done that shows that a lot of people don’t recover with the traditional exercise programs that we’re prescribing right and just for the listeners what would be a traditional exercise program what have you found is is usually commonplace for people with achilles tendon problems when they go and see a physio what’s typical for them to get so the most commonly researched exercise program for the achilles is the eccentric program or heavy eccentric half training and what that consists of is three sets of 15 eccentric heel lowers off a step with a straight knee followed by three sets of 15 with a bent knee and then you do that twice a day so you’re looking at 180 eccentric heel drops a day seven days a week over 12 weeks and that’s the most researched protocol out there that was initially eccentrics were reported in the early 90s but then the first proper study looking at eccentrics was by alfredson in 98 which showed that when you compare that to a surgical cohort they tended to do much better if they had the eccentric loading and um could you just for the listeners explain i think most people will know what eccentric means but for those who don’t what what are you referring to then when you say an eccentric loading program yeah so eccentric muscle activation is referring to when the muscle is contracting but it’s being lengthened at the same time so if you think of a simple exercise like a leg extension when you’re sitting down on a leg extension machine when you’re straightening the leg the muscles activating and the muscles getting shorter whereas when you lower the leg the muscle is getting longer even though it’s still contracting and the same for a heel raise when you go up onto the toes the upwards phase the muscle is contracting and getting shorter whereas when you go downwards the muscle is lengthening while it’s still contracting and it’s that lengthening that we call the eccentric component of the exercise so these eccentric um coffers which sounds a little bit backwards but you know what i mean like um these have been very popular and i can certainly vouch for this these have been very popular for the last 20 years and i think they are like the most commonly prescribed and certainly in there in the physio world if a runner comes in with achilles tendon problems nine out of ten physios or eight out of ten physios are going to give them this protocol i mean does it work does it work most of the time does it work half the time like what what is what does the research say about this this eccentric program yeah so if you look at the short-term outcomes for eccentrics it definitely is effective for people with achilles tendon pain and most people have a reduction in their symptoms however it’s not that common that people get a complete reduction in their symptoms so one of the studies that we did was a large review looking at all exercise intervention programs and very few studies achieved an average greater than 90 and with the scale that they use which is the visa a 100 is perfect zero so the higher you are the better you are and at the end of the intervention period very few studies had a average of greater than 90 meaning that most people were still having some level of impairment of function due to their achilles after a 12-week loading program and um i mean am i thinking correctly like the visa a i kind of think of it like a percentage like 100 percent a hundred a score of a hundred is like i’m a hundred percent my achilles is fine i can run as much as i want i’m good to go and then like 60 will be like i’m 60 i’m almost half my normal um because i’m so restricted from my achilles is that the way to think about that um probably the as a very severe group of people with achilles tendon issues so someone that has quite significant levels of disability would be sitting at like a 40 okay so even even below i would say sub 50 is a severe restriction in function and the difficulty sometimes with the visa is depending on the level of the athlete even a very high visa score might be substantially restricted so someone can be getting an 80 on their visa but the difference between an 80 and 100 is the fact that they can’t train normally so they can have low levels of symptoms just at rest and everything else but they’re really struggling to get normal training so even at those high levels if you’re someone that does a lot of running if you’re someone that wants to you know run marathons and do a fair bit of training even for change of direction team-based sport as well as your individual running sports you want a relatively high score like 90 plus to mean that you can train normally right okay so if it if we are like just for me i always think about runners then as you say they they the research is saying about these eccentrics that a lot of them are ending up after doing a really good program of three months of rehab and they’re ending up with these scores below 90 which means that they can’t really train the way they want to if they didn’t have that injury that they they’re still going to be restricted in terms of maybe if they’re trying to up it from a half to a full marathon distance or something their achilles is really going to be stopping them from doing that and stopping them from training normally and it’s and it’s sort of these these really commonplace rehab programs they’re not quite getting people back to you know what we would like to think you know if someone if a runner comes into me with an achilles problem i like to think you know this is going to be a problem for a while and then when you’re over it you’re going to be able to do what you want and you’ll be back to normal but that’s not really what’s happening in in the research trials is that fair yeah exactly and you did say that and this is more so that they’ve done most of the research on people who’ve had the problem longer and do we sort of need to separate these people out you know so if people are listening and they’ve had achilles pain for a few weeks should they be thinking about it differently from someone who’s had it for a few years for example yeah there’s not a lot of evidence for well not a lot of studies that have split the the two different groups but i think clinically we have some very different presentations that really sort of acute crumbly sorry acute flare-up type presentation i think you would definitely treat very differently to how you would treat a more significant flare-up so yeah someone that’s had the problem for you know nine months they’re grumbling along they’re able to do some loading but you know they’re just grumbly tender and aren’t training at 100 i think is very different to your short term flares up of someone that’s done a huge amount of training in a short period they’ve had a big load spike their pain significantly flared they’ve got a high level of disability you’re going to want to treat those groups differently um and how would they differ i’m thinking actually um had a young girl come in last week and um her achilles she she’s i don’t know maybe 17 18. her achilles is like was killing her she was limping in and she’d been doing a lot of work um and she was wearing heels at work and she’d started working a lot more recently and um you know i was really angry she couldn’t do even one car for us you know she couldn’t stand on the edge of a step and go up and down we got her just standing and staying still because that was all she could manage and this week she came in and she was doing three sets of 15 with holding a 15 pound dumbbell and then doing a bit of hopping as well within a week which is all down to my wonderful treatment obviously so um are these short-term things will they just get better on their own is that is that what the takeaway there or do they need some kind of intervention if it is a short term or do we just not know at the minute i’d say that they don’t get better on their own given that a group of people will go on for long lasting symptoms some might and but i think the biggest issue here is that when they have these flare-ups a lot of the time unless they’re a high-performing athlete that need to be training at a certain level what they might start to do is decrease their load so let’s say it’s a runner they run four times a week and they’re averaging you know 60 k’s a week in kilometers and that’s what they do and then all of a sudden they start to build up to something larger they get to 80 kilometers a week and then they start to get a little bit of achilles tendon soreness okay i think the most common presentation that you would see in the clinic is the person then backs off the load they go oh they’ll take one or two weeks off and that can be fine for that person and that may help resolve it but the issue is if they go and take one or two weeks off and then get straight back into that 80 kilometers a week even if their achilles doesn’t get sore again and i’d say most times it will their risk of other injury because of that fluctuation in their training load is going to be increased if they decide not to do the 80 kilometers and they go i’m just going to stick to 60 they’ve decreased the load that they had from before which is a good idea they don’t want to you know if you’ve had some time off you don’t want to go straight back into where you were but it might put them off ever trying to build towards that higher load again and then if in you know they take a month off and then they go and try and just go back to 60 and then 60 saw they might go you know what i can’t do 60 anymore i’m going to drop off to 40 and i think we see this gradual decline in what people have as function so their pain might be relatively stable they might have little flare-ups here and there but overall their load is dropping and i think that’s what we don’t track very well within the tenant studies is that we’re really focused on pain and we’re focused on you know asking someone whether they can train normally or trained with pain we’re not really quantifying what that training consists of and i think clinically based off the presentations that we would see people do decrease their load if they get sore because they think that they’re just doing too much which may be based on their physical capacity they are but we also don’t want people to just keep getting intermittent flare-ups and gradually dropping a load because they started with a load capability here and then they end up down here which is not good for overall physical function yeah and i’ve certainly seen that with runners over the years that they have dropped from maybe the higher like the ultras the trails the the marathons they’ve had an achilles issue and then they’ll just sort of mention casually oh yeah i sort of dropped down from that and i do half snow or i only do tens now because i don’t want to um i don’t want to damage my achilles it’s usually the wording they use so yeah i mean is that the wrong thing to do is that should they be taking a different approach well it really depends on how you define better i would say that if someone runs 80 kilometers a week and gets achilles pain and then the next week they run 60 kilometers a week and don’t have achilles tendon pain i wouldn’t necessarily say that that person is better i would just say that they’re exercising at a sub pain threshold so clinically you might deload them and go oh this is improving really nicely but you’re not actually testing them at the loads that aggravated them in the first place and that’s what’s really tricky to do within a lot of the research so i think what we’ve got to move to is not just asking you know is your pain improving but whereabouts is your pain score but also what you’re doing physically because if you haven’t tested it with what you did that first aggravated it sometimes we can be fooling ourselves into thinking we’re doing a great treatment but we’re not yeah that’s um loads that’s really interesting actually it’s not i’ve never really thought of it like that but you could um i mean for runners it would be quite it’d be harder for team sports but for runners it usually most runners these days are tracking with something and you can just look at their you know weekly and monthly kilometers for pre-injury and you know their goals for the year and then you can see you know have we got them back to that and and what you’re saying is that potentially we’re kind of fooling ourselves sometimes maybe because they’re just dropping down to a sub-symptom level of learning and then we’re like ah great it doesn’t hurt anymore and then in the research you’re saying that this might come through as a positive outcome whereas actually it’s it’s just not an adjustment in what they’re doing it’s not really a full recovery yes but on so i think we need to track that a little bit better um especially in the clinic because runners are great like runners are some of the best patients that you’ll ever have for knowing what their loads are and they’ll be able to tell you what the surface was like what the kilometers are what their averages are you know they’re crazy like that which is really handy from a physio rehab point of view but i think you do need to be cognizant that if someone is trying to run at higher loads and they drop off that the goal should be to get them back to where they want to be and not just to a pain-free threshold because there’s a lot of things we can do as far as interventions to build them back into a higher level of function but i think just dropping loads and assuming that they’re better because it was over a certain time or because you did a great loading program or because you did a great massage but if they haven’t tested it with what initially flared them in the first place i don’t think you can say that you’ve made a huge improvement because it could just be a decrease in the overall load right and then i mean is this is this a problem where the tendon you know say they’re doing 80k a week the tendon starts to hurt is that just their max you know is that or or is it just their max then and could their max go up you know as i’m thinking in there in the mind of a runner who goes up to a higher level of mileage and then they get achilles pain so they drop down and it’s not hurting like oh i’m okay now maybe they just think that’s what i can do is that fair is that correct or is it likely that if they tried they could surpass that sort of ceiling that they’ve found yeah there’s this really lovely paper by sean docking and jill cook which really describes increases in load and this really slow graduated increase in loading leading to overall better function so i think you definitely can like i don’t think there is a clear ceiling effect for this obviously you’re going to get to the point eventually even if you’re a world record pace that you do start to just hit barriers and there is physiological constraints but from a rehab point of view if someone’s getting an onset of pain with a certain load i do think that for the majority of patients if we work on their physical function if we work on their training schedule if we work on a bunch of different components of what makes up that person’s risk for getting pain that we can sort of modulate how they’re going to go with a running task so for the the classic that i would do in clinic is if i’m seeing a runner that’s running every day and they’re running 10ks seven days a week okay so 10k a session seven days a week the first thing i would do if they’re getting tendon pain is i would say listen if you want to keep a volume of 70ks that’s that’s not an issue let’s drop that a tiny bit but let’s give you rest days so let’s program breast stays into your program because giving the tendon a you know a 48-hour window to start recovering after a bout of impact exercise is going to be extremely beneficial even if you end up doing a high load on one of those days so it might be that you do for 15 kilometer days instead of seven ten kilometer days and even though each individual running session is longer the overall pain pattern for the patient i would expect to improve because you’re getting longer rest periods in between the runs and the other thing we know with most tenant complaints is that they warm up with exercise so if it’s a true tendinopathy of the achilles they’ll start to feel better as they exercise they’ll feel okay it’ll then get sore afterwards particularly the next morning so that’s where i think we can change our loading and we can have a really good education effect on any patients of how they break that up because runners do like to traditionally run every day sometimes this is easier in triathletes because triathletes will traditionally not run every day so they can flex their program a little bit more and i have found it a little bit harder in the running cohort but introducing things like cross-training days introducing strength days where they can do their resistance training and some form of cross-training so that they’re still meeting their sort of physiological adaptation but they’re not loading the achilles can be really really helpful um yeah i’ve certainly looked come across the the face of of hatred when you suggest some sort of crosstrading to a rudder it’s uh it’s as if you’ve suggested something truly terrible um but um why why is it important to have those days off for tendons specifically and why would it be even potentially easier for a tendon to tolerate the achilles tendon to tolerate running the same amount just spread out over four days instead of spread out over seven what what’s going on there so i’ll butcher this explanation because i’m not a hystopathologist but basically what what happens within the tendon is when you load a tendon and with the specific load that’s gonna cause it to adapt you’re gonna get some form of change within the tendon now if that’s a small amount of change okay you might get really positive adaptation and it will settle down and heal and you’ll end up with a stronger tendon but that adaptation period takes or they suggest about 48 to 72 hours within the studies that have been done just on the rates of collagen synthesis and other things within the tendon so we’ll try and always suggest a sort of 24 hour to 48 hour rest period in between runs some now some people are freaks and they can just run every single day and they’ll never get a tendon injury for whatever reason but when people are presenting with these issues it is very helpful to break up their scheduling even if it means that they do more in the single day and that’s not just for tendon that’s very similar principles for bone right okay um so chin splints uh stress fractures things like that it may be helpful to to have try and get to the same volume or weekly volume but spread it out over more runs in a similar way as with achilles tendons yeah again if someone’s never had an injury and they’re tolerating those volumes and running six days a week i wouldn’t mess with that if they’re going fine leave it but if they do start to get flare-ups and they’re starting to get signs of bone stress or they’re starting to get signs of tendon irritation then one of the easiest things that you can often do is just add in a rest day and the other thing with this i feel people go a little bit crazy when they’re looking at deloading an athlete they’ll tell them to have a whole week off or they’ll tell them to you know go every only run every second or every third day whereas if they’ve got low levels of pain and it’s just on set you could actually just look at taking out one of those sessions so if you’ve got the like i said before the athlete running seven days a week for ten k’s you might just go well let’s give you a rest day on a sunday and split those that 10 kilometers into a tuesday and a thursday so that you’re doing 15ks on a tuesday thursday your overall running volumes are the same but you are having a full rest day and see how that goes and then they can monitor their symptoms at a similar amount of load and then they can keep a pain diary because i do find that with this group pain diaries are very very informative and runners are great because they’re really diligent with this and you want to find some form of aggravating task and for achilles usually it’s a single leg hop and then it’s just you know when you get up in the morning try and keep the time similar every morning do a single leg hop do a series of single leg hops do five okay and then let me know what that pain is out of ten is it a zero is it a ten is it somewhere in the middle and then if you’re changing their loading schedule and that’s starting to go down you’re very happy so if they start initially getting fours out of 10 of a morning and then they start to get threes out of 10 and twos out of 10 it may take a couple of weeks but you’re really happy because they’re maintaining their load and they’re getting an improvement in symptoms alternatively what you might do with those rest days is you might say okay if you wake up with a four out of ten achilles pain on those single egg hops and then you go for a big run and you’ve had a big day on your feet and the next day you wake up as a seven out of ten achilles pain you might decide to not run again until it drops down to a four which might be the day after so they can use a pain diary to really listen to their symptoms and figure out whether or not it’s a good idea for them to reload that tissue because again the hard thing with the achilles and why i think sometimes people get into a bit of strife is that it’s getting gradually sore but because they warm up with exercise they can still get through their function so they’re still gonna hit it with exercise and just pay for it at other times during the day and by the time it starts to impact on their exercise it’s already you know one or two months into this aggravated structure yeah i can see what you’re getting at there and i’ve tried this before with the you know i call it like a like a litmus test right and it’s like hop five times um and then i stopped and i had um do you know mike stewart um he talks about pain research and that kind of stuff so i had him on the podcast a couple of weeks ago and he was talking about this um and he was saying you know if we’re if we’re doing things like this that we might be bringing too much attention and and concentration to a problem and actually end up making the problem inadvertently worse and i know that i tried to reach one of your papers i think it was on conditioned pain modulation i couldn’t understand a word of it it just went like the way overhead so i know that you’re interested in sort of um the difference between pain and and and maybe changes in tissue i’m just wondering what your thoughts are there is that a risk if we’re taking that kind of approach um can we pay too much attention to these things and if so how might we get around it yeah so i think that that is a completely valid point but it depends how you sell it to the patient so if you’re telling someone that you know we’re really worried that you’re damaging your tendon and we want you to monitor pain because we want to know how much damage is going on in your tendon that’s a disaster definitely don’t do that but what what i say to my patients is that there’s actually evidence that suggests that your painful achilles is less likely to rupture than your non painful achilles i don’t get it though yeah so the the risk of rupture appears to be lower on the painful side and i’ll tell that to people because i do find that patients are worried about achilles tendon rupture and then i’ll say to them one the thing is it’s just getting irritated you’re loading it and it’s getting sensitive it’s getting sore a bit like a bruise and what we want to do is we want to either improve your function and keep a stable pain level or we want your pain to improve and keep a stable functional level what we don’t want is pain to go up or to function to go down too much okay so we can obviously decrease function if we need to stop the pain from going up and i i find that’s a really valuable tool the other thing is it gives a very nice insight into what patients are doing that flare them up so they’ll come in initially on the initial console and you’ll fire 30 questions at them about you know the running or this that and the other and what they might come back with is and after a week of tracking they go you know what the day that i really get sore is after i run hills it’s my hill running day that really flares me up and they know that because they’ve had some form of monitoring into their symptoms and you might go well what we’re going to change this week is we’re going to remove your heel running and just going to run on flats so it’s all these little cues that you can get from the patient which i find they get a little bit more awareness of because of the the pain diary but it’s all just about why you’re monitoring the pain and for this you’re monitoring the pain level so that they can keep doing function and that’s why i’m comfortable doing this if it was if it was you know you’re just monitoring pain for the sake of pain but if you’re going you know if you’re pain stable and you’re running 70 k’s a week that’s fine if you’re happy with your pain at a 4 out of 10 every morning and you can run 70 k’s a week and the pain is not getting worse and we’re going to rehab you on top of that i’m actually happy with that whereas the patient that’s getting gradually increasing pain because they’re training we actually do need to back them off so if someone is doing so much loading that it is exacerbating their symptoms we need to deload them and that’s where this gets a little bit complicated as opposed to say the back pain world where you’re just trying to encourage physical activity in people with chronic pain we’re in a cohort of people that are typically physically active and we’re trying to keep them as physically active as possible while managing their symptoms and so i i guess we kind of skipped over this a little bit i don’t know you said that your research interest is more um it seems to be more practical right like the how do we fix this problem but um i mean if we could just try and make some sense so people are gonna be listening and thinking yeah but why does my achilles hurt anyway you know what what how would you like how do you explain when you get a verna vein and then achilles hurt and what what how do you explain that to them yeah so i try not to explain the basics of pain too much to patients in the achilles because we don’t actually have a great understanding of what causes pain within the tendon i tend to talk more about the structure being sensitized or the structure being irritated or flared up so i’ll say you know you’ve overloaded it it hasn’t like what you’ve done and as a result it’s gotten really irritated and there’s a bunch of different reasons as to why that irritation can happen but to be honest it doesn’t really matter what we want to do is just decrease the irritation and the way we’re going to do that is by x y and z and i will tell them that it’s not a inflammatory condition there is some evidence for low levels of inflammation within tendinopathy but it’s definitely not a condition that you’re going to treat with the traditional anti-inflammatory approach so this is never the cohort that are just going to smash anti-inflammatories and get better so i think it’s really unhelpful to go too deep into the inflammatory versus no inflammatory debate of tendons i’ll just say you know it’s not a predominantly inflammatory condition therefore things like anti-inflammatories well they may be useful a little bit for pain and to calm down some symptoms they’re not going to fix you what we need to do is increase the physical capacity in and around the structure so that it can tolerate the loads that you want to do and that’s the way that i would approach it i would just talk about the tendon being sensitized the tendon being really irritated and then what we’re going to do from a management point of view is decrease the things that irritate it so it starts to feel better we’re also going to build it up so that it’s more resistant to getting irritated in the future and if they because a lot i had a guy come in this week just with an ultrasound scan um because he’d been having some tendon pain he’d gone to the doctor and it said that he had some um i think the wording was tendonopo tendinopathic changes um you know that must come up in your consultations how do you discuss that um and and what what relevance that has in terms of uh is it different if they have a scan that shows these changes or do we do we approach this in the same way yes i think you always have to discuss the scan so if people have had the scan you need to talk about it because for a lot of patients i feel like the scans their validation of why they have pain they feel like their pain is justified because they’ve got these changes on imaging um but we try and always frame that in a really positive light for the achilles and the patellar tendon is the same is that the thickening and the changes that you see are an adaptation to loading and not everyone that has them has pain so if you do more running you would actually expect to see changes within the structure of the achilles tendon and that’s not causing pain that’s actually an adaptation of the tendon to the increase of load and the increased demands you’re putting upon it and there is some research that shows that changes are more apparent based on the years that someone’s been running so we do we definitely expect to see that um and i’ll say that to a patient you know that’s that’s actually a good thing it means your attendant is adapting and one of the good things out of the work of sean docking and co is that when you actually quantify within that tendon the good structure so the aligned fibrillar structure that’s what we use for load transfer so what the achilles is really important for versus the other structure that isn’t important if you compare a healthy non-thickened achilles versus someone with tendinopathic change the actual quantities of good aligned fibrillar structure are exactly the same i didn’t know that that’s interesting yeah so that’s something that can be reassuring for patients because they they look at the scan and go oh i’ve got this big grotty foul looking tendon and you know i’ve had it explained to me and it’s going to rupture whereas you can actually reassure patients that that’s a physiological response based on the fact that you’re running or loading and that the amount of good tenant structure within your tendon even though it’s got that tendinopathic change is going to be comparable to someone that hasn’t had tendinopathy so you don’t have to freak out much about the scan right and the other the other thing we know is that over a course of so there was a study that tracked people over a couple of years and looked at tendon structure and even though patients improved so their symptoms got substantially better there was no changes in their tendon structure so the symptoms will improve and change completely separately to what the tendon structure is doing so we don’t tend to worry about it too much yeah it’s not going to dictate whether you have a successful return to full running and training what your scan says regardless of what it says it’s really about what you can actually do or as you said the capacity of your tendon to do stuff is really what you’re focused on um i think i might just reiterate because that was really interesting i didn’t know that but what you’re saying is uh sometimes when people have an achilles tendon problem the achilles gets a bit fatter right and then if you have a scan and it shows some changes in the tendon what you’re saying is that the fatter tendon has actually fattened up but the useful sort of uh collagen strings or chords that are doing the job of of pulling the heel bone are quite comparable to someone with a quote-unquote healthy tendon is that right yeah so the the i’m going to use the the same description that um jill and sean and ebony and herds uses they say treat the donut not the hole so in the patella tendon when you do these scans the if you think of the tendon like a just like a circle the donut component of the circle is the good healthy aligned tissue and the hole in the middle is the poor non-aligned tissue that isn’t weight bearing so it’s no longer a stretchy elastic tendon and the concept is treat the donut not the whole because the size of the donut is exactly the same in someone that’s had has significant pathology and someone that doesn’t own the imaging but the stuff that’s not weight bearing we don’t really worry about anymore we’re more focused on good quality tissue and wanting to enhance the function of the good quality tissue as opposed to worrying about the tissue that’s essentially become redundant right okay so yeah you take what you have and make that stronger and you don’t worry about anything that you might have lost spot on especially because the overall quantity of the good structured tendon is the same as someone else that’s got a healthy non-pathological tendon i’m definitely gonna make sure i talk about that with people because that i i can see that being very helpful for people to to think actually i’ve got enough good tendon left there i just have to make it stronger because i want to do 80k a week not 50. but if we can circle back here you know you talked about um the research on these eccentric loading programs and um you know that’s that’s sort of typical um uh let’s say physiotherapy practice for people who come in with achilles pain as you get these eccentric loading programs and you’re saying they’re not quite getting these um you know full full recovery type things um is there a better way um to do it i mean you’ve been talking a lot about um managing that training load right so splitting it up over multiple days and a few days a week instead of every day and drop drawing back temporarily and then building back up very slowly over time but then still having that goal of getting back to whatever you were doing before or whatever you want to do not sort of just long term chopping down to a lower level of training and is this is this the path is that do we need to do the exercises differently um to the are the exercises needed you know what does what does the research say about this kind of stuff yeah so there’s no studies to date that have shown that any specific programs are superior to the eccentrics program that was initially proposed but that being said a lot of the protocols don’t really mirror what would happen if you went and saw a strength and conditioning coach so if you went and saw a strength and conditioning coach and said listen i want to increase the strength of my carbs i want to you know increase my plantar flex of power at the ankle whatever it might be you’d be very hard-pressed i think to find a coach that’s going to prescribe you 180 heel drops a day and you won’t look for another coach yeah it’d be it’d be really unusual so if we think that strength has something to do with modulating the load of the achilles or is a decrease in strength is a risk factor for why these people get sore then we want to try and target the programs at what’s most likely to give us improvements in strength and we can do that in a couple of different ways so you can do that with heavy slow resistance training now heavy slow resistance training has been studied in the achilles and did have good results comparable results to the eccentrics but the protocol that was used in this study was a double leg programs they didn’t use single leg training whereas in the clinic traditionally what we do i think for most physios is that we target single leg training for someone that has a single leg pathology we wouldn’t you know if someone’s coming in for an acl their mainstay of knee strengthening isn’t double leg press you’d hopefully get them doing single leg press so i think doing some single leg training is really important especially when the strength deficits are greater on the painful side than the non-painful side or less painful side so single leg training is the key some really heavy weights really build up the capacity because the thing with tendons is it’s all about the speed of the movement and that’s why things like running and jumping are really aggravating for the tendon because the tendon’s quickly having to store and then release energy because of the speed that the ankle is moving in whereas if you look at really slow weights contraction so something like a really slow seated calf raise for example the aggravation through the tendon is extremely low because the movement’s extremely slow so if you go to a really slow and i’m talking really slow so you know four to five seconds of time under tension so a couple of seconds for your concentric a few seconds for your eccentric phase of your your heel raise the tendon load is quite low but you’re really hitting the muscle pretty hard and then you would do that with as heavy as load as possible in different positions they’re going to target predominantly the gastroc and then positions they’re going to target predominantly the soleus which what most people would do is a calf raise or ankle plantarflexion movement in knee extension and then an ankle plantarflexion movement in about 90 degrees of knee flexion just to try and hit the two different muscle groups but then you can also work on their overall calf endurance so just a body weight calf raise with technique so that they’re predominantly loading the calf and not hinging off their lateral sort of compartment group and then working on getting as many endurance calf raises out just to try and improve the capacity through the tendon but taking them again nice and slow because the slower you go the less likely you are to aggravate any problem at the achilles and that’s one of the things we use to sort of diagnose these groups is that if you have a patient coming in you’re expecting to see an increase in pain with an increase of 10 and load so if you do a double leg calf raise they might not have a lot of pain with a double leg calf raise because the load through the tendon is pretty low if you go to a single leg calf raise that might be a little bit sore because there is some load going through the tendon but then when you move to things like double leg jumping so you know just hopping with both legs versus hopping with the left leg versus the right leg or affected side you’d really expect to see an increase in pain your single leg hop should be much more painful than your single leg card phrase and if that’s not the case you’re automatically thinking that maybe this isn’t a tendinopathy and that there’s something else going on but the little clinical tip with the single leg hopping is to make sure that their heel doesn’t hit the floor so often as clinicians we can get tricked because if someone’s hopping but they’re hitting their heel on the floor and having a decent rest in between efforts they’re actually not using energy storage and release because they’re not springing off the tendon they’re really just using the heel to hit the ground and slow them down so making sure that when you hold yeah so when you’re hopping it’s a series of consecutive hops where the heel doesn’t touch the ground and comparing the aggravation of the tendon with that versus your single leg calf raise which is a nice slow movement and you’d expect to see like i said that the hopping is sorer but when you’re applying that to the rehab the opposite is true you’re going to want to smash them early with those slow exercises they’re going to be sub pain or low pain threshold and then you’re going to gradually increase over time into the more aggravating tasks as their capacity within the tissue is improved okay i might just um just try and paint a little picture so the runner’s got an achilles tendon pain and they’re they’re engaged in a rehab program and something they might expect if it’s a really good rehab program is they’re going to be doing car first um certainly initially and they’re going to be very heavy and they’re going to be very slow so taking five or six seconds to even do one rep so to do like 10 or 11 reps takes a long time and then they’ll not just be doing it with the leg strip but also with the leg bent so maybe um there’s an exercise machine called a seated coffer is is that what you would suggest for that where the knee is bent and you sort of you’re pushing up onto your toes and the knee pushes the weight up a little bit and again going very slow and very heavy on those two yep and the the other machine that we find quite useful for this um i don’t know if it’s got a universe name but it’s just the smith’s rack or the smith’s machine so the barbell that’s fixed inside the tracks can be really good because you can load up your single leg calf raises relatively heavy for that slow movement but you can also do your seated calf raise in the smith rack if you don’t have access to a seated calf so they’re quite useful you can use things like dumbbells and kettlebells to weight down the knee but i’ve found with patients that you tend to just get much better sort of burn and feeling within the calf using either the smith’s machine or the seated calf as opposed to the dumbbell yeah and i’ll um i’ll embed in the show notes for anyone listening who doesn’t know what exercise is referring to i’ll just put some videos in there the different exercises so people can understand what we’re talking about um and i think yeah that my experience with the seated car first so when we’re trying to do the leg bent version um i only came across that smith machine variation recently i really like it because a lot of places have smith machines and don’t have seated coffers so it works just as well in my experience actually um but when you try and use like dumbbells or plates you need so much weight i mean especially for runners i mean maybe if you have you know a very an elderly inactive person who’s who hasn’t lifted weights in a long time but if you’ve got a runner they’re going to have like three or four plates on their knee before they start to feel the burn and it’s like just difficult to handle them when you’re trying to do a seated coffers in that way yeah it becomes really really difficult and especially if you’re in the seated car phrase putting on 40 and 50 kilos versus you’re in the trying to do that with plates or a dumbbell like good luck lifting those dumbbells and those plates on yeah just practicing on your leg yeah yeah if you can use one of the machines it’s so much more tolerable and so much simpler for the patient and so i mean you said we’re going really heavy like how heavy are we talking about here and how many reps and sets and you know is this something that we need to do you know like you said with the running do we need to have a rest day in between to give the tendon that chance to adapt like how do you structure your programs i know it’s going to be different for depending on the person but just to give people a vague idea what what something typical might look like so there’s a really nice paper by ebony rio and co looking at sort of the right to load for tendons they did a review of the different literature and um have coined the term neuroplastic training and so with that it’s really low level of reps so you’re only looking at about six repetitions of extremely slow movements with time under tension and you’d pick a weight that would fit that now on the first console you’re very rarely ever going to get the correct weight so you might have to play around with it and you know set one might be too heavy and then you drop it down for set two or something like that so you can play around with it but um you want it to be relatively heavy for that slow movement now for your endurance work where you’re doing you know single leg calf raises with good form you might just be looking for absolute failure so you might be just trying to get as many out as possible within a set and doing a couple of those forms of endurance exercises as well and that’s how i would tend to tailor what i would prescribe if provided they’ve settled to the point that they can tolerate doing some exercises without being sore i would go within their program i would do their heavy slow resistance training so they’re heavy strength work and then i’d finish them off with a set of or one or two sets of endurance calf raises to failure the thing with the endurance calf raised to fail because they’re already going to be quite pre-fatigued from the strength work they won’t get out too many reps compared to what they would do otherwise but they’re still challenging the system and you can play around with when [Music] when they do that but it for my point of view it has to be after a run so the last thing you want to do is do your gym and then go for a run because your calves will be absolutely cooked your cars will have nothing on the run and then you know that modulatory or protective buffer that you’ve got in your calf strength has gone because they’re so fatigued so i would tend to do the the functional task first which is aggravating which is the run and then do either the strengthening that evening or the following morning or something like that then have your rest period of the day and then run the day following that um yeah and that’s um that’s not something i’ve typically done but i think i’ll make a point of now is i put the run do you run then do you your strength work to condition your tendon and then you have your 48 hours rest and then you hit it again so that’s kind of i’m going to apply a heavy stim i’m going to apply my running stimulus which is what i want to be able to do and then i’m going to apply my heavy training load stimulus then i’m going to have my time of adaptation before i then hit it again and i think i certainly haven’t structured it as as specifically as that but i think that would be helpful for people and then they kind of know why they’re doing what as well yeah the the other thing is you like i’ll usually just get out like i’ve just got pre-printed like calendars of mondays to sundays and then i sort of just go well let me know what you’re doing in the week because the hardest thing unless they’re an elite athlete where they’ve got time to do whatever they want to is people are working people have other commitments they’ve got to pick kids up from school they’ve got to you know work on this day there whatever it might be that unfortunately sometimes the ideal scheduling just doesn’t happen and you do need to work around that but as close as you can get it to that sort of principle in my clinical practice i find quite helpful and is that sort of three days a week is this the is that your typical um amount for people um it depends how much they’re running to start with i think most of the runners that i would see would run probably five times a week so if i’m going to drop them off i’d usually drop them off just one session a week to start with so they might be running four times a week or every second day which will be seven over the course of the fortnight and then i will add their loading into that depends if they’ve got access to a gym if they don’t have access to a gym those things are always considerations but i will try and encourage people to if they don’t join a gym because they strengthen adaptations that they can get by using some of the equipment are really really useful and then i will try and throw that in a few times a week yeah so now we’ve got um you know they’re doing that the coffers is they’re doing their seated coffers as they’re doing some endurance coffers is without weight where they’re going until they can’t do anymore and then you were saying that you would bring in some like hopping bouncing type stuff when do you bring that in and how would that uh look how how many uh how many reps and sets and all that kind of stuff yeah so one of the things that i would do before i get someone hopping is i’d make sure that they can actually tolerate isometric holes in their sort of mid to upper range position because what i don’t want is as soon as they start going into hopping is to start slamming that heel down on the floor i want them to be able to maintain that calf activation without it letting go and losing the heel so what i would do initially is i might get them to start doing some stair climbing so up on the tippy toes up and down stairs things like farmers carries with kettlebells or dumbbells but on tippy toes just to make sure that they can maintain a really nice high range isometric calf position which is what they’ll traditionally do if they’re more of a sprinter as opposed to enduro runners but um yeah getting them up on the forefoot to really get some isometric calf burn while they’re moving around and provided they can do that i would then start some basic running drills and the running drills will be different for different people it will depend on the coach so if the coach has got a lot of preferences on what learning drills they want to do i’ll just incorporate that in i’m pretty flexible but i do find that that is useful for drilling technique and then they can start to build up into what they need to do the thing to be conscious of a little bit if someone’s a jogger and they just jog at really slow speeds for higher volumes hopping can sometimes be more aggravating than jogging so if you’re getting someone into sprinting or high fast-paced sports then i think moving through a progression of hopping is really really important but what you might do clinically especially because in clinic you don’t get the same access that you do in the elite world you might actually just start to build up their loads just by increasing their running once they can get to good car control you might not play around too much with a huge amount of hopping especially if they are an endurance or another thing to consider there is that they’re obviously not going to run on their forefoot for the entirety of the of the runs that they’re doing so every case is different and you’ll need to prioritize whether or not you think that you need to do a huge amount of hopping or whether or not you are actually just going to start to build up loads with their jogging because that is where it starts to get tricky because the patients are feeling better they’ve got this increased capacity they’re feeling stronger they want to start to increase their loads um and you yeah you just have to be a little bit conscious of why you’re giving them the certain exercises and are you just following a recipe and you’re getting too hot for the sake of hopping or do they actually need to be able to control specific running drills and specific sort of sprint related hot tasks before they can get back to jogging right so and then that sort of layers on top of the the heavy strength training that you’ve been having them do and then those kind of drills come in as they can be tolerated so if they’re very sore at first and it hurts to do it then we’re not doing it then but as they get uh more um capacity they’ll be able to start including a little bit of those and then a little bit more as they get more uh capacity is that is that right yep correct and it’s almost like there’s a sliding scale is there’s no there’s no end point of you know you finish just phase one and then all of a sudden phase one is gone it’s more that you’ll start to have you know this is doing this and then when you get to here something else might start to be increased and then you’ll add something in and you’ve got this continual progression of at some stage you’re going to start adding in different tasks but that doesn’t mean that you stop everything that you were doing okay um unfortunately i have a ton more questions specifically about how to structure the the programming um but i can see the timer which we’re just running short on time there so i will let you go there because i don’t want to interrupt your um next um next uh appointment so um is there any way you would like to direct people to if they wanted to um hear more from you or anything you would like to point people to um so i’m on twitter so it’s miles underscore physio on twitter so yeah obviously if you’ve got any questions or anything you can direct them there but otherwise there’s some really great online resources for tendons so the latrobe sport and exercise med research center have some fantastic resources podcasts infographics things like that that can be interesting if people specifically want to just know about some specific component of the tenant they tend to be quite focused and they’re a good resource especially because a lot of the content is free so you’re not having to get access to journal articles and stuff which i know can be tricky for some people um but yeah i think that would probably be the the best way to get some of those resources otherwise yeah just flick me a message or something on twitter and i’m happy to answer questions if people want more info cool that’s a that’s awesome i will put links to those things in the descriptions to the episode so that people can find you and that people can find the latrobe and sport and exercise medicine center in there um yeah i’ll see if they have anything specifically on the achilles and i’ll link to that directly um so thank you very much for your time miles i will be pestering you to come back on next time i read a new paper that you have published so um i i think i’ve read three or four from you in recent months and i’ve found them really informative so um thank you and keep up the good work no worries thank you so much and thank you for having me okay uh take care i’ll uh talk to you again soon alright see you later bye [/su_spoiler] [/su_accordion]