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Achilles Tendinopathy TEAM 1 Trial

This page should act as a reminder and provide you with further guidance on completing the exercises that your physiotherapist has taught you. Ensure that you are only completing the exercises that your physiotherapist has advised you to complete.

Physical Activity Table                 

 MTWTFSS
Rehab✓✓✓✓✓✓✓✓
Other PA    

 

Physical Activity needs to be managed through the day as not to over-rehab what is essentially an overuse injury. If the participant is continuing to exercise in recreational sport 3 days a week, then on those three days you would likely cut down to 1 rehab session only. If the participant has a manual job where they’re on their feet for prolonged periods, then this would also count as a session in itself. The table above shows the participant engaging in other physical activity on 3 days, thus reducing prescribed rehab to 1 occasion on those days. This is done in order to balance time under tension and allow sufficient recovery.


Physical Activity Guidelines

It is advisable that the participants potentially modify their training program if engaged in recreational sport. Impact training should be limited, if not stopped due to the strenuous and potentially damaging nature it has on the tendon and its recovery. Other activities can be maintained as long as it does not directly influence symptom exacerbation. If your participants are active runners, encourage the participants to switch to a more Achilles friendly sport such as swimming or cycling. In doing so they can maintain or even improve their cardiovascular fitness and prevent weight gain along with general deconditioning. However, they can do so in a way without preventing the Achilles from recovering due to the accumulated stress placed upon it.


Pain Monitoring Model – NRS Score during Rehabilitation

The pain monitoring model is a tool that should be utilised to help guide both the patient and treating clinician about when to progress the exercise program. This is done on a scale of 1-10 similar to the numerical rating scale. Due to the nature of the rehabilitation program focusing on high volume weight-bearing exercise multiple times daily, we are expecting participants to experience some discomfort during this program. This is traditionally towards the end of the session when there is much more of a burn in both the tendon and the muscle belly of the calf. If the burn is too severe and is classified by the participant as a 6/10, then it would be advisable to adjust the program. If the participant comments that the program is too easy and only is 2/10, then again you can look for ways to progress the program to participants needs.


Progressive loading

ProgressStay at LevelToo Much
12345678910

 

Pain during exercise should ideally fall into the "Progress" category. If pain is too much then negotiate a reduced load / speed / repetitions with the participant.

Achilles Loading Videos


Video 1 – 3539
https://youtu.be/xiO2aAA_UNE
Isometric Loading (Knee straight)
To be done from a standing position with the knees straight (3 sets x 30 second holds) This will be done by holding a heel raise 1 inch when knees are straight These are to be done at least twice daily and up to five times daily – ideally early in the morning and later in the evening. Increase load from two legs to one leg gradually as pain and strength allow.

Video 2 – 3540
https://youtu.be/4Bh8g0UhqCw
Isometric loading (Knee bent)
To be done from a standing position with the knees bent (3 sets x 30 second holds). This will be done by holding a heel raise 2 inches when knees are bent. These are to be done at least twice daily and up to five times daily – ideally early in the morning and later in the evening. Increase load from two legs to one leg gradually as pain and strength allow.

Concentric exercise is to be introduced when the participant’s pain has begun to settle OR when pain is stable and able to do isometrics on one leg as above without excessive pain exacerbation as defined by the pain monitoring model.
Reduce the isometrics down to twice per day. The participant can elect to do more IF they get good pain relief from this however. Start the concentrics with 3 sets of 3 reps (both knee flexed and extended) once per day AFTER the isometrics then progress as able. If symptoms are within the green limits of the Pain Monitoring Model (shown on page 1) then add 1 repetition to each set per day. When the participant can successfully do 3 sets of 8 reps on the affected tendon then progress on to eccentrics.

Video 3 – 3541
https://youtu.be/W89CqQT11Q8
Eccentric Achilles Loading (Knee Straight)
Once able to complete the concentric exercise then progress to eccentrics. These should be done in stable training shoes on the edge of a step. We would initially be aiming for the eccentrics to be done twice daily starting at 3 sets of 8 reps and progressing to 3 sets of 10 reps (low activity) or 3 sets of 15 reps (high activity) as the Pain Monitoring Model allows. The exercise should be performed in a way where you raise on to the toes using the non-affected side, therefore allowing the affected side to be targeted during the eccentric lowering phase. The eccentric lowering should take a count of approximately 5-6 seconds: in a 2:6:2 (pause:move:hold) ratio

Video 4 – 3542
https://youtu.be/ktlLqcpcs4Y
Eccentric Achilles Loading (Knee bent)
Once able to complete the concentric exercise then progress to eccentrics. These should be done in stable training shoes on the edge of a step. We would initially be aiming for the eccentrics to be done twice daily starting at 3 sets of 8 reps and progressing to 3 sets of 10 reps (low activity) or 3 sets of 15 reps (high activity) as the Pain Monitoring Model allows. The exercise should be performed in a way where you raise on to the toes using the non-affected side, therefore allowing the affected side to be targeted during the eccentric lowering phase. The eccentric lowering should take a count of approximately 5-6 seconds: in a 2:6:2 (pause:move:hold) ratio

Video 5 – 3543
https://youtu.be/Xlv-EC2PyYI
Additional Achilles Loading (Knee straight and bent)
If the participant is able to comfortably complete 3 sets of 10 (low PA) or 3 sets of 15 (high PA) on the eccentric program with both knee extended and flexed, then we should progress by adding resistance to the exercise. This should be done with a backpack that has approximately 10kg in. Each week add an extra 10kg until the load on the back is 40% of bodyweight. Tendon pain should not enter the red zone for this activity.

Video 6 – 3544
https://youtu.be/hO9x_K2rAeg
Achilles Loading Eccentrics with speed ‘drop and stop’
The next phase of increasing the load is to make the eccentrics faster in their descent and thus more strain placed on the tendon at the catching point (mid range) This will be done with no additional weight placed on the body (ie no backpack) . The eccentric lowering should be done at a speed of approximately 1-2 seconds – the so-called ‘drop and stop’ approach.

Once the participant has increased the strength of the triceps surae and tendon to a sufficient point then you can start to plan for a return to more strenuous activity including impact based sport specific training. The impact based activity should only be offered to those more active and for the less severe tendinopathic population to avoid any form of regression. This is based on the premise that only those who do impact exercise (even if occasional) need to condition the tendon for impact.

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