In part one of our achilles series, I covered critical goals for the initial management of runners with achilles tendinopathy. If you have not had a chance to read that post, check it out HERE.
After we have removed the aggravating positions, movements, and footwear we want to start challenging the achilles tendon (AT) with progressively more challenging exercises. Your AT has to handle A LOT of stress when we run. Implementing gradually more strenuous exercises during rehab helps us bridge the gap between not running and running. Progressively loading the AT serves two purposes. First, it helps condition the tissues of our body to be ready to run. Second, it allows us to assess if we are doing too much. If it’s painful and difficult to perform basic exercises, we probably aren’t ready to run.
We want to find the level of loading the body feels comfortable with and methodically increase the demand over time.
Is The Tendon Ready for Exercise?
Irritable tendons often progress through different stages of recovery. A typical progression is a highly irritable, “reactive” tendon in the early stages, moving to a lower-level, stable pain near the end. Every tendon is a little different.
When a tendon is in the “reactive” stage, it is often warm, swollen, and anything irritates it. In this stage, the tendon is MAD! It hurts, and you don’t want anyone messing with it. Reactive tendons don’t like aggressive exercise and can stay irritated for a while. It’s important we allow the tendon some breathing room to calm down. Once a runner isn’t limited with day-to-day tasks we can get them started on an exercise program.
To run, the AT has to handle being compressed against the heel (ankle dorsiflexion), tolerate the strain of the calf muscle tugging on the AT, and deal with the stretch-shortening cycle or the spring-like mechanism that allows us to explode from one foot to the next.
What Exercises Should I Do?
Tendon compression, calf contraction, ballistic loading.
We want our exercise program to cover these three criteria.
Our tendons have preferences just like each person likes different movies and music. Some tendons do really well with strenuous loading, others with footwear modifications, and some with more of a plyometric focus. It’s important to continually assess how a runner responds during the rehab process to tailor the program to the individual. In my experience, runners do well with picking one exercise under each goal and performing that three days a week. Let’s go through the three questions I want to answer with our exercise prescription.
Can You Handle Compression?
In order to progress forward when running, our knee needs to move over our toes. This picture below reflects the midstance position of running right in the middle between our foot hitting the ground and coming back off.
I like to progress runners back into this position in two ways: footwear progressions and exercise progressions.
If we are in a higher drop shoe and perform a squat, lunge, or run, our AT doesn’t have to deal with as much compression. It’s not as demanding on the ankle. Over time, we can progress into lower-heeled shoes as the symptoms progress.
We do the same thing with exercise. We start with less demanding activities requiring us to assume this position. Over time, we get to single leg, weight-bearing movements that reflect the positions of running.
This progression gradually increases the demand on the ankle and achilles as we progress from one leg to the next. We can also move these from “shoes on” to barefoot.
Goblet Squats > Squat Clocks > RFESS
Can You Load Your Calf Muscle?
A large portion of the “springiness” of running arises from the combination of our calf and AT. Our second goal is to increase stress on these structures by incorporating exercises that put us into ankle plantarflexion or up on our toes. These are some of the most common calf strengthening exercises runners perform. It’s really important that we continue to make these more challenging over time. Incorporating quicker movements or external load through dumbbells, barbells, and weight vests.
Single-Leg Calf Raises > Calf Raise + Dumbbell > Calf Raise + Dumbbell on Non-Working Leg
Can You Jump?
When you run, your foot is on and off the ground in a blink of an eye. The explosive nature of running should be reflected in rehab. We want to restore that “springiness.” Performing plyometric exercises like the progression listed below requires the AT to manage high-velocity movements. Plyometrics helps us condition the tendon to the stresses of running and allows us to assess if we are ready to run. If we can’t perform basic plyometric exercises, we’re not ready to run.
Bilateral Pogo Jumps > AP Pogo Jumps > Single-Leg Hopping > Single-Leg Hopping AP
None of these are absolute requirements to move to the next exercise or phase of rehab. These have been helpful progressions for myself and my patients before resuming running.
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