• Lionel Pannunzio PT / SCS

Achilles Pain In Soccer Players - Tendinopathy - Part II Rehabilitation Exercises| Weston | Florida



Introduction


Treatment of Achilles tendinopathy requires a comprehensive approach including pain control exercises, then strengthening followed by power and finally a well rounded return-to-play program to restore strength and function to this affected tendon.

In this blog, you will learn the main exercises we use with soccer player recovering from an Achilles Tendionpathy


Should I rest the Achilles or Loaded ?


Many soccer players may think that they need to ‘use’ the tendon ‘less’ in order to improve the pain and reduce the symptoms, so they rest or reduce the activity significantly and the pain usually gets better but here is the catch, once these players return to practice the pain comes back almost immediately

In our approach to Achilles Tendinopathy, the key is to fully rehabilitate the tendon by using the tendon more. More means progressive loading of the tendon to increase its resilience for the sport activity.


What are the best exercises for Achilles Tendinopathy?


Build plantar flexor capacity !!!! Do all types of calf raises

We discussed above that in Tendinopathies, loading the tendon is the way to improve this condition.

The goals is a progressive increase in loading the tendon through rehabilitation exercise that ultimately will include what is known as ‘heavy slow resistance’ work that typically is performed in a gym setting with appropriate resistance.


I like to see soccer players being able to do heavy gastrocnemius and soleus work in a gym (targets 1.5x body weight soleus seated calf raises & 0.3-0.4x body-weight standing calf raises aiming for 3x 8 reps with good control.


Of course even though the goal is to go heavy on the tendon, we cannot start with heavy stuff because it will most likely irritate the tendon and create more pain.


The logical progression for this exercises is to build up capacity with Isometrics first, then isotonics (full Range of movement) , then eccentrics (emphasis on the movement down of the calf raises ) and finally plyometric exercises with all types of jumps to challenge the super important and ultimate function of storage-release mechanism of the tendon )



Isometrics


Isometric contraction is a very powerful type of muscle activity in which the muscle contracts quite strong but there is no movement at the adjacent joint. Isometric exercises help with pain in the tendon as well as with the develop of force.

Isometric contractions are used early in the treatment process for these reasons.



Bilateral Calf Raises - Isometrics




Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Slowly raise your heels off the ground and hold that position. Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended .

As you get stronger you can add weight to this exercises with a vest or backpack



Unilateral Calf Raises - Isometrics



Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Raise your heels as high as you can then Bend one knee up to 90 degrees and hold the weight of your body on the opposite Foot raised , hold that position . Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended.



Isotonics Exercises


Once you are able to manage the Isometrics without a flare-up in pain or symptoms we start loading the tendon progressively in the full Range of motion available. Adding a step to the equation allows for more demand on the tendon fibers.

It is very important with these exercises below that you control the pace of the movement and go from one end of the movement to the other. This is how we will show the tendon where to align the newly formed fibers of collagen : “in line “ with the force which makes the tendon more resistant to the load.


Calf Raises on Step



Setup.

Begin standing at the edge of a step with your heels hanging off the edge. You may hold onto a stable object for support.

Movement.

Raise up onto the balls of your feet, then slowly lower your heels down off the edge of the step and repeat.

Tip.

Make sure to maintain your balance during the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.


Bent Knee Calf Raise on Step



Setup

Begin standing on a small step or platform with your heels off the edge, holding onto a stable object for balance.

Movement

Bend your knees, then raise both heels up, and lower them down slowly. Repeat these movements.

Tip

Make sure to keep your back straight and knees bent throughout the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.





Excellent… by doing calf raises Am I cured ? ….

The answer will be NO... YET....


Building plantar flexor capacity is just part of the treatment. Once you have more control of your calf muscles we need to reproduce the demands on the tendon. Tendons are like springs. Let’s say you are running and every step you take you absorb your own weight in the foot and then you push your body forward to continue running. This load absorption and release is the main function of the Achilles Tendon.






So in order to get completely better, strengthening only will not be enough and you need to reproduce and train this energy storage-release mechanism.

To recreate this, Therapists use what it is called Plyometrics exercises intended to simulate this function. Examples of Plyometrics are bilateral and unilateral leg jumps , quick calf raises , box jumps and other.

Plyometrics are high level exercises need to be done by a therapist to properly choose the right doses in order to avoid irritation of the tendon



Ankle Plyometrics - Double Leg and Single Leg Ballistic Heel Raises


Set Up

Stand up on the ball of your feet

Movement

Do Quick Rebounds mid amplitude

Then switch to one foot only and repeat mid amplitude heel raises

Sets of 10 reps


Load Management



When returning to the activity in this case playing soccer, you must do it gradually. Knowing exactly what brings out your symptoms will empower you to make the right adjustments for the healing process to take place.

Movements that create high loads and use the tendon as a spring (jumping or sprinting activities for example) increase cell signaling and can create the over-response that sparked the pain you are feeling. Therefore, start with walking and jogging session, followed by jogging only session, changes of speed (50-75-90 %), cuts 45-90-180 degrees, speed and agility drills, ball possession drills until you can practice a whole week without irritation of the tendon. If during the progression there is pain after the activity of the morning after it means the pain you’re experiencing is your tendon telling you it is not tolerating the loads you are placing on it. It is there for a reason. Listen to it.

For such cases, try changing one variable in your training program and see how your tendon responds. For example, if you currently train seven days a week, decrease the frequency by dropping one session. If you can’t sacrifice one day of training, you must make a change to either the amount of high intensity loads or the total volume of your training. Regardless of which variable you choose, only change one factor at a time and wait to see how your body responds (everyone will be slightly different so there is no golden rule).




Finally...Should I stretch Tendon Pain?

Despite what you may have learned elsewhere, we do not want to stretch an Achilles tendon injury!

No matter what form of tendinopathy you may be experiencing, stretching should not be a part of your rehabilitation program.

Remember that Insertional Achilles tendinopathy injuries occur due to high levels of compressive load to the tendon against the calcaneus bone. Stretching your calf muscles will only serve to add more compression (and lead to more pain) on the already injured area.

While there is less cause for concern for those dealing with a mid-tendon tendinopathy injury, research has not shown any benefits to stretching whatsoever.

Instead, if you do have limited ankle mobility or you feel tight in your calves, you can safely perform soft tissue mobilization to the calf muscles with a foam roller or massage stick. Foam rolling has been shown in research to improve ankle mobility without placing harmful compressive loads on the tend




Conclusion


  • Achilles Pain from Tendinopathy is very common in Soccer players (see statistics at https://www.ncbi.nlm.nih.gov/pubmed/23770660)

  • In this Tendinopathy there is an imbalance between the amount of load that the tendon in receiving and the tendon's capacity

  • Weakness in the calf musculature is the main reason for Achilles Tendinpathy.

  • Physical Therapy can help by building Calf Raise Capacity to improve the strength of the calf and reinforce the remaining of the healthy tendon.

  • A combination of Isometrics, Isotonics, Eccentrics and Plyometrics exercises is necessary for a safe and pain-free return to play process

  • Education in Load Management and a strategy to progressively load the tendon without (or minimal) irritation are also mandatory if you want to play pain-free



Do you have other questions about Achilles Tendinopathy?

Do you want to know if Physical Therapy can help your particular case ?



Give us a call at 754 244 2561 and we will help you answer these question and even we will schedule you a Free consultation


Visit www.wbsphysicaltherapy.com for more information

on how to talk to a Sports-Certified Specialist

and start getting better today...



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