Friday, September 18, 2009

Achilles Tendon Injuries

      Although many people associate the Achilles tendon to an image of Brad Pitt getting an arrow through his back ankle, it is actually a fairly debilitating sports injury. There have been many attempts and different approaches to treating the Achilles. However the key to residing the pain may actually be in a treatment that provokes it.

       From Sweden Hakan Alfredson has done considerable research on a strict exercise regiment to help people relieve their Achilles problems. The best part about it is its non invasive, completely conservative and can be done from the comfort of your own home.
Alfredson’s study found that doing “eccentric heel drops” will results in subjects with mid-portion Achilles tendinopathy returning to preinjury activity levels within 12 weeks. The success rate of these subjects was 89%.

The exercise has to be done in both a knee straight position and the knee bent. The idea of these two different positions is to try and train the Gastrocnemius muscle (Knee straight) and the Soleus muscle (Knee bent). Both of these muscles join to help form the Achilles tendon. The protocol is outlined as 3 sets-15 reps, twice a day, every day for 12 weeks. This includes both the knee straight and knee bent exercises (180 reps a day). The patient has to return to the starting position by using their hands or good foot. Concentric contractions have to be completely avoided.

      Besides the protocol being extensive the downfall also lies in the fact these exercises have to be performed with some level of pain. If the patient is performing the exercises with no pain they have to have the exercises progressed by putting on a backpack or using weights. This increases the amount of load and force now travels through the Achilles tendon.

      Furthermore, Alfredson wanted to figure out why his results were not as good for those subjects with insertional Achilles problems (enthesopathy). A couple years later he performed the same protocol on those with Achilles entheopathies but changed the exercise to only bringing the foot to 90°. By this simple change the results went from 32% success rate in the past to 67%.

   The idea behind the change was those with enthesopathies also have retrocalcaneal bursitis accompanying the problem. By bringing the foot past 90° the calcaneous shifts backwards to impinge the bursa. Doing this repeatively did not help the problem and by simply bringing the foot to 90° you eliminate this factor.

       Make sure to rule out other diagnosis such as inflammatory anthropathies, posterior impingement syndrome, Haglunds disease and Sever’s disease.

1.Alfredson, H., & Cook, J. (2007). A treatment algorithm for managing Achilles tendinopathy: new treatment options British Journal of Sports Medicine, 41 (4), 211-216 DOI: 10.1136/bjsm.2007.035543
2.Jonsson, P., Alfredson, H., Sunding, K., Fahlstrom, M., & Cook, J. (2008). New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study British Journal of Sports Medicine, 42 (9), 746-749 DOI: 10.1136/bjsm.2007.039545

3. Pain in the Achilles Region with Hakan Aflredson and Jill Cook chapter 32 Brukner and Khan, Clinical Sports Medicine Medicine 3E, McGraw-Hill Australia 2006.


  1. Great article Dr. Button. Do you have pictures of the exercises?

  2. Damn. I have Haglund's Deformity so this isn't for me.

    Anyway, an editing note:
    "...strict exercise regiment" should be "...strict exercise regimen" without the "t".

  3. This comment has been removed by a blog administrator.

  4. We occasionally feel pain in our tendon but we normally don't know what it is. Tendon injuries are as common as headaches but we don't tend to notice that all the time.

  5. Thanks for sharing the post.It was really helpful.

  6. Good and informative content ...Really described your content in a different perspective.Thanks For Sharing!!