● Phase 2—Isotonic calf raises : As pain subsides, the patient can be progressed to isotonic calf raises, progressing from seated. As pain subsides, the patient can be progressed to isotonic calf raises, progressing from seated heel raises to standing heel raises to heel raises with weights (e.g., holding dumbbells). ● Phase 3—Energy storage loading—Plyometric exercises : This phase helps prepare the client to return to running. It involves deformation of the tendon via hopping and jumping exercises. Examples of exercises in this phase include single and double leg hopping (Achilles Tendinopathy, 2024). Mobilization/manipulation A study by Jayaseelan et al. (2017) looked at the influence of joint mobilization and manipulation in the treatment of Achilles tendinopathy. These techniques were used to address subtalar joint hypomobility and limited talocrural joint dorsiflexion. Subtalar joint hypomobility was addressed with talar anterior-posterior (AP) and lateral glides as well as subtalar joint distraction with thrust manipulation. Limited talocrural joint dorsiflexion was treated with supine talocrural joint distraction with thrust manipulation and standing mobilization with movement with belt for dorsiflexion. Treatment also included eccentric Achilles tendon loading, gastrocnemius stretching, and patient education. The study was limited to three runners, but the study showed these interventions were effective in decreasing pain and increasing function. Other interventions that have shown some effectiveness include soft tissue mobilization and gastrocnemius stretching (McCormack et al., 2017). Extracorporeal shock wave therapy Extracorporeal shock wave therapy (ESWT) is the transcutaneous applicating of acoustic waves transmitted in a narrow or focused manner. It is used to break down tissue and promote healing and repair (Mayo Clinic, 2022). A systematic review by Feeney (2022) looked at the effectiveness of ESWT in treating mid-substance Achilles tendinopathy. They concluded that ESWT is a safe and effective means of treating this condition, especially when used in combination with stretching and eccentric exercises.
of subtalar joint pronation. This can be assessed during video analysis of the client’s running by looking at heel eversion as described previously. In addition, static analysis of the forefoot and rearfoot for varus deformities should be completed as these deformities correlate with increased subtalar joint pronation. The other biomechanical factor that has been shown to predispose a runner to Achilles tendinopathy is the inversion angle of the tibia relative to the ground (Willwacher et al., 2022). Both tibial varum and genu varum increase the inversion angle of the tibia. Treatment Patient education Important elements of patient education include Achilles tendon anatomy, clinical pathology, pain science, healthy training principles, and optimal footwear (Jayaseelan et al., 2017). Eccentric loading of the achilles tendon Eccentric exercise is the most recommended form of conservative management of Achilles tendinitis (McCormack et al., 2017). Eccentric loading/stretching has been shown to achieve a 40% reduction in pain (Medina Pabón & Navqi, 2023). According to McCormack et al. (2017), the protocol for eccentric exercise involves doing heel raises as follows: the uninvolved heel completes a heel raise while in unilateral weightbearing. Now weightbearing switches to the involved side, and the heel is eccentrically lowered to the ground. Three sets of 15 reps is the recommended frequency. A more comprehensive eccentric exercise protocol is as follows: ● Phase 1—Isometric loading via achilles tendon holds : Isometric tendon loading Isometric tendon loading has been found to have pain-relieving effects. In addition, it aids in maintaining plantar flexor muscle strength. For highly tender tendons, they can be done using both legs, progressing to only the involved leg as pain subsides. The patient holds a heel raise at either full range or half-range. Other treatment options Other treatment options include the following: ● Lontophoresis —evidence supports use in the acute phase but not the chronic phase of Achilles tendinopathy (Achilles Tendinopathy, 2024). ● Dry needling —current research supports the use of this intervention (Stoychev et al., 2020). ● Night splints —expert opinion supports use of night splints in the acute phase. ● Taping —expert opinion supports the use of anti- pronation taping. ● Ultrasound and low-level laser therapy —these is no evidence to support the use of these modalities (Achilles Tendinopathy, 2024). Medial tibial stress syndrome Medial tibial stress syndrome, formerly called shin splints , is one of the most common exercise-induced lower extremity injuries (Mattock et al., 2021). It is considered the most common running-related injury with a frequency of approximately 15%. It is thought to be caused by inflammation and muscle traction on the periosteum of the tibia and stress reactions of the tibial bone (Menendez et al., 2020).
Self-Assessment Quiz Question #2 A lack of what motion is considered a risk factor for
Achilles tendinopathy? a. Ankle plantarflexion. b. Ankle dorsiflexion. c. Great toe extension. d. Subtalar joint supination.
Risk factors The following risk factors for medial tibial stress syndrome have been identified: ● Increased navicular drop (subtalar joint pronation). ● Increased body mass. ● Less running experience. ● Female gender. ● Lean lower leg girth. (Mattock et al., 2021)
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