Achilles Tendinopathy Recovery:
Acupuncture, Chinese Medicine & Rehab

Achilles tendinopathy injuries (previously referred to as achilles tendonitis or tendinosis) can cause long term pain and dysfunction. The term "tendinopathy" is a blanket term for tendon pathologies, but typically refers to a degenerative injury where the structure of the tendon is compromised from overuse. In recent years, research has shown that inflammation plays a minimal role in the progression of these injuries, which is why it is no longer referred to as a tendonitis which involves tearing and subsequent inflammation of the tissue.

There are 3 main phases of tendinopathy injuries:

1. Reactive tendinopathy: initial adaptation to overloading of tendon where there is a non-inflammatory swelling of the tendon due to increased fluid in the cellular matrix. Often in response to a sudden increase in load without appropriate rest.
    
2. Tendon dysrepair: if the tendon is continued to be overloaded, tendon structure begins to breakdown and collagen fibers become disorganised. There may be an increase in vascular and neuronal growth into the area.
    
3. Degenerative tendinopathy: after chronic prolonged overloading, there are multiple structural changes leaving the tendon less effective at handling load. The collagen fibers are further disorganised and there is an increase of neural and vascular growth. The tendon will likely appear thickened or nodular at portions. At this stage there is an increased risk of rupture due to the compromised structure.

So how could acupuncture and Chinese medicine help your recovery process?

At Village Remedies clinics in Sydney CBD and Balmain, we work with a wide range of people recovering from various injuries such as achilles tendinopathy. This page is a resource of recovery advice and exercises for those concurrently undergoing treatment with us or another healthcare professional. It is important you take your achilles injury recovery seriously as a poorly rehabilitated tendon will be prone to future rupture, so make sure you're working with a professional who can tailor the advice to your specific circumstances.

Our goal with acupuncture and Chinese medicine is to help support your recovery process and hopefully speed things up for you. At Village Remedies we use a very safe style of acupuncture where points distant to the injured area are used to trigger the body's innate healing response. This means that during the initial phases of healing and inflammation, we can still safely treat the injured achilles without causing further trauma to the area by working on it directly. As treatments and your recovery progress, we layer on other techniques to address imbalances and further promote tissue remodelling.

Your practitioner will also be looking to treat you as whole person, rather than just an injured achilles. This means we look at how we can help support your body's overall ability to heal by looking to reduce the stress response (which is often elevated in pain and injury), improve sleep quality and promote health digestion. To help support this and your achilles tendinopathy recovery, your practitioner may also recommend Chinese herbs. The benefit here is that you'll be getting a little treatment daily from the inside, and we find that it can help boost the effects of acupuncture.

Watch the videos below for an idea of what the treatment and recovery process is like if you were to come and work with us at Village Remedies, as well as simple assessment, some acupressure points for pain and dietary advice for better recovery:

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Below we will summarise the different phases of recovery you can expect to go through and the associated exercises to work on. Depending on the severity of your achilles tendinopathy, full recovery can be anywhere from 1 week to 3 months or more, which is why it's important to work under the guidance of your acupuncturist or other trained health professional, progressing through phases gradually as you can perform the exercises consistently without pain.

PHASE 1: DAMAGE CONTROL

This phase is for any acute flare up of achilles tendinopathy pain (6 or more out of 10 on a pain scale after repeated full range calf raises), usually associated with the reactive tendinopathy phase. This might be the first time this has happened, or associated with chronic tendon pain. Often pain is worst in mornings and there may be swelling of the tendon and aching into the foot or ankle.

The goals initially are:

1. To reduce pain and deload the tendon
2. Minimise atrophy - don't rest so much so as to cause dramatic loss of strength

In the clinic we'd be using distal acupuncture (points distant to the injury) to stimulate your body's natural healing processes. Our goals will be to help reduce pain and swelling. Certain Chinese herbs can also be useful in reducing pain and swelling, and promoting circulation.

Outside of the clinic you want to deload the tendon by avoiding any exercises that cause increased force through the tendon - in particular is running (jogging and sprinting) and jumping. Stretching the calf, though it might feel like the right thing to do, should also be avoided as this will cause compressive load to the tendon. This doesn't mean being stationary, however, movement is still important for circulation and healing, but lower impact exercises like walking, swimming or cycling are better options.

The main thing to keep in mind is to use pain as your guide. If you are experiencing achilles pain during an exercise or you pain flares within 24 hours afterwards, then what you're doing is too much load for now. It will get better, but not if you keep pushing through it, so do a little less or give yourself more time to recover in between.

In addition to this, there is a simple rehab exercise you can do to help reduce pain and start working on strengthening the tendon. We cover this in the video below but essentially it's a mid-range calf raise isometric hold (i.e. standing halfway up on your toes and holding). Avoid full range as this will add unwanted compression to the achilles:

• Hold for 40-60 seconds (do this near a wall for balance)
• Rest for 15-30 seconds
• Repeat for 4-5 reps
• Do this 3-4 times throughout the day, again using pain as your guide
• Once feeling strong and pain free with both feet at once, can progress to just one foot at a time

When you can perform repeated full range calf raises with 5/10 pain or less, you are ready to move onto phase 2.

PHASE 2: RESTORING STRENGTH

You can start with phase 2 recovering when you can perform repeated full range calf raises with 5/10 pain or less. This might be after an acute episode of reactive achilles tendinopathy, such as the situation in phase 1, or you may have been experiencing chronic mid-low grade achilles pain in a tendon dysrepair phase or degenerative tendinopathy.

Phase 2 goals are:

1. Stimulate tendon repair
2. Strengthen tendon

In the clinic we'd be using distal acupuncture again, combined with gentle movement of the injured leg with the goal of helping to rebuild neuromuscular connections. We may also be incorporating some local acupuncture with electro stimulation. Tendons are do not have good circulation and so are naturally slow to heal, but they are electrically conductive so we find electro acupuncture useful in encouraging tendon repair. Chinese herbs can also be useful to help support overall health and recovery.

Outside of the clinic we still want you avoiding jogging, sprinting and jumping exercises as these will cause excessive force through the tendon and impair healing progress. You should keep up with lower impact exercises like walking, swimming or riding. 

For your rehab exercise, we recommend using the Alfredson eccentric protocol which is considered the gold standard for mid-tendon tendinopathy recovery, however, if you have insertional achilles tendinopathy, the protocol needs to modified otherwise it will likely aggravate your symptoms (see our assessment video in the introduction of this page for the difference between mid-tendon and insertional tendinopathies). Watch our video for pointers, but here are the main points to remember:

• FOR MID-TENDON: Stand with the balls of your feet on the edge of a step, then using both feet stand up on your toes. At the top, take the uninjured foot away and lower your heel down on the injured side. 
   
• FOR INSERTIONAL: Do this on flat ground rather than a step, this will reduce extra compression at the insertion.
   
• Perform 15 reps with a straight knee for 3 sets, then 15 reps with a bent knee for 3 sets.
   
• Do this twice daily for 12 weeks. Use pain as your guide, but muscle fatigue aching is normal in the calf.
   
• We recommend building up to this and just performing 1 set of 15 reps of both straight and bent knee twice daily for the first few days. If no aggravation of symptoms, progress to 2 sets and then eventually to 3 sets, regressing w. It is also a good idea to do both sides to balance out the strength and help prevent achilles tendinopathy developing on the other side

You can incorporate exercises from the next phase after you've done 6-8 weeks of the above protocol and you're pain free.

PHASE 3: REBUILDING ELASTICITY

Phase 3 is just some additional exercises to add to the Alfredson eccentric heel drop exercises you've already been doing. By this point you should be mostly pain free in your day to day and we want to start preparing your tendons for the increased force of running and sport.

Phase 3 goals are:

1. To restore elasticity and shock absorption of the tendon
2. Prepare for reintroducing running and sport

In the clinic we're using the same kind of approach as in the previous phase, but treatments can be less frequent if you're progressing well. Chinese herbs may still be useful if there are any underlying issues with sleep, digestion or stress.

Outside of the clinic, you're continuing on with your daily Alfredson eccentric heel drop exercises, but 2-3 times per week you can add in these plyometric jumping sessions (watch video below for more):

• Jumping on the spot 60 times
   
• Jumping forwards and backwards 10 times
   
• Jumping side to side 10 times
   
• Repeat for 3 sets, but work up to it by starting with just 1 set and seeing how you feel over the next 24 hours. If okay, you can add a second and eventually a third set in the next sessions, but regressing as needed.
   
• Once you can do this comfortably on both feet without any aggravation of pain for a whole week, you can swap out sets of jumping for hopping instead.

Depending on your progress, your practitioner may be happy for you to experiment with some short distance, lower intensity running while keeping pain as your guide. From here it won't be long before you're back to full capacity, but it is important you continue to look after your achilles as it can still be a weak spot for months into the future. Check out our next section for ideas of re-injury prevention and maintenance.

ACHILLES TENDINOPATHY PREVENTION & ANKLE HEALTH

If you've had a history of achilles tendinopathy it is important to continue to take particular care of your achilles tendon strength and the overall mobility and stability of your ankle.

We recommend keeping eccentric heel drops and/or the jumping we discussed earlier as part of warm up for your normal exercise. You may benefit from adding a short ankle strengthening routine to your week. See the video for more details, but here are the pointers:

• 25 reps of tibialis raises - back against a wall, legs straight out in front with knees locked, lift toes up and lower. The closer your heels are to the wall, the easier. If you can't finish the reps where you start, just shuffle closer to make it easier and finish it off.
   
• 25 reps of straight legged calf raise with hands on wall - you're trying to create as much length in the calf as possible while still being able to touch the ground with your heel at the bottom of the movement. Move closer to the wall as needed to make it easier.
   
• Repeat 25 reps of tibialis raises.
   
• 25 reps of bent legged calf raise with hands on wall - maintain bend of knee through the movement.
   
• Do this routine 2-3 times per week.
   
• Once this is easy, you can switch to single leg variations of the calf raises, making sure you complete the reps on both legs, switching between sides if one side fatigues before you've finished your reps.
   
• This protocol is borrowed from ATG training and will help support knee health as well as strong ankles.

In addition to your exercises, you'll also want to make sure you're getting enough quality rest and quality nutrition, as lack of sleep will leave you more prone to injury and lack of certain vitamins and minerals will make you more prone to inflammation and compromise the quality of your tissues.

Regular check up sessions for acupuncture or with your healthcare professional can be useful to make sure things are keeping in good condition, giving you a chance to catch any imbalances or issues early. The main focus will be on hip balance and mobility, and core stability.

Our Acupuncture Clinics in Sydney's CBD & Balmain

If you would like to try traditional Chinese acupuncture in Sydney for your achilles tendinopathy pain, you can book online, contact us or call.

• Sydney CBD: 0412 728 227
• Balmain: 0478 753 881

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