Physiocure

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  • Achilles Tendinopathy in Runners & Athletes | Sports Physio Mumbai

    Achilles Tendinopathy Treatment for Athletes 

     

    Achilles tendinopathy is one of the most common lower-limb injuries seen in endurance runners, cricketers, footballers, and racquet sports athletes. Unlike an acute tear, this condition develops gradually due to repetitive overload, poor load management, and biomechanical inefficiencies.

    One-fourth of the Achilles tendinopathies is located at lower portion of the back of the heel Middle-aged male athletes are considered to have a greater risk of developing Achilles Tendon injury, although high rates (31% of all Achilles injuries) have also been reported in people who don’t participate in sports. Often professionals are puzzled as to how to resolve this tendinopathy

    In 2025, sports physiotherapy has moved beyond “just calf strengthening” to a whole-body, sport-specific and neuromuscular approach — especially for athletes aiming to return to high-level performance without recurrence.

     

    What Is Achilles Tendinopathy?

    Achilles tendinopathy is a degenerative overuse condition affecting the Achilles tendon — the structure connecting the calf muscles to the heel bone. It commonly presents as:

    • Pain during or after activity
    • Morning stiffness
    • Reduced push-off strength
    • Thickening or tenderness of the tendon

    Contrary to older beliefs, current research shows it is not primarily inflammatory, but rather a load-related tendon adaptation failure.

     

    Anatomy and Histology

    The Achilles tendon is a tendon formed from the calf muscle, which is formed from the gastrocnemius and the soleus muscles. The gastrocnemius is a 2 joint muscle, as it starts above the knee joint, and ends at the back of the heel in the form of ACHILLES tendon . Soleus, on the other hand, starts below the knee and connects to  the achilles tendon .

    Achilles Tendon injury

    The Achilles tendon inserts not only into the calcaneus but also connects to the plantar fascia and the two structures act as a continuum. The tendon’s fibers rotate in its insertion into the calcaneal bone at approximately 90 degrees, with the medial fibers coming posteriorly and the lateral fibers coming inferiorly .

    The insertion of the tendon is protected by two fluid filled sacs called BURSA , the retrocalcaneal, which is between the Achilles and the skin, and the retro Achilles, which is between the Achilles and the calcaneus. The area of the Achilles insertion, the calcaneus, and the two bursas are known as the enthesis organ.

    The Achilles tendon does not have a true sheath, but it is covered instead by a loose, fatty sheath called paratendon. The paratendon provides vascular supply to the achlles tendon and helps it to glide with minimal friction within the sheath. Deeper to the peritendon is the endotendon, which encloses the collagen fibers of the tendon, its small blood and lymph vessels, and its nerves.

    Blood supply to the tendon is also provided by the musculotendinous junction and through its attachment to the bone.

    “The area 2-6cm above the tendons insertion has been proposed to have poor vascularity, which explains why it is prone to injury

    As far as the histology is concerned, the tendon consists of cells and extracellular matrix . Approximately 95% of the tendon’s cells are tenocytes and tenoblasts, with the rest 5% being chondrocytes, vascular cells, synovial cells and smooth muscle cells.

    Pathology behind the Tendon Injury?

    Achilles Tendon injury can be an acute and overuse injury.

    An acute Achilles Tendon injury follows the same healing principles as every other area of soft tissues, starting with inflammation and eventually healing into a scar tissue.

    Chronic Achilles Tendon  injuries, though, do not seem to follow the same procedure . The microtrauma caused to the tendon does not produce inflammation, thus there is poor healing of the tissues. This condition is described as “failed healing response”.

    There are four basic elements seen in the majority of the patients with degenerative Achilles:

    1) Altered cell function. The metabolism of the cells increases in order to produce more collagen and ground substance

    2) The amount of proteoglycans in the ground substance increases

    3) Microrupture of the collagen type I fibers and production of the thinner type III- which makes the tendon fragile

    4) Appearance of new vessels and nerves into the tendon as a result the tendon is more sensitive than normal

    The degenerative Achilles tendon does not have macroscopically a normal white shape and it rather looks grey and unstructured . Instead of parallel orientation, there is a random orientation of the collagen (especially type III), of the ground substance and of the vessels, which makes the tendon less capable to withstand loads .

    Although, there is not true tissue inflammation in Achilles tendinopathy, evidence of neurogenic inflammation exists .  Substance P, CRGP and glutamate have been found in symptomatic chronic tendinopathies .

    Research states that chronic tendinopathies could be in fact caused by nerve tissue dysfunction, rather than being the result of repetitive overload of the tendon. considers it possible that local nerve damage in the Achilles area could be produced by long distance running due to the repetitive load, in a similar way that vibration causes trauma to the tissues. may be thats the reason, the tendon takes upto 12 months to reverse back to normalcy post rehab??

    Moreover, a potential nerve pinch  in the lower back region, the buttock area or between the two heads of calf could have a similar impact on the tendon.

    Why Achilles Tendinopathy Is Common in Specific Sports

    🏃 Marathoners & Long-Distance Runners

    Marathon running exposes the Achilles tendon to thousands of repetitive loading cycles. Sudden mileage increases, speed work, or hill training often exceed the tendon’s capacity.

    Common contributing factors:

    • Poor calf-soleus endurance
    • Reduced ankle dorsiflexion
    • Fatigue-induced altered running mechanics

    🏏 Cricketers

    Cricket involves repeated short sprints, sudden stops, bowling load, and prolonged standing, all of which strain the Achilles — especially in fast bowlers and all-rounders.

    Key risks include:

    • Asymmetrical loading
    • Poor posterior chain strength
    • Inadequate recovery between matches

    ⚽ Footballers

    Football places high eccentric and plyometric demands on the Achilles tendon through sprinting, cutting, and jumping.

    High-risk factors:

    • Frequent acceleration/deceleration
    • Multi-directional stress
    • Inadequate tendon load progression during preseason

    🎾 Racquet Sports Athletes (Badminton, Tennis, Squash, Pickleball)

    Explosive lunges, rapid push-offs, and lateral movements make racquet sports a high-risk category for Achilles tendinopathy.

    Common issues:

    • Poor foot-ankle control
    • Over-reliance on calf muscles
    • Inadequate eccentric loading capacity

    Clinical Findings:-

    • A careful subjective examination of the patient will reveal that the area of the symptoms in the midportion tendinopathy is along the main body of the tendon , while in the insertional the pain is experienced at the tendon’s insertion .
    • Achilles tendinopathy pain does not usually refer to other areas .
    • The pain can vary from minor to severe and may be accompanied by swelling, thickening and crepitus . If crepitation coexists, the paratendon is involved in the pathology too , although it is not common in chronic cases .
    • The pain at the first stage of the disease appears at the beginning of the training and immediately after it, with no symptoms in-between.
    • If it progresses it may not allow the patient to participate in sports and pain may be even present during his daily living activities .
    • Running and hoping usually aggravate symptoms , while rest, slow walking and heat relieve them .
    • Morning stiffness is one of the main complains of the patients .
    • The history reveals a sudden onset of symptoms after an increase in the intensity, the frequency or the duration of training .

    The objective examination we check for the following:-

    observation of the patient for

    1. muscle bulk wasting,
    2. swelling of the tendon as well as for
    3. malalignments of the foot .
    4. Single-leg heel raises (are useful as pain provocation test, but also to assess the muscle-tendon unit strength and endurance .)
    5. hopping .(In athletes that might need a more challenging test for pain reproduction)

    The palpation will reveal any possible

    1. thickening,
    2. increased heat,
    3. areas of tenderness or
    4. crepitus

    Finally, we believe. it is very important to assess the whole kinetic chain of the lower limb and pelvis for possible impairments that might contribute to the problem .

    The calf squeeze test is a quick test done in clients who might be suspected for tendon rupture

    Paratendonitis

    The “painful arc sign”, is uded for differential diagnosis of paratendonitis in clients to understand the type of achilles tendinopathy. If the area of maximum tenderness is palpated, then the foot is moved from plantar to dorsiflexion and the area of tenderness remains in the same position, in that case the paratendon is the source of symptoms .

    The retrocalcaneal bursitis

    Usually presents as a prominent warm area of the back and the outer part of the heel. In the retro-Achilles bursitis on the other hand, pain presents as very superficial and the area of the back of the heel is warm

    while in the insertional tendinopathy the pain is around the central part of the back of the heel .

    Lastly, our physiocure clinicians  always remember that enthesopathy is a common symptom of rheumatoid arthritis and spondyloarthropathy so the diagnosis is made accordingly.

     

    2025 Research Trends in Achilles Tendinopathy

    🔬 1. Tendinopathy Is a Neuromuscular Problem Too

    Recent research shows athletes with Achilles tendinopathy demonstrate altered nervous system control, including reduced muscle recruitment efficiency and increased cortical inhibition.
    👉 This explains why strength alone isn’t enough.

    🏋️ 2. Progressive Loading Still Remains the Gold Standard

    Eccentric, isometric, and heavy slow resistance training continue to show strong evidence in improving tendon capacity — but now with sport-specific dosing and progression models.

    🧠 3. Whole-Body Biomechanics Matter

    2025 studies emphasize the role of:

    • Hip and glute strength
    • Core control
    • Foot mechanics
    • Running and sport-specific movement patterns

    Achilles load is influenced by the entire kinetic chain, not just the calf.

    📊 4. Early Detection & Load Monitoring

    Advanced imaging and workload monitoring tools are increasingly used in elite sport to detect early tendon changes — reinforcing the importance of early physiotherapy intervention.

    The Sports Physio approach at Physiocure

     

    ✅ Stage 1: Load Management & Pain Control

    • Activity modification (not complete rest)
    • Isometric loading for pain modulation
    • Soft tissue and myofascial techniques when indicated

    ✅ Stage 2: Progressive Tendon Loading

    • Eccentric & heavy slow resistance calf training
    • Soleus-specific strengthening (crucial for runners)
    • Controlled plyometric preparation

    ✅ Stage 3: Kinetic Chain Correction

    • Hip, glute, and core strengthening
    • Foot-ankle control drills
    • Gait or movement pattern retraining

    ✅ Stage 4: Sport-Specific Return to Play

     

    Return to sports

    A short recovery time and an early return to sports without a gradual loading of activities is a recipe for reinjury or repeated tendoachilles strains. we do not recommend our players to stop playing while they are undergoing rehab for 8 to 12 weeks , but instead we recommend them to perform activities that will promote healing and restrict activities that will worsen the tendon. after a certain point in rehab the players do not have nay symptoms and hence they may be tempted to return to playing early.

    Under a guided rehab program symptoms like pain, swelling, stiffness are monitired and give an idea on wether to further increase the activity level or not.

    Here is a small table explaining how a runner will feel when he starts running and what should it feel like. for instance, if walking for 70 minutes causes pain more that 2 (as per the pain scale) you have not recovovered yet to pursure walking . you need to take it easy.

     

    AS PER THIS RESEARCH BASED PROOF, WE RECOMMEND AN ATHLETE TO START WITH RUNNING OR JUMPING ACTIVITY ONLY IF ACTIVITIES OF DAILY LIVING ARE PAIN FREE

     

      Classification of activities
      Light moderate Heavy
    Pain level during activity , NPRS (0-10) 1-2 2-3 4-5
    Pain level after activity (next day) 1-2 3-4 5-6
    Athletes’s RPE in regards to the Achilles tendon 0-1 2-4 5-10
    Recovery days needed in between activities 0 2 3
    Examples of activities for a runner Walking for 70 mins Jogging on flat surface for 30 minutes Running at 85% of preinjury speed for 20 minutes
    Abbreviations:- NPRS- numeric pain rating scale, RPE- rate of perceived exertion

    The return to sport program is introduced, within few weeks of the start of the rehab program. the athlete is educated even if  they do not wish to follow a return to sports phase. for atheletes who do sign up a training diary is made and they are asked to note down symptoms as per the daily schedule.

    Sports Specific Physio rehab points we follow:-

    • Sprint mechanics for footballers & cricketers
    • Running load progression for marathoners
    • Lateral agility and reactive drills for racquet sports

    How Long Does Achilles Tendinopathy Take to Heal?

    Most athletes require 8–16 weeks of structured rehabilitation, depending on:

    • Chronicity of symptoms
    • Training load history
    • Sport-specific demands
    • Adherence to rehab protocols

    Rushing return to sport is the most common cause of recurrence.

    Frequently Asked Questions (FAQs)

    Is Achilles tendinopathy the same as an Achilles tear?

    No. Tendinopathy is a degenerative overload condition, while a tear is an acute structural rupture. Treatment strategies differ significantly.

    Should I stop running or playing completely?

    Not always. Modern sports physiotherapy focuses on load modification, not total rest, unless symptoms are severe.

    Does shockwave therapy help Achilles tendinopathy?

    Shockwave therapy can be beneficial when combined with a structured loading program, especially in chronic cases.

    Why does my Achilles pain keep coming back?

    Recurrence often occurs due to:

    • Incomplete rehab
    • Poor load progression
    • Ignoring kinetic chain weaknesses
    • Returning to sport too early

    Can sports physiotherapy prevent surgery?

    Yes. Most Achilles tendinopathy cases respond well to evidence-based physiotherapy, avoiding injections or surgical intervention.

    Why Choose Physiocure: The Sports Rehab Clinic?

    ✔ 17+ years of sports injury experience
    ✔ Expertise with runners, cricketers, footballers & racquet athletes
    ✔ Advanced biomechanical and movement-based rehab
    ✔ Return-to-sport focused protocols
    ✔ Located in Santacruz West / Bandra / Juhu

    Book a Sports Physiotherapy Consultation

    If you’re an athlete dealing with persistent Achilles pain, early intervention can make the difference between full recovery and chronic limitation.

    📍 Physiocure: The Sports Rehab Clinic
    📞 Book your assessment today
    🏃‍♂️ Train smarter. Recover stronger. Perform better.

    References:-

    1. Alfredson, H & Cook, J 2007a, ‘A treatment algorithm for managing Achilles tendinopathy: new treatment options’, British Journal of Sports Medicine, vol. 41, no. 4, pp. 211-216.
    2. https://bjsm.bmj.com/content/50/19/1187
    3. Alfredson, H & Ohberg, L 2005, ‘Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial’, Knee Surgery and Sports Traumatology Arthroscopy, vol. 13, no. 4, pp. 338-344.
    4. Cook, J, Khan, KM & Purdam, C 2002, ‘Achilles tendinopathy’, Manual Therapy, vol. 7, no. 3, pp. 121-130.
    5. https://www.researchgate.net/publication/282047223

     

  • Running

    Running is one of the most popular sports in the world. This not only covers marathons and track and field running – running is also part of the training in virtually all other sports, including soccer, rugby, handball and triathlon. Modified levels and intensities of running can also be used as alternative training for most athletes with certain types of injuries

    Running is a very efficient method for maintaining or improving overall fitness and increasing the structural strength of the leg muscles. Running can be over a distance, in a variety of intervals or as a varied running-jogging-walking program. The intensity and the distance must be proportionate to the runner’s ability and objectives.

    Running on a hard surface

    However,before running on a hard surface, such as roads or astro turf, the runner must be able to withstand the repetitive impact of the ground on to the legs, as each stride will create an impact force of five to ten times body weight for a fraction of a second. Since each stride stresses the same structures, their tensile strength and endurance lie between positive training effects and injury.

    Running on a hard surface mainly loads the lower limbs, where 90 per cent of running injuries are found. The most common error an inexperienced runner makes is to run too fast and too long too early, so that training causes new injuries instead of promoting the healing of another.

    Prescribing hard surface running

    It is important to use common sense when prescribing hard-surface running. For an inexperienced runner the safest way to build up performance after an injury is a slow and steady running tempo,
    including a proper warm-up. The best test of improvement in running capacity is repeatedly to measure the runner’s effort and time in a simple test race.

    Running for general fitness

    For a fairly unfit but otherwise healthy person who wants to improve their general fitness and aerobic performance, running can be recommended as part of a progressive program. From a reasonable starting point, such a program would usually increase less than 15 per cent in distance and intensity per year.

    When to stop/reduce running on a hard surface!!

    • An elite marathon runner with an over-use injury may simply reduce their running time from two hours to one hour per day; not pushing over the pain threshold but gradually increasing the time day by day.
    • A 130 kg rugby player, even though extremely fit, is not a good candidate for long-distance or road running. Their knees will undoubtedly say ‘no!’ to this madness.
    • This type of exercise also cannot be recommended for obese or generally unfit recreational athletes or people with structural knee or hip problems, such as osteoarthritis.

     

    How do you know your running capacity is decent!!

    A reasonable running tempo that can be maintained for 30 minutes is essential for a persistent training effect. Runners should aim for a pace at which they can chat with a running mate while breathing almost normally; this is equivalent to 60 to 70 per cent of maximum aerobic capacity.

    The subjective experience of running is far more important than the heart frequency, which is not directly proportionate to the runner’s feeling. Even with the same heart frequency, for example 160 beats per minute, running can be very easy one day and very uncomfortable the next.

    Training to run efficiently

    The subjective experience of training is very important for a non-runner’s motivation. Since the surface is consistent for each stride the same structures in the lower limbs will be put under repeated stress. While this leads to a functional adaption of the strength of the structures it can also lead to
    injuries in the short term.

    The comfortable fitting shoe for running

    This also highlights the importance of proper, comfortably fitting of The Running Shoe with a cushioned sole, which can reduce the impact from touchdown in the stride, distribute the forces and provide stability to the ankle and foot.

     

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    Regular runners will soon find their own style, but might have more trouble getting a consistent style of footwear. Most running injuries are caused by training errors.

    We usually recomment these ankle mobility exercises for runners training for a marathon

    Don’t get carried away!!

    The commercial running shoe market is unfortunately mainly fashion-orientated and new models are pumped out every six months. Despite improved bio mechanical knowledge, which manufacturers claim has revolutionized the market, and lighter high-quality materials and technology within the sole to compensate for different individual factors, modern running shoes do not last long. It may also be questioned whether they have reduced the incidence of injuries.

    Soft Surface Running

    Running on soft surfaces maintains or increases fitness and tensile strength of the lower limbs and with less eccentric impact compared to running on hard surfaces. A well-balanced running programme over beachess, in parklands or in forests can be recommended as a primary alternative
    training for most runners and other athletes with over-use injuries, even those of the lower limbs.

    People with mild or moderate knee or hip osteo-arthritis, who struggle to run 500 m on the road, may be able to jog a 5 km orienteering course without adverse effects.

    people with knee or hip arthritis must do these stretches before going for the run

    Advantages of soft surface running

    • A varied and soft running surface creates a lower impact on the musculo-skeletal system, due to the longer time for shock absorption from each stride and the wider distribution of forces over the kinetic chain.
    • On the other hand, the runner is forced to work harder, from a muscular point of view; they need to lift the knees higher when running uphill or over obstacles on the ground like vegetation.
    • This consumes more energy and, all in all, uses more muscle groups than running on hard surfaces.
    • Running in forests consumes up to twice as much energy per kilometer as road running.
    • Running on soft surfaces is less demanding for the lower limbs but, due to the increased energy demand, puts more stress on the cardiovascular and respiratory system and so is good for weight reduction and general fitness.

    Risks of soft surface running!!

    • There are risks in the prescription of this type of training. Over uneven terrain, the risk of ankle sprains and falls increases.
    • Even though temporarily running on soft surfaces can be recommended for a marathon runner with over-use injuries of the lower limbs, they must be aware of the increased risks.
    • Proprioceptive ankle training and core stability training must accompany alterations in running type.

     

    Who should avoid running on soft surfaces

    Older athletes, or fragile patients with osteoporosis or disabling injuries, may jog or walk on softer surfaces instead of running

    Last but not the least if you are into running you must follow these three stretches everyday to prevent yourself from injuries.

  • The Running Shoe ?

    As more and more people resort to running for health and fitness, so have the number of  Running injuries increased. A visit to Physiocure we can help you educate with the foot types, shoe designs and a simple examination can reveal which foot type you run with and is your current running shoe good enough.

    When we happened to interact with our professional runners on how they choose their shoes, we were not surprised at all. Most consumers are nowadays visiting the sports shoe showrooms and are made to walk on the treadmill, a foot scanning is done and then the shoe is prescribed at least in metro cities in India, for smaller cities it’s more of what feels comfortable and what fits my budget.

    A lot of people pick up running shoes based on

    • available discounts,
    • latest styles or
    • they are consulted by so called “storeroom shoe prescription experts” into buying the motion controlled or pronation control type footwear.

    this is common and is not always bad, but really it is a matter of concern. after 12 years of practice, I believe, a low arch, motion-controlled shoe, a high arch are secondary factors that contribute to running injuries, and its just a “fear-based marketing approach” to sell new, highly-priced running shoes

    overpronation is normalmarketing strategyEthopian athlete

     

     

     

     

     

     

     

     

     

    Before you go for the new shoe selection trip to these stores again, ask yourself these questions:

    • Would you take the advice of a person trained by a marketing expert into explaining the foot scanning in these stores or your physio/health care provider?
    • Did you check your foot type from a podiatrist/physio/health care provider or the sales guy at these stores?
    • Has choosing shoes on based of feel, prevented your number of sports injuries.
    • Is you running pattern in sync with the motion control shoes you’ve been offered.
    • Is the sales guy really a shoe prescription expert?
    • Was there something wrong with my last shoe or my running style or fitness?

     

    What does research say??

    Where can we find the truth, as physiotherapists? Peer-reviewed research is a fantastic source of information and can guide us to the truth when it comes to what Running shoe is best for our patients.

    It was once believed that those with low arches should wear “motion-control” shoes which are designed to be more rigid. Those with a more neutral or “normal” arch should be placed in “stability” shoes, and those with a high arch should be placed in more cushioned, “neutral” shoes.

    Despite common “knowledge” in the running community, selecting a shoe based on arch-height does not lead to reduced injury (1).

    Another misnomer commonly used for shoe prescription indicates that excessive pronation of the foot and ankle leads to injury, so shoes should be fitted to reduce pronation.

    Current research is inconsistent and conflicting but has not shown a strong correlation between “excessive” pronation and injury (2, 3).

    Pronation or foot posture can not confidently be used as an indicator for shoe prescription, barring further research.

    What about “minimalist” shoes?

    Once again, not enough research has been completed to confidently say that wearing minimalist shoes leads to reduced injuries. Minimalist shoes are designed to mimic running barefoot, resulting in a foot-strike closer to forefoot (4). This “strike-pattern” is linked to reduced forces placed through the shin bone ( a.k.a thetibia) and the knee.

     

    Also, running barefoot actually has been shown to reduce ground-reaction forces through the leg, when compared to running with neutral shoes (5).

    As discussed, much of the “common knowledge” about Running shoe selection is either false or has little evidence to support it. So, what is the best way to recommend shoes?

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