Our Achilles tendon is usually more resistant and robust than ten meters of reinforced concrete. Before it breaks, it can withstand loads of around one ton — unless it has already been damaged. Care should therefore be taken.

In our blog post, we explain everything about “Achilles tendon pain” and, above all, how you can fight them.

Because in soccer in particular, the Achilles tendon is exposed to enormous forces, which it must absorb or transfer. But not only in soccer, but also in all other sports that involve a certain amount of running and jumping, we find the so-called 'mid-portion of Achilles tendinopathy' — an Achilles tendon injury.

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Symptoms of Achilles tendon disease

Those affected are mostly male and suffer from pain that is localized 2 — 6 cm above the base of the tendon. In addition, there is a certain sensitivity to pressure, local heating and a thickening of the tendon in the affected area (see Habets et al, 2015). Players often complain of a starting pain in the morning and pain at the beginning of a load, with the pain usually reducing again during the activity.

As a result of increasing fatigue, it usually becomes permanent and a pain-related cessation of movement/exercise often takes place. During acute phases of tendinopathy, occasional pain at rest may continue.

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Causes of Achilles tendon disease

It is important to know that such injury or overload damage is highly likely to be caused by multiple factors, i.e. there may be several reasons for this:

• Severe pronation of the foot
• footwear (-change, even in everyday life!)
• Stress change (range, intensity, frequency)
• low calf muscle strength
• Subsoil change (hard course, artificial turf)
• genetic determinants (e.g. gender)
• preponderance
• Foot, knee & hip injuries
• Nutrition (!)
• age

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Why people don't (yet) talk about an inflammation

Some readers may ask themselves why I'm not talking about “Achilles tendonitis.” Well, historically, this excessive or incorrect load injury has been associated with or reduced to various inflammatory processes. The fact is that it has not yet been clarified exactly what the causal relationship between the various indicators is in the end. Mascaro et al. (2018) find that pain, tendon pathologies, dysfunctions and faulty tendon structures are often correlated, but in no way have to be interdependent.

There appears to be agreement that tendinopathy results from misguided tendon healing and is associated with moderate symptoms of inflammation (see Habets et al., 2017; Cook & Purdam, 2009).

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Combat Achilles tendon problems

Sure, you can buy a family pack of “Ibu” and take a break for 2 weeks. This may even work in the short term. It's just stupid that we still don't know what the exact pathomechanism, i.e. the cause of a faulty tendon, is. In addition, we also do not know WHY exactly YOU are suffering from the described problems.

The worst thing you can do is stop any form of movement. But what exactly does an Achilles tendon need?

1. Load
   
2. neuroplasticity.
   

Load implies mechanical stress on the Achilles tendon. In English, “load” stands for the usual load parameters of volume, intensity and frequency.

Neuroplasticity is the ability of our brain and body (this primarily refers to nerve cells and muscle cells) to adapt due to a specific load. It is therefore primarily the interplay of muscles and brain.

We can take an example from everyday life to make it more clear. If we drive a sports car (musculature) on a dirt road (nervous system), then we have to drive very slowly, otherwise the car will break down. However, if we drive on the A7 in a microcar, we can only drive very slowly although we could go faster. We therefore need our sports car on the motorway.

Let's briefly summarize the whole thing again:

If you have tendinopathy, then you are well advised to keep moving. Before everyone starts running and starts indiscriminately mistreating their tendons, we still need to embed the training into a properly controlled framework of action.

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Pain monitoring to evaluate pain

What we need first of all is an evaluation of pain over a certain period of time (see Thomeé, 1997; Cook & Purdam, 2009; Silbernagel et al., 2007).

To do this, we use a scale that runs from 0 to 10.

• 0 = no pain

• 10 = worst pain you can imagine

With this “pain monitoring”, you can check your pain during exercise for up to 24 — 48 hours after the end of training. It doesn't matter which stage you are at and which training you are doing. If your pain is still above a value of “5” after 48 hours at the latest, you must reduce the load, change the time interval or choose another form of exercise in the next training session.

If the pain indication is between 0 — 5, you can increase the load, extend the time interval or choose more progressive forms of exercise in the next training session (attention: depending on the level). Especially in the acute phase, it is important that you do not exert even more excessive stress (see “Pain Monitoring”) on the tendon. Of course, you can still do additive strength training or go cycling, aqua sports and use the elliptical trainer for cardio training as long as you test yourself.

In addition, you are now installing a training intervention in your “replacement training units.” Since a tendon adapts very slowly, great patience is required here. You can expect that you will probably only see an improvement about two weeks after the start of the intervention. Most protocols are designed to last twelve weeks, some of them even over a year (see Murphy et al., 2018).

In our opinion, it is advisable to incorporate the exercises entirely into your own training.

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Stress program

Below is an overview of a gradual stress program in tendinopathy (see Mascaro et al., 2018; Murphy et al., 2018; PMS, 2018).

1. Isometry:
   This means “holding” forms of exercise over a certain time interval. For example, stand on your toes with your knees slightly bent. Hold that position. Depending on the pain, you can do this with one leg or with both legs at the same time.
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2. Eccentric feat. Isometry:
   Eccentric (diminishing) exercise content paired with isometric exercises is described here. Stand on a step (with a weight pack) with your heel sticking out of the step. Stand on your toes (preferably one-legged). Now let the heel sink down very slowly (approx. 4 seconds) until the ankle movement ends. Evaluate your pain level
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3. Increasing functional strength:
   It is important that you maintain points 1-2 at least three days a week. In doing so, we change the work into an eccentric/concentric movement. If you like, this describes the classic calf raise. However, with the premise that the movement should be relatively fast in the “upward phase” and relatively slowly in the “downward phase” (1/1/3). It is a good idea to train with one and both legs in alternation.
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4. Plyometry:
   You are already back in sport-specific training, but you are still doing the eccentric and isometric exercises at least three times a week. It is now a good idea to perform plyometric exercises such as box jumps, one-leg jumps, etc. at least 2x/W.
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5. Return to Play:
   You can play again. congratulations!

However, you should incorporate points 1-2 into your training at least two to three times a week. Away from the other points. Of course, it would also be best to maintain the classic calf raise as well as a sophisticated weight training program and plyometric content, but first we try to internalize feasible suggestions in everyday life.

Keep in mind that this intervention requires a high degree of adherence as it must be designed for the long term.

If you follow these essential points, you have a good chance of getting the pain symptoms under control so that you can finally play pain-free. Of course, setbacks can also occur within this. It should also be said that not every workout is suitable for everyone. However, we're talking about a high intersection that can be successful with this type of training program.

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synopsis

1. Keep moving. The biggest mistake that is made here is to stop every form of load. Although rest alleviates the pain, it does not improve the function of the tendon.
2. Avoid excessive tendon strain in the initial/acute phase of tendinopathy. Modifying the forms of burden is probably the best choice of means. Cycling, specific strength training and aqua sports would be my recommendation. The focus is on expanding energy storage (isometry) and reducing pain.
3. The most important tendon treatment is training. To date, all forms of treatment have been scientifically evaluated. Tendon training has the best evidence for improving pain symptoms while improving function.
4. Forms of stress must be individualized. Therefore, everyone must evaluate their pain presentation themselves and therefore find their own stress management system.
5. progression. This point is extremely important. Progressions can be: load increase, time interval extension, set number increase, break time reduction and other forms of contraction and exercise (isometric, concentric, eccentric, ballistic, plyometric...). In my opinion, increasing the load is the most important form of progression, as the mechanical stimulus can be selected to be relatively high here.
6. Tendinopathy takes time. The tendon will only adapt slowly as it reacts slowly to training. This is also the reason why progression appears so important. However, enormous patience is required here. There are also no abbreviations.
7. By the way, passive measures are only considered an addition to a training intervention. Ultrasound, shock wave therapy, injections or active-dynamic stretching (“mobility”) are only additive measures, but do not replace training. These things can be very useful in combination with training. Standing alone, they are unlikely to bring long-term success (see Abate et al., 2009; Cook at al., 2012, Littlewood et al., 2013, Malliaras et al., 2013; adapted from physiomeetscience.com).
8. overweight and diet. Unfortunately, both points are often considered completely underrepresentative in popular sport. Obesity, i.e. a BMI above 25, is a risk factor for a wide range of diseases and also a “driver” for injuries with symptoms of inflammation. As it were, a poor diet (alcohol, smoking, too few micronutrients) “fuels” the inflammatory process or makes it last longer.

The attentive readers have seen that there are no specified times for the individual levels. With the help of the Thomeé and Silbernagel pain monitoring system (2007), you can evaluate your progress anew every day.

As already outlined, the first improvements take place after approx. 2 weeks. However, it can take much longer before you notice a real pain reduction under stress.

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Be fearless. Be focused. B42