L1: What to prescribe them for and how to prescribe them

What to prescribe them for

Mid portion Achilles tendinopathy1

How to prescribe them

This exercise prescription advocates a case-by-case approach to managing Achilles tendinopathy as well as providing further novel exercises. Choose the most appropriate exercises from the prescription to give to your patient – sometimes this may be only one at a time. The most straightforward exercise to start with is single leg heel raises on a box. 

The main focus is on improving the patient’s plantar flexion strength and coordination while progressing at a rate that the patient can tolerate. It is based on the premise that the patient must build the strength capacity of gastrocnemius and soleus, muscles that are required to withstand high levels of body weight. In addition, it has been shown that an increase in muscle strength can be accompanied by an increase in tendon stiffness.*2-4 Some researchers consider optimal training to induce tendon adaptation to be 85 – 90% of maximum voluntary contraction with a duration of three seconds – in other words the load needs be appropriately heavy.5-7 

*Patients commonly think that an increase in ‘stiffness’ of any tissue would be detrimental; however, stiffer Achilles tendons for trained runners (in particular sprinters) seems to be beneficial as they can stretch and recoil faster and more effectively.8 Having said this, too much stiffness may affect the tendon’s compliance so it is not the goal to increase tendon stiffness maximally. Therefore there is probably an ‘optimal’ Achilles tendon stiffness for each individual depending on the activities they wish to perform. Unfortunately there does not appear to be a way of measuring or monitoring this to date, although a device (the MyotonPRO) is being investigated.9

For patients who cannot tolerate load you could start with one of the isometric exercises. For other low load exercises please refer to Return-to-Sport Exercises for Achilles Tendinopathy.