Prevention and Treatment Strategies for Achilles Injury - Part 2

Brad Walker provides an overview of the treatment of Achilles tendon injuries.

In part 1 of this article, we took a look at exactly what an Achilles injury is. We had a look at the muscles and tendons that make up the Achilles; what happens when an Achilles injury occurs; and the major causes and risk factors that contribute to Achilles injury. In part 2, we are going to outline a detailed strategy for the complete treatment and rehabilitation of Achilles tendonitis. Firstly, we will look at the importance of immediate treatment (the first 48 to 72 hours), and then we will outline the ongoing treatment necessary for a full recovery.

Immediate Treatment

The immediate treatment of any soft tissue injury is vital. Proper care and treatment now will go a long way towards a full recovery later. Without a doubt, the most effective, initial treatment for Achilles tendonitis is the R.I.C.E.R. regime. This involves the application of (R) rest, (I) ice, (C) compression, (E) elevation, and obtaining a (R) referral for appropriate medical treatment.

Where the R.I.C.E.R. regime has been used immediately after the occurrence of an injury, it has been shown to reduce recovery time significantly. R.I.C.E.R. forms the first, and most important stage of injury rehabilitation, providing the early base for the complete recovery of an injury.

When an Achilles injury occurs, and the tendon has been damaged there will be a large amount of uncontrolled bleeding around the injury site. This excessive bleeding causes swelling, which puts pressure on nerve endings and results in increased pain. It is exactly this process of bleeding, swelling, and pain that the R.I.C.E.R. regime will help to alleviate.

R: (rest)

The Achilles and lower leg must be kept as still as possible. This will help to slow down blood flow to the tendon and prevent any further damage.

I: (ice)

This is the most important part. The application of ice will have the greatest effect on reducing bleeding, swelling, and pain. Apply ice as soon as possible after the injury has occurred. How do you apply ice? Crushed ice in a plastic bag is usually best. However, blocks of ice, commercial cold packs, and bags of frozen peas will all do fine. Even cold water from a tap is better than nothing at all. When using ice, be careful not to apply it directly to the skin. This can cause "ice burns" and skin damage. Wrapping the ice in a damp towel provides the best protection for the skin.

How long and how often?

This is the point where few people agree. Let me give you some figures to use as a rough guide, and then I will give you some advice from personal experience. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours. These figures are a good starting point, but remember, they are only a guide. You must consider that some people are more sensitive to cold than others. Also, be aware that children and elderly people have a lower tolerance to ice and cold.

Finally, people with circulatory problems are also more sensitive to ice. Remember to keep these things in mind when treating yourself or someone else with ice. I recommend that people use their judgement when applying ice to themselves. For some people, 20 minutes is way too much, but for others, especially well-conditioned athletes, they can leave ice on for much longer. The individual should decide how long the ice should stay on.

My recommendation is that people should apply ice for as long as it is comfortable. There will be a slight discomfort from the cold, but as soon as pain or excessive discomfort is experienced, it is time to remove the ice. It is much better to apply ice for 3 to 5 minutes a couple of times an hour, than not at all.

C: (compression)

Compression achieves two things. Firstly, it helps to reduce both the bleeding and swelling around the Achilles, and secondly, it provides support for the ankle and lower leg. Use a wide, firm, elastic, compression bandage to cover the entire ankle and lower leg.

E: (elevation)

Raise the injured leg above the level of the heart at all times. This will further help to reduce the bleeding and swelling.

R: (referral)

If the injury is severe enough, you must consult a professional physical therapist or a qualified sports doctor for an accurate diagnosis. They will be able to tell you the full extent of the injury.

Before we finish with the initial treatment and move on to the next phase of the rehabilitation process, there are a few things that you must avoid during the first 72 hours. Be sure to avoid:

any form of heat at the injury site - this includes heat lamps, heat creams, spas, Jacuzzis, and saunas
all movement and massage of the injured area
excessive alcohol

All these things will increase the bleeding, swelling, and pain of your injury. Avoid them at all costs.

So, what happens after the first 48 to 72 hours?

When any damage occurs to the soft tissue (muscles, tendons, ligaments), the body immediately goes into a process of repair. Where the individual fibres have been ruptured or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen or, as it is more commonly known, scar tissue. When a tendon is torn or strained, you would expect that the body would repair that damage with a new tendon. In reality, this does not happen. The tear or rupture is repaired with scar tissue. Now, this might not sound like a big deal, but if you have ever suffered an Achilles injury, (or any soft tissue injury), you will know how annoying it is to keep re-injuring that same old injury, over and over again.

Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged tendon to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue surrounding the injury site. In some cases, it is even possible to see and feel this bulky mass under the skin. When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also tends to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished but the flexibility of the tissue is also compromised.

So, how do we get rid of that annoying formation of scar tissue?

Firstly, you must keep active and not listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours, and you are now ready to start light activity. Light activity will not only promote blood circulation but will also activate the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system. Before we move on, a quick word of warning. Never do any activity that hurts the injured area. Of course, you may feel some discomfort, but never push yourself to the point where you are feeling pain. Listen to your body. Do not overdo it at this stage of the recovery; you have come too far to blow it now.

To remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is used by physical therapists (or physiotherapists), and primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients in the damaged tissues. The Achilles tendon receives very little blood supply, as compared to a muscle, for example. So, it is vitally important to increase the blood flow to the injured area. This will help supply the tendon with the oxygen and nutrients they need for a speedy recovery. Physical Therapists accomplish this aim by using several activities to stimulate the injured area.

The most common methods used are ultrasound and heat. Ultrasound or TENS (Transcutaneous Electrical Nerve Stimulation) uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues. Secondly, to remove the unwanted scar tissue, you must start to massage the injured tendon and connecting muscles. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that. To start with, the Achilles tendon may be quite tender. So, start with a light stroke and gradually increase the pressure until you can use firm strokes. Concentrate your effort at the direct point of injury and use your thumbs to get in as deep as possible to break down the scar tissue.

Just a few final points

Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body. Also, I recommend you purchase a special ointment to use for your massage called "Arnica". This special ointment is extremely useful in treating soft tissue injuries, like sprains and tears. Arnica can be purchased at most health food shops and pharmacies.

Article Reference

This article first appeared in:

WALKER, B. (2006) Prevention and Treatment Strategies for Achilles Injury - Part 2. Brian Mackenzie's Successful Coaching, (ISSN 1745-7513/ 30 /March), p. 1-3

Page Reference

If you quote information from this page in your work, then the reference for this page is:

WALKER, B. (2006) Prevention and Treatment Strategies for Achilles Injury - Part 2 [WWW] Available from: https://www.brianmac.co.uk/articles/scni30a1.htm [Accessed

About the Author

Brad Walker is a prominent Australian sports trainer with more than 15 years of experience in the health and fitness industry. Brad is a Health Science graduate of the University of New England and has postgraduate accreditations in athletics, swimming, and triathlon coaching. He also works with elite level and world champion athletes and lectures for Sports Medicine Australia on injury prevention.


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In part 1 of this article, we took a look at exactly what an Achilles injury is. We had a look at the muscles and tendons that make up the Achilles; what happens when an Achilles injury occurs; and the major causes and risk factors that contribute to Achilles injury. In part 2, we are going to outline a detailed strategy for the complete treatment and rehabilitation of Achilles tendonitis. Firstly, we will look at the importance of immediate treatment (the first 48 to 72 hours), and then we will outline the ongoing treatment necessary for a full recovery. Immediate Treatment The immediate treatment of any soft tissue injury is vital. Proper care and treatment now will go a long way towards a full recovery later. Without a doubt, the most effective, initial treatment for Achilles tendonitis is the R.I.C.E.R. regime. This involves the application of (R) rest, (I) ice, (C) compression, (E) elevation, and obtaining a (R) referral for appropriate medical treatment. Where the R.I.C.E.R. regime has been used immediately after the occurrence of an injury, it has been shown to reduce recovery time significantly. R.I.C.E.R. forms the first, and most important stage of injury rehabilitation, providing the early base for the complete recovery of an injury. When an Achilles injury occurs, and the tendon has been damaged there will be a large amount of uncontrolled bleeding around the injury site. This excessive bleeding causes swelling, which puts pressure on nerve endings and results in increased pain. It is exactly this process of bleeding, swelling, and pain that the R.I.C.E.R. regime will help to alleviate. R: (rest) The Achilles and lower leg must be kept as still as possible. This will help to slow down blood flow to the tendon and prevent any further damage. I: (ice) This is the most important part. The application of ice will have the greatest effect on reducing bleeding, swelling, and pain. Apply ice as soon as possible after the injury has occurred. How do you apply ice? Crushed ice in a plastic bag is usually best. However, blocks of ice, commercial cold packs, and bags of frozen peas will all do fine. Even cold water from a tap is better than nothing at all. When using ice, be careful not to apply it directly to the skin. This can cause "ice burns" and skin damage. Wrapping the ice in a damp towel provides the best protection for the skin. How long and how often? This is the point where few people agree. Let me give you some figures to use as a rough guide, and then I will give you some advice from personal experience. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours. These figures are a good starting point, but remember, they are only a guide. You must consider that some people are more sensitive to cold than others. Also, be aware that children and elderly people have a lower tolerance to ice and cold. Finally, people with circulatory problems are also more sensitive to ice. Remember to keep these things in mind when treating yourself or someone else with ice. I recommend that people use their judgement when applying ice to themselves. For some people, 20 minutes is way too much, but for others, especially well-conditioned athletes, they can leave ice on for much longer. The individual should decide how long the ice should stay on. My recommendation is that people should apply ice for as long as it is comfortable. There will be a slight discomfort from the cold, but as soon as pain or excessive discomfort is experienced, it is time to remove the ice. It is much better to apply ice for 3 to 5 minutes a couple of times an hour, than not at all. C: (compression) Compression achieves two things. Firstly, it helps to reduce both the bleeding and swelling around the Achilles, and secondly, it provides support for the ankle and lower leg. Use a wide, firm, elastic, compression bandage to cover the entire ankle and lower leg. E: (elevation) Raise the injured leg above the level of the heart at all times. This will further help to reduce the bleeding and swelling. R: (referral) If the injury is severe enough, you must consult a professional physical therapist or a qualified sports doctor for an accurate diagnosis. They will be able to tell you the full extent of the injury. Before we finish with the initial treatment and move on to the next phase of the rehabilitation process, there are a few things that you must avoid during the first 72 hours. Be sure to avoid: any form of heat at the injury site - this includes heat lamps, heat creams, spas, Jacuzzis, and saunas all movement and massage of the injured area excessive alcohol All these things will increase the bleeding, swelling, and pain of your injury. Avoid them at all costs. So, what happens after the first 48 to 72 hours? When any damage occurs to the soft tissue (muscles, tendons, ligaments), the body immediately goes into a process of repair. Where the individual fibres have been ruptured or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen or, as it is more commonly known, scar tissue. When a tendon is torn or strained, you would expect that the body would repair that damage with a new tendon. In reality, this does not happen. The tear or rupture is repaired with scar tissue. Now, this might not sound like a big deal, but if you have ever suffered an Achilles injury, (or any soft tissue injury), you will know how annoying it is to keep re-injuring that same old injury, over and over again. Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged tendon to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue surrounding the injury site. In some cases, it is even possible to see and feel this bulky mass under the skin. When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also tends to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished but the flexibility of the tissue is also compromised. So, how do we get rid of that annoying formation of scar tissue? Firstly, you must keep active and not listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours, and you are now ready to start light activity. Light activity will not only promote blood circulation but will also activate the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system. Before we move on, a quick word of warning. Never do any activity that hurts the injured area. Of course, you may feel some discomfort, but never push yourself to the point where you are feeling pain. Listen to your body. Do not overdo it at this stage of the recovery; you have come too far to blow it now. To remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is used by physical therapists (or physiotherapists), and primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients in the damaged tissues. The Achilles tendon receives very little blood supply, as compared to a muscle, for example. So, it is vitally important to increase the blood flow to the injured area. This will help supply the tendon with the oxygen and nutrients they need for a speedy recovery. Physical Therapists accomplish this aim by using several activities to stimulate the injured area. The most common methods used are ultrasound and heat. Ultrasound or TENS (Transcutaneous Electrical Nerve Stimulation) uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues. Secondly, to remove the unwanted scar tissue, you must start to massage the injured tendon and connecting muscles. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that. To start with, the Achilles tendon may be quite tender. So, start with a light stroke and gradually increase the pressure until you can use firm strokes. Concentrate your effort at the direct point of injury and use your thumbs to get in as deep as possible to break down the scar tissue. Just a few final points Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body. Also, I recommend you purchase a special ointment to use for your massage called "Arnica". This special ointment is extremely useful in treating soft tissue injuries, like sprains and tears. Arnica can be purchased at most health food shops and pharmacies. Article Reference This article first appeared in: WALKER, B. (2006) Prevention and Treatment Strategies for Achilles Injury - Part 2. Brian Mackenzie's Successful Coaching, (ISSN 1745-7513/ 30 /March), p. 1-3 Page Reference If you quote information from this page in your work, then the reference for this page is: WALKER, B. (2006) Prevention and Treatment Strategies for Achilles Injury - Part 2 [WWW] Available from: https://www.brianmac.co.uk/articles/scni30a1.htm [Accessed About the Author Brad Walker is a prominent Australian sports trainer with more than 15 years of experience in the health and fitness industry. Brad is a Health Science graduate of the University of New England and has postgraduate accreditations in athletics, swimming, and triathlon coaching. He also works with elite level and world champion athletes and lectures for Sports Medicine Australia on injury prevention.