Q+A: How can I deal with Achilles scar tissue?

Q I’m a triathlete, and a few months ago I damaged my Achilles tendon while cycling. I tried to control the problem with rest, ice and elevation, but to no avail. It now regularly becomes inflamed and painful, and I have to have three to five days off. I’ve fitted an orthosis in my left cycling shoe, and heel raises in my running shoes. I mainly run off-road and do plenty of static stretches, along with stretches over a step, and massage the tendon. But it still hurts – what can I do?

A Your injury has probably left scar tissue on your Achilles, and once scar tissue has become inflexible and tight, it can be very difficult to mobilise. The efforts you have made to massage and stretch the tendon are good, but it may be worth discussing some modifications and other options to your programme. Massaging needs to be very deep (in the form of deep friction), and it may be necessary to do this daily for up to 30 minutes to break very tight scar tissue.

The stretches should be performed daily and be aimed at stretching not only the gastrocnemius, but also the soleus (these are the upper and lower calf muscles). Use the standard calf stretch, in which you lean into a wall with your arms outstretched. Stretch your gastrocnemius with the knee straight, and your soleus with the knee bent. The soleus stretch is the most important, as most of the fibres of your Achilles tendon originate here. Moreover, as you damaged the tendon with your knee bent, it’s likely to be those fibres that are damaged the most.

Stretching is important, but it doesn’t prepare you well for running on its own. Stretching is static, while running is very ballistic. You must therefore prepare for this in the gym to complement your stretching. The sort of exercises you should be doing are the calf press on a recumbent leg-press machine, and seated calf raises. Start off with slow, controlled movements, but as you get used to the movements, try increasing the speed (without losing control) and start working ballistically. Speak to your gym instructor; hopefully they will be familiar with this type of rehab.

If you have good flexibility in your calves, orthoses might be helpful. You mentioned the orthosis in your cycling shoe. This needs to be a full-length plate that affects the forefoot. If not, it will be ineffective, as the rearfoot cannot be controlled by an orthosis without any weight going through it.

It may be that the scarring is too advanced for any treatment but surgery. If, and only if, the options above are not successful, then perhaps you should consider this if you want to have a chance of a long-term, uninterrupted running career.

Martin Haines, chartered physiotherapist and sports injury specialist