When we treat older patients with Achilles tendon injuries, their age is not the main factor we consider when deciding how best to rehab the injury so they can do their normal activities again. This article explains that there are, however, some issues that do play a role when over-65s recover from their Achilles injuries. It also details how we take these into account when designing a bespoke rehab plan for an older Achilles tendonitis patient. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.
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Fitness and strength levels are more significant for Achilles rehab than age
Age is not the main factor we consider when we prescribe an Achilles tendon rehab plan. You can get two people of the same age, and one can be quite fit and strong, whereas the other could be unfit and weak. Likewise, a 67-year-old triathlete might be fitter and stronger than a 40-year-old whose main form of exercise is walking between their front door and their car.
It's also rather about the injured tendon’s specific ability at the time when we see the patient than it is about their age. One person’s tendon may be super sensitive and become even more painful in response to certain rehabilitation exercises, whereas another’s may be able to tolerate quite a lot.
So, the main thing we look at is, how fit and strong are you and your injured tendon? We have an in-depth conversation to understand your lifestyle and circumstances, and we test your tendon’s strength and sensitivity by getting you to do certain movements.
I explain further down how we take these factors into account when designing a rehab exercise programme to suit a patient’s specific situation.
Age-related factors that do play a role in Achilles rehab
There are, however, some factors related to age that we do consider. These won’t influence our basic rehab approach, but they help us to tweak an older patient’s personalised programme so they could get the most benefit from it.
Collagen production
Whenever we exercise – whether it’s to get fitter or as part of an injury rehab programme – our bodies get micro-damage in our muscles, our joints, our bones, and also our tendons. This sounds much more serious than it is; our bodies are constantly turning over cells, taking away old, damaged ones and replacing them with new ones.
The Achilles tendon is made up mostly of collagen fibres, and it is these fibres that get the micro-damage when the tendon is subjected to exercise or any other activity where it has to carry load, such as walking.
By repairing the micro-damage, our bodies make the tendon stronger than it was before. However, it needs some time to complete this process – usually up to 48 hours after a hard exercise session. If we don’t allow sufficient time for this between bouts of exercise or other activities that cause micro-damage, the damage accumulates. This is how many Achilles injuries are caused in the first place.
As we get older, the process of getting rid of old or damaged cells and replacing them with new ones slows down. So, when we look at a rehab plan for an older person, we will likely factor in more recovery time between exercise sessions to allow the patient to get the full benefit of the micro-damage repair cycle.
Medication
Some types of medication can have side-effects that will influence the rate at which the Achilles tendon of a patient of any age will recover. They could also be the reason why an Achilles tendon got injured to start with. And, as people get older, it is more likely that they will be using medication.
Please don’t stop taking medication or reduce the dosage without having consulted your doctor. The benefits of the medication may outweigh the possible negative effect on your tendon.
You can click on the medication names below for a video or article with more details about each, including what research into their effects on Achilles tendons have found.
Statins – Statins are commonly prescribed to control cholesterol levels. However, they can affect the structure of the collagen fibres in an Achilles tendon, thereby weakening them. They can also reduce the collagen content of a tendon and slow down the rate at which new collagen cells are formed.
Steroids – Steroids are used for a variety of purposes, including corticosteroid injections for Achilles tendon pain relief. However, it is thought to then weaken the tendon in the long run by causing an increase in collagen breakdown. Steroids that are taken for any other reason (including via an inhaler or tablets) will have the same effect.
Fluoroquinolone antibiotics – This is a specific type of antibiotic that has been shown to cause Achilles tendinopathy and even Achilles tendon tears by inhibiting collagen formation. This can happen as soon as two hours after the first dose and up to six months after the last dose.
How to adapt Achilles rehab for over-65s
The basic principles of Achilles tendonitis rehab remain the same, and it has two interrelated components: relative rest and strength training exercises for your tendon.
Relative rest
Relative rest means that you don't rest your Achilles tendon completely, because this will actually cause it to lose more strength and therefore become even more painful when you then do an activity where the tendon has to work.
The trick is to find that sweet spot of being as active as you can (or wish to be) without irritating your tendon. This includes taking into account not only your tendon strength training exercises (see below) but also other day-to-day activities such as going for a walk and even household chores – anything where you spend time on your feet.
Relative rest is a moving target because, as your Achilles tendon recovers, it will be able to deal with more. So, this might require a bit of trial-and-error, but a good physio can help you to figure it out.
A good way to go about it is to keep a pain diary, where you log what you did during the day. It’s amazing how easy it is to forget or ignore seemingly innocuous activities that may turn out to be important after all.
In addition to your rehab exercises, you’re looking to log in your diary things like: How much time did you spend on housework or gardening? Did you go for walks? If you did walk, how fast did you walk? For how long? What shoes did you wear when you walked?
For example, it may be that you think walking hurts, but actually when you analyse it, it turns out that it only hurts when you go walking in your flat shoes (which put more strain on an Achilles tendon), but when you go walking in your running shoes which have a bit of a heel on them and you take it easy, there’s no problem.
It is particularly important to take notice of walking, because it might become a part of your rehab to strengthen up your Achilles tendon gradually.
There’s much more detail in this article about relative rest for Achilles tendonitis.
Strength training
Once injured, your tendon loses some of it’s strength. So now we have to strengthen it back up again with an exercise programme that fits into and progresses with that relative rest sweet spot.
Where to start
It’s important to start at the right level of exercise. Too easy, and your tendon won’t get stronger; too difficult, and it will get even more painful. And obviously this depends on the patient’s level of fitness and how weak and sensitive their Achilles tendon is.
If somebody has a super sensitive tendon that's really painful, we may start them off with something easy, like repeatedly raising their heels off the floor while they are sitting down.
If your tendon is not really that painful, and it can do quite a lot before it gets painful, we might start you off straight away by going up-and-down on your toes while only standing on the injured leg. And it may even be that you do it over the side of a step so that your heel goes down lower than your toes – something that loads the tendon even more.
When to do what
It’s important to schedule your exercises into your daily activities so that your tendon gets enough time to recover between sessions.
Most of our rehab programmes have low-load activities and high-load activities. Low-load activities are typically things that are done on two legs (so the uninjured leg carries some of the load) and are designed to improve circulation and keep things going. High-load activities are more strenuous and are meant to work the injured tendon harder to stimulate tendon growth via the micro-damage-and-repair cycle.
A good rule of thumb is that you can do low-load activities every day and in combination with things like going for a walk. However, high-load activities should not be done on consecutive days and also not on days with a lot of other activities such as walking or cleaning the whole house. And there’s no harm in having days where you just give things a rest in general.
For example, one day you might go for a long walk and do some low-load exercises, the next day you do high-load exercises and short walk, and the third day might be a recovery day.
A recovery day doesn’t have to mean doing nothing. You still have to go about your normal day-to-day business, after all, and you can still do things like swimming or going cycling as long as the activities don’t load your Achilles tendon much.
How to progress
No matter at what level you start, you will eventually have to progress to more difficult exercises to get your tendon to a point where it's strong enough to do all the activities you want to be doing without becoming painful again.
Because the micro-damage-and-repair cycle is slower in older people, we would not expect them to progress as quickly as a younger person.
But again, there's no cookie-cutter approach like “Do these exercises for two weeks, and then you move up to the next level.” We set our patients targets for certain things they have to be able to do without aggravating their pain before their exercises become more challenging. And this should take as long as it takes.
This article has more advice on progressing Achilles rehab exercises.
Where does it end?
This depends on your idea of a normal, active day and week for yourself, and it’s something we’ll ask you about right from the start.
If you just want to go for a walk once day and maybe do some gardening, your exercises will be tailored to aim for your tendon to be able to cope with that. If, on the other hand, you would like to go running or hiking in the mountains, the later stages of your rehab programme should include things like running, going up and down on your toes while carrying quite heavy weights, as well as plyometrics (hopping and jumping).
How we can help
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
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