Sunday, 20 October 2013

Youngsters: Epiphyseal Plate Injuries

Getting children involved in climbing is fantastic, especially as climbing can be viewed as a life-long sport. However, we'd like to keep it that way, and the process to do this is prevent any injuries that will impact the kids in the future.
The main problem with injuries in children is any damage to the growth plates of any kind, and the most likely growth plate to injure is those that are sustaining high stress forces through them, such as the fingers. This post will aim to explain what growth plates are, the incidence of these injuries, and how best to avoid them.

Remember, children are children, not just “mini adults”!!!

What are growth plates?

As a child grows, all their bones start of as cartilage, and develop into bone as they get older. This is why a child's rib cage is much bouncier than an adults (please don't test this out!). This is why children are more likely to get greenstick fractures than pure fractures (this is where the bone bends and splinters, rather than a pure breakage – try this out with a freshly cut tree branch and try and snap it). As these bones develop, there are areas where the bone needs to grow.

The epiphyseal plate (or growth plate) is where new bone is formed to make the bone grow in a longitudinal direction, and on the otherside of the plate, the new bone growth becomes calcified. There is one of these growth plates at either end of the growing bone.

When this growth plate is damaged, the growth of the bone can be changed, from direction, to rate of growth or even stop growth altogether.

Whilst growth plates are still growing, they are the weakest area of the growing skeleton, 2 to 5 times weaker than adjacent ligaments. This is due to the connective tissues needing to allow for the growth of the bones.
Once growth has stopped, the epiphyseal plate is replaced with solid bone through calcification, and ceases to be an area of weakness.

Obviously, weight bearing is key for bone development and growth, however, it is the overuse and over-stressing of these structures that we are concerned about.

Time line of growth plates

If I remember correctly, during the closure of growth plates, the larger bones will fuse first, then the smaller joints. Also, the dorsal aspect of the growth plate closes last. 

This means that the fingers are susceptible to injury longer than larger bones such as the femur or humerus, and the dorsal aspect of the epiphyseal plate is usually where an overuse injury will occur in a child’s finger.

The picture above demonstrates this area of weakness, with a grade 3 Salter-Harris fracture.

Fingers stop growing at a biological age of 17 years old, but key timings to note is that of growth spurts, occurring from around age 12-13 for girls, and 13-15 for boys.

Especially for boys, this is key to note, as growth spurt plus testosterone = temptation to train harder due to the ease in which muscle bulk is put on in this period.

Incidence of growth plate injuries

Amongst junior competition climbers studied within the German National Junior Team by Volker Schoffl and friends found two-thirds who trained regularly on the campus board got fractured growth plates in a finger.
Shigeo Omori and Hajime found over 3 years, 182 junior competition climbers aged 7 to 19 had their fingers medically examined and 77.6% of these climbers had abnormalities, mostly deformation and light flexion contracture (can’t place hand flat on table).

In general, non-climbing public:
Growth-plate injuries comprise 15 percent of all childhood fractures. They occur twice as often in boys as in girls, with the greatest incidence among 14- to 16-year-old boys and 11- to 13-year-old girls. Older girls experience these fractures less often because their bodies mature at an earlier age than boys. As a result, their bones finish growing sooner, and their growth plates are replaced by stronger, solid bone.
Approximately half of all growth plate injuries occur in the lower end of the outer bone of the forearm (radius) at the wrist. These injuries also occur frequently in the lower bones of the leg (tibia and fibula). They can also occur in the upper leg bone (femur) or in the ankle, foot, or hip bone.

Mechanism of injury

Can be acute injury such as a fall, or can be a chronic onset caused by intense training, campus boarding or over-use of the crimp hold grip which causes compression or shearing of the growth plate.
It has been found that these injuries normally occur in climbers within the training scenarios rather than competitions.
Crimping or campus boarding has been found to be a cause of growth plate injuries due to the high loads put through the fingers, therefore causing an overload of growth plate (repetitive stress).

Signs and symptoms

Lack of mobility in fingers
Constant pain
Chronic swelling
Lack of crimping ability due to pain/swelling

The old mandate of “No pain, no gain” is crazy! If it hurts, get it checked out!

Diagnosis of injuries

The diagnosis and classification of a growth plate injury is normally via x-ray, and is classified as 1 to 5 Salter-Harris fracture.


As with all fractures, this depends on the severity of the fracture, but will probably comprise of:
Manipulation or surgery
Strengthening/Range of movement exercises

Implication of these injuries

Rotation/shortening of finger
Incomplete growth
Some papers suggest there is a link between climbing from an early age and early degenerative changes later on in life such as arthritis.
These will all obviously affect the child later on in life.

How to avoid these injuries?
  • Avoid campus boarding under 18 years of age. Many famous climbers never touch a campus board – Steve Mclure, Tyler Landman so why does the kid?!
  • Excessive Crimping – try and promote versatile grip strengths
  • Long / intense training sessions
  • No need to train strength pre-pubescent – due to motor skills still need to catching up with growth spurt.
  • Avoid additional weight when climbing
  • Dynamic moves – limit
  • When training, try to discourage competition, as it will inevitably lead to someone getting an injury
  • Train other areas, such as core, antagonists, balance, movement technique
  • Respect growth spurts.
  • Maintain good nutrition

No campus boarding (feet-off or dynamically) for under 18's! (to allow margin of error for late developers) UIAA approved advice!


Swiss medical weekly

Hochholzer T, Schoffl VR. Epiphyseal fractures of the finger middle joints in young sport climbers. Wilderness Environ Med. 2005;16:139–42.

One Move too many

Sunday, 6 October 2013

Injures in Indoor Rock Climbing: New Research

Now the winter is fast approaching, all but the most tenacious of climbers will scurry indoors. But just how "safe" is indoor climbing?

Well, a new paper has been published this year by Schoffl, Hoffmann and Kupper in Wilderness and Environmental Mecicine has reported on the rate of injuries reported in an indoor climbing wall in Germany.

This study was performed over a 5 year period and was performed prospectively, rather than retrospectively as previous studies have. This meant that less bias could be introduced to the study, due to the events not having already occurred and the results unknown.

This study also had the advantage that climbing time could be monitored exactly due to an electronic entry and exit system at the climbing wall used.

There was a large number of participants registered in the study (515, 337), but this could of been higher due to those involved in group sessions not being counted separately.

Demographic data of the study found 63.6% of climbers were male, the remaining female, with ages between 8 and 80 years old (median being 34 years old). Average climbing time was 2 hours 47 minutes.
The authors reported 30 injuries in total over the 5 year period; 6 cases whilst bouldering, 16 lead climbing, 7 toproping, and in 1 case as a third person (not climbing or belaying) while watching another climber. Bouldering injuries were mostly the result of falls onto the mat, whereas in lead and toprope climbing various scenarios happened, but mostly resulting from belaying mistakes. Fifteen (50%) injuries were UIAA MedCom grade 2, 13 (43%) were grade 3, and 2 (7%) were grade 4, with no fatalities.

Injuries happened in beginner climbers in 5 (16.7%), in intermediate climbers in 16 (53.3%), in experts in 6 (20%), and in professionals in 3 (10%) cases.

In studies such as this, the safety aspect of a sport is given as a number of injuries per 1000 participation hours. The authors concluded that this study had 0.02 injuries per 1000 hours of climbing time, (similar to previous studies) and also much lower than other sports, such as surfing (13 per 1000 hours of competitive surfing (Nathason et al 2007)) and rugby (91 injuries per 1000 player hours (Brooks et al 2005)).

Of the injuries that occurred, the authors report that many of them were preventable, such as belaying or knot tying mistakes.

However, this study did have some flaws, of which are discussed below:

  1. This study was only performed in one climbing gym, which may have been a particularly well run gym, and therefore have a better safety record, which the study recognises
  2. Climbing time less than 30 mins and over 5 hours was omitted (due to probability of less than 30 mins not going to have been a climbing visit, or over 5 hours someone forgetting to log out). However, how many of us pop in to our local wall for a lunch time session, or spend the whole day there and stop for lunch etc?!
  3. Only injuries that occurred while at the wall that required medical attention then and there were recorded. No overuse/chronic injuries, or those that may have been discovered after the climbing session were recorded.
But there you are, relative to other sports, indoor rock climbing has a much lower risk of injury. 

This article is also available on the BMC website, along with information on preventing becoming an indoor wall injury statistic yourself!

    Brooks JHM, Fuller CW, Kemp SPT, Reddin DB 2005 Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med 39:757–766

    Nathanson A, Bird S, Dao L, Tam-Sing K 2006 Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers.A m J Sports Med. 35(1):113-7.

    Schöffl VR, Hoffmann G, Küpper T 2013 Acute injury risk and severity in indoor climbing-a prospective analysis of 515,337 indoor climbing wall visits in 5 years. Wilderness Environ Med. 24(3):187-94

    Monday, 23 September 2013

    IFSC International Paraclimbing Cup

    So I've just returned from a very busy weekend, volunteering at the Westway Sports Centre as a physiotherapist for the GB Paraclimbing Team, as part of the IFSC International Paraclimbing Cup.

    It was a fantastic weekend, with teams from USA, India, Italy, France and Spain, along side the GB climbers. The competition was hosted by the BMC and the IFSC. 

    Over the weekend, I got to meet Mark Wilkinson, of Paragon Physiotherapy, who specializes in spinal injuries and had done some previous work with the GB Paraclimbing Team. We did some joint assessments on a couple of the Team who required some guidance on their rehab, such as an ankle, wrist, and the obvious finger injuries. This was great learning as we got to brainstorm different theories and share knowledge.

    Then, the climbers got on with the two qualifying routes. It was really inspiring to see climbers who were visually impaired, had a neurological physical disability, or had an amputated limb climb hard routes with such style and finesse, you wouldn't think they had a disability once they were on that climbing wall. 

    Lower limb amputees warming up

    Fran Brown (GB) on the qualifiers

    Sianagh Gallagher (GB) on the qualifiers

    The following day, the climbers entered isolation and proceeded to exit one by one to compete in the final. The hardest of these routes, on a steep, overhanging wall, were up to F7c+ and it was impressive, and inspiring to see the climbers work the way up these. 

    Ronnie (USA) on the qualifiers

    Tom Perry (GB) on qualifiers

    One of the French visual impaired climbers on qualifier

    Over the weekend, I got to meet many people just as invested in paraclimbing as the paraclimbers themselves, such as Graeme Hill (GB Team manager), Andy Colbart (GB Team assistant manager and IFSC Paraclimbing President),  John Ellison (of Climbers Against Cancer), the family, friends, supporters, spectators, photographers, route setters....just too many to mention. 
    It was fantastic to meet some of the athletes themselves, such as the USA climbers Ronnie and Jon, GB Team Fran Brown, Tom Perry, Sianagh Gallagher and Reanne Racktoo. 

    One of the French climbers on the final route

    Spanish finalist being lowered from his high point

    I also thoroughly enjoyed watching the skill and balance that these climbers demonstrated and the mature attitude shown by all the climbers involved. It was also brilliant to see the comradeship of those competing with each other, with all athletes cheering each other on.

    I came away awed, with more knowledge than I had previously, and I am very much looking forward to future work with the GB Paraclimbing Team.
    Hopefully more pictures will follow as they surface!
    Check out the BMC report on the competition.

    Lower limb amputee podium

    Friday, 20 September 2013

    Children's feet and footwear

    "The foot is the foundation, and if that isn't working correctly, nothing will"

    We all know children grow, most of the time, too quickly. Especially their feet.
    So how do we target this, and what is the impact if we don't? This blog post is to discuss the impact of rock climbing footwear on children's feet, especially due to the growing market of climbing shoes available for the younger climber.

    The first thing to note is the rate of growth in children's feet.

    In girls, the foot grows linearly fashion in both width and length from 3 to around 12 years old, and stop growing completely around 14 years old.
    In boys, the foot grows in a linear fashion in both width and length from 3 to around 15 years old, and stop growing around 16 years old. 

    A child's foot can grow 3 sizes in a year, so it is really important to monitor growth closely.
    Children's feet also sweat more, so need more ventilation from their chosen footwear to prevent poor foot hygiene.

    A study done into the German Junior National Team found a higher incident of hallux valgus in those members who had spent a relatively longer time active in indoor competition climbing, as well as 74% of the team having feet pressure marks compared to 28% recreational climbers, indicating tight fitting shoes (even though the importance of tight fitting shoes in indoor walls is less important due holds being relatively larger than outdoors, enabling children to wear shoes too long if required).

    Another problem with the climbing shoes is the supinated foot position as mentioned in the previous foot and ankle post, which can put a child more at risk of ankle injuries. With children, this puts them more at risk of ankle growth plate, as their growth plates are not fully formed until the age of 17 years old.

    Rigid shoes or too much cushioning can limit the development of the connective tissue, muscles and bones, due to these structures requiring the mechanical stimuli to aid the growth. This is especially important as the connective tissue strength and foot flexibility does not stop forming until the age of 15.

    Finally, shoes that do not cut into Achilles tendon are recommended, as this can cause shortening of the tendon when the calf is flexed, causing torsion in the plantar fascia leading to a higher arch causing a change in the biomechanics of the foot.

    Any children's shoes that are too tight or too small will limit the growth of a child's foot at the key stages of their development. A poorly developed foot will impact a child for the rest of their life.

    In summary, a child's climbing shoe needs to be:

    • flexible
    • not cutting into the Achilles tendon
    • not too much cushioning
    • not restrictive
    • needs ventilation
    • review the sizing often

    Coming next, will be the impact of climbing on children's fingers. 


    Hochholzer T, Schöffl V. 2006. One move too many… (2nd edn). Lochner Verlag: Ebenhausen.

    Morrison A 2009 Climbing shoes: is pain insane? BMC

    Morrison AB, Schoffl VR 2007. Physiological responses to rock climbing in young climbers. Br J Sports Med 41;852-861.

    Walther M, Herold D, Sinderhauf A, Morrison R 2008 Children sport shoes—A systematic review of current literature. Foot and Ankle Surgery 14(4): 180-189

    Monday, 26 August 2013

    Feet and rock climbing

    So you're out climbing, and you pull your climbing shoes out the bag. What size are they? One size smaller than your normal shoes? Maybe two? Well, this post is to discuss the links between feet, footwear and climbing, and other foot injuries/problems.

    Do remember, however, that we aren't the only sport or hobby to do this to our feet.....

    In a study of 104 rock climbers, Killian et al (1998) found that 81% suffered from an acute or chronic pain or pathology in the foot and/or ankle during or after rock climbing. They suggest that this is in relation to the biomechanics of wearing small rock shoes.

    First, as always, I will discuss the anatomy of the foot.



    Tibialis anterior is also the main dorsiflexor of the ankle.
    The gastrocnemius, soleus and plantaris are the plantarflexors of the ankle (there are more muscles involved with platarflexion due to needing to lift the entire body weight, whereas dorsiflexion only consists of lifting the foot.)

    Movements of the foot

    Feet position within climbing shoes

    Arches of the foot

    Forces through feet when climbing

    Robert Bradshaw-Hilditch and Gary Gibson (yes, THAT Gary Gibson) are both podiatrists who have been conducting some brilliant studies in collaboration with Staffordshire University regarding the forces that are exerted through climbing shoes, and where. 

    Their research has found that the forces when front pointing on the hallux (big toe) during climbing causes more force through the metatarsal head, and puts the plantar fascia under tension.
    During edging, the forces through the hallux again puts most of the force through the hallux metatarsal head, and stresses the plantar fascia, but also places the foot in a supinated position.

    This is just the tip of the iceberg for this research, and Rob and Gary are looking at expanding this much further, as this was only looking at the plantar aspect of the foot in an indoor climbing situation.

    But what does it mean?

    This means that the feet are more prone to ankle injuries due to the supinated position (see below), and this increase in pressure on the plantar fascia could cause plantar fasciitis (see below as well). The forces being placed through the metatarsal head will change the biomechanics of the foot through the strength of certain muscles, and could cause problems with the arch of the foot (see below) and these problems will surpass what happens on the rock alone. 

    So what can be done? 

    Read on...

    Problems with the feet

    Hallux-Abducto Valgus (commonly known as bunions)
    Hallux valgus is defined as a 20 degree difference between the axis of the first metatarsal and the axis of the proximal phalanx of the toe, and was noted in both feet in 53% and in one foot in 20% of climbers participating in the sport for more than 5 years and climbing UIAA degree IX. (Peters 2001)
    Bunions are not actually caused by wearing tight shoes, but climbing shoes can worsen the deformity. Bunions are most often caused by an inherited faulty mechanical structure of the foot. 
    Treatments include wearing bunion pads, orthotics or different footwear and pain killers, or there is the surgical route if the pain is severe. There is no physiotherapy intervention that can help here, therefore prevention is the best cure, by avoiding wearing tight shoes and decreasing the effect of escalating the problem. 

    Vessel Compression
    65% of sport climbers have found to have tingling and/or pins and needles in their feet, thought to be caused by medial to lateral compression of blood vessels and nerves of foot by smaller climbing shoes. This usually dissapates quite quickly once the shoes are removed. If it doesn't, I'd get it checked out by a professional fairly quickly.

    Arch Disorders
    Rock climbing has been found to have a beneficial impact on longitudinal arch of the foot (due to strengthening), but does cause an increase in frequency in transverse arch disorders such as tansversal platypodia (flat foot),and an increased frequency of abnormal toe-to-surface adhesion.
    Both these problems affect the frontal areas of foot, caused by climbing footwear - changes in the biomechanics of the foot, can cause weakness in muscles controlling 1st metatarsal head extension.

    Ankle sprains
    Ankle sprains are an injury that don't just affect rock climbers, as you may well realise. They are much more likely to affect other sports persons such as fell runners, however, with climbing, due to the already supinated/inverted (turned inwards) position of the foot means that there is an increased risk of an ankle sprain, normally due to jumping/falling off (this has happened to a few friends, one bouldering in Font, the other trad climbing at Stanage – and both those walks out seemed to take forever!) Hochholzer & Schöffl (2006) found that 24% of climbers have suffered from an ankle sprain.
    Ankle sprains are normally caused because the muscles around the ankle don't act quick enough to stop the ankle surpassing it's normal range of movement and the ligaments have to take the brunt of the force.It is normally when the ankle is inverted.
    Therefore, the preventative measures you can do to improve the acting of your muscles around the ankle would be to improve the proprioception of the ankle (knowledge of where your body is in space).
    To do this, you can use the use of a wobble board or wobble cushion. Stand on the board/cushion on one leg until you can do it for 1 minute. Then close your eyes and try to reach one minute. This can also be used as late stage rehab for an ankle sprain.

     Early stage treatment for an ankle sprain would be to follow the management of acute injuries, along with maintaining range of movement in a non-weight bearing manner.
    Taping can also be used to support the ankle if injured, such as the technique below, to prevent further inversion:
    To read more about ankle sprain and preventative measures, check out Global Therapies recent blog.

    Plantar Fasciitis

    Plantar fasciitis is heel pain that is caused from an inflammatory process of the connective tissue, the plantar fascia. 
    It is commonly caused by long periods of weight bearing and flat feet, as well as poor footwear, poor biomechanics, high arches, and/or running/walking long distance on hard surfaces.
    The treatment is normally rest, ice, reduce inflammation and swelling, calf stretches, and finally, correcting what caused the problem in the first place, be that poor footwear, muscular imbalances etc.

    Achilles Tendinopathy
    This has already been covered by a separate post here.

    Ankle fractures
    So, an ankle fracture, as you'd have guessed, is when a bone involved in the foot or ankle gets broken. There is no real preventative measure for this, and will normally occur from a fall. Therefore, the approach for a fracture is surgical intervention, or conservative treatment (which normally involves just casting the foot and ankle in plaster and waiting it to heal).
    The time frame and approach is entirely dependant on where the fracture etc is, and what other structures are involved.
    Post op/plaster, you should be referred to physiotherapy for rehab anyway.
    So I'm just going to leave you with a tasty X-ray of an ankle fracture and repair!

    Other problems
    There are also other non-musculoskeletal problems hat can occur with the foot, such as corns, cuts, toe infections etc which just needs you to look after your feet!


    Just a few tips to try and prevent foot and ankle problems:

    As previously mentioned, use of the wobble board or cushion can help prevent some ankle injuries.

    Ensuring you have appropriate sized climbing shoes, or if not possible, remove them at all opportunities, or alternate your shoes for different routes

    Parallel training to strengthen the muscles around the foot and ankle

    Appropriate sized normal footwear

    Foot hygiene

    If you are a diabetic, please please please avoid tight shoes!! This is because of change in the sensation in the feet (neuropathy) that can be caused by diabetes, and can cause much more serious foot problems!

    To avoid some ankle injuries, have some (decent!) spotters when bouldering, and try to have dynamic belay techniques when roped climbing, to avoid clattering into the rock and giving you time to slow down the motion with your upper legs rather than at the ankle!
    However, the main take home message is that with footwear, pain is insane! here possible, make your climbing shoes fit properly, feel comfortable, and look after your feet!

    Kids feet and climbing shoes

    This will be covered in the next post, just to break up the amount of information I'm giving you! 


    Peters P 2001 Orthopedic problems in sport climbing. Wilderness and Environmental Medicine, 12; 100-110

    Killian RB, Nishimoto GS, Page JC 1998 Foot and ankle injuries related to rock climbing. The role of footwear. J Am Podiatr Med Assoc. 88(8):365-74.
    Morrison AB, Schoffl VR 2007. Physiological responses to rock climbing in young climbers. Br J Sports Med 41;852-861.

    Hochholzer T, Schöffl V. 2006. One move too many… (2nd edn). Lochner Verlag: Ebenhausen.
    Killian RB, et al. 1998. Foot and ankle injuries related to rock climbing. The role of footwear. JAPMA 88(8);265-74.

    DrJulian Saunders 2009 Ankles Away

    E. Demczuk-Włodarczyk, E. Bieć, T. Sipko, E. Boerner, R. Jasiński 2008
    Biology of Sport 25(1)

    Tuesday, 9 July 2013

    Achilles Tendinopathy

    So I'm going to take you back to ancient times, where Gods ruled the lands, and the Greeks invented the Achilles heel! This weeks post is going to focus on Achilles Tendinopathy.
    Other common rock climbing foot issues will come in a later post.

    Achilles tendon anatomy

    Movements of the Achilles

    The Achilles tendon supports 6-15 times your body weight and provides spring like action.

    Tendonitis/tendinosis/tendinopathy, what is the difference?

    Tendonitis – inflammation
    Tendinosis – chronic tendinopathy
    Tendinopathy – a disorder of the tendons – an umbrella, catch-all term
    Obviously, depending on -osis/-itis depends on the management strategies (to counter the inflammatory process or not).
    The common consensus is that these conditions are a tendinosis rather than a tendonitis.

    The entheses is where the tendon attaches to the bone, and an achilles tendinopathy that occurs within the first 2cm of the tendon attachment to the calcaneus is an enthesopathy.


    • Rule out complete tendon rupture using the calf squeeze test. See above picture.
    • Posterior ankle impingement
    • Os trigonum syndrome
    • retrocalcaneal bursitis
    • Posterior Tibial Tendon Dysfunction
    • Haglund's deformity

    However, to discuss what all of these things are would take a whole blog post unto itself, so I'm just going to leave it there!


    • Pain in the heel/around the tendon
    • ?swelling - if a tendinitis
    • ?heat - if a tendinitis
    • Painful to touch or on movement
    • Early morning stiffness
    • Difficulty standing on your tip-toes (/single leg stress/repetitive/hop)


    • Repetitive strain on tendon
    • overuse
    • inappropriate footwear
    • poor technique
    • high-arched foot
    • increase intensity in training regime
    • lots of jumping
    • tight calves
    • excessive inversion or eversion

    Achilles tendinopathy is more a problem for runners or walkers, but can affect climbers, especially as many climbers are mutli-sports persons.

    Enthesopathies: compression of calcaneus from repeated platarflexion e.g. aggressive climbing shoes and/or dynoing etc. as climbing shoes with an aggressive heel, such as 5:10's, could cause this repeated compression on the calcaneus. (obviously, other aggressive climbing shoe are available!)


    If you suffer from the "5:10 syndrome" as mentioned above, you could try this method of editing your climbing shoes by Llanberis Resoles

    I mark this with a question mark, because it depends on your school of thought – whether it is a chronic overuse, or an inflammatory response. If you find it is swollen, then NSAID's may well help, but there is a school of thought that they may inhibit healing if used inappropriately.
    There is also the dangers of overuse of NSAID's, as listed in Risks of Ibuprofen post

    Acute management (see Management of Acute Injuries post) – again, may not be necessary if the tendinopathy is not an inflammatory process. e.g. if you use RSI of the wrist as an example.

    GTN (Glyceryl trinitrate)
    This is the same as the spray commonly used for angina, but is utilised topically – i.e. localised patch of GTN. However, the reasoning behind why it works is unclear, and commonly patients exhibit headaches and/or a rash as side effects.

    A corticosteriod injection may help, but has been shown to only have a short term pain-relieving effects, and not much else. Also, these injections may increase the risk of tendon rupture by weakening the tendon.

    A surgical intervention is rarely required for Achilles tendinopathy, and would always be a last resort. A very last resort!

    There are other such treatments such as extracorporeal shockwave therapy and sclerosing injections, but they are rarely used.

    The best bet is for physiotherapy, and using specific protocols, outlined below:


    Mobilisations of the Achilles tendon

    Ultrasound – useful if the tendinopathy is a tendonitis, as ultrasound can be used to reduce the inflammation.


    Eccentric – Alfredson et al 1998

    Two types of Eccentric Exercises will be used: (Refer to Photo A, B, and C)
    • The calf muscle is to be eccentrically loaded with the knee straight.
    • To maximize the activation of the soleus muscle, also performed with the knee bent.
    • Perform each exercise 3x with 15 repetitions.
    • Use your hand on the wall as a guide for balance
    • Begin with weight bearing load, progression to backpack weight when patient can perform the
    • exercise routine without pain or discomfort (Photo D). Advanced progression under therapist’s guidance may include resistance from weight training equipment such as a Smith machine or a squat machine.

    Eccentric-concentric – Silbernagel et al 2007


    These exercises need to be performed regularly, and for a time period of at least 3-6 months if not much longer!

    Why do these work?

    Effectiveness of eccentric exercises has been proved, however, there are differing theories on why it works.
    Some say it affects type 1 collagen and production and, in absence of repeated aggravation, may increase tendon volume over longer term. As such, this increase the tendons tensile strength.
    The repetitive stretching of the tendon with a lengthening of the muscle-tendon unit may have an impact of the capacity of the unit to effectively absorb load.

    Another theory is that it changes the mechanism of pain-producing nerves by an alteration of neovascularisation (which is an increase of blood flow to an injured area, and along with this, an increase in nerve fibres, meaning increased pain), as the repetitive nature may damage these nerves and vessels.

    Exercising during rehab

    Due to the length of rehab being several months rehab, many patients ask “Do I have to stop exercising?” Silbernagel et al 2007 found that if the pain in your Achilles tendon does not exceed 5/10 on visual analogue pain scale (VAS) (during or after sport), then it is ok to carry on with your sport, whilst continuing with the exercise protocol.

    Risk of rupture?

    80% of ruptures completely asymptomatic
    97% associated with underlying pathology

    As always, if in doubt, always seek advice from a professional!


    Alfredson H, Cook J 2007 A treatment algorithm for managing Achilles tendinopathy: new treatment options Br J Sports Med. 41(4): 211–216.

    Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J 2007 Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study. American Journal of Sports Medicine 35(6): 897-906

    Alfredson H, Pietilä T, Jonsson P, Lorentzon R 1998 Heavy-Load Eccentric Calf Muscle Training For Chronic Achilles Tendinosis American Journal of Sports Medicine 26(3): 360-366