Achilles Tendinopathy and Low Back Strain Rehabilitation Protocols

Posted on Feb 9, 2026 in Physical Education

1. Insertional Achilles Tendinopathy

Pathology: Sudden increase in load leading to tendon failure to adapt. Follows stages of tissue healing:

  • Reactive Phase (0–72 hrs): Hematoma formation, inflammatory cells migrate, release of cytokines/prostaglandins/bradykinin causing pain, swelling, and warmth. Nociceptor sensitization increases resting and movement-related pain.
  • Proliferative Phase (3 days–3 weeks): Fibroblasts/myofibroblasts produce collagen, granulation tissue forms. Collagen reorganizes along lines of stress, leading to gradual improvement in function and decreased pain.
  • Maturation Phase (2–6 months+): Collagen matures, fibers realign to functional demands, gradual return to tensile strength and functional capacity. If overload occurs too soon, re-injury risk increases.

Contributing Factors:

  • Psychosocial: Increased motivation, pressure from team, stress from parenthood.
  • Biomechanical: Deconditioning, pregnancy hormones (laxity), increased load.

Assessment (AX)

Confirms diagnosis, establishes baseline measure, and guides exercise prescription:

  1. Range of Motion (ROM) (with ankle off the bed).
  2. Palpation and squeeze test.
  3. Functional observations: Single-leg (SL) and double-leg (DL) hop, heart rate (HR), hop forwards.

Early Management

  1. Education: Explain diagnosis, unloading for 1–2 weeks, exercise modification (e.g., swimming), pain decrease.
  2. Pain Management: Heat application.
  3. Exercise: Isometric Plantar Flexion (PF) for 45 seconds–1 minute, 3 repetitions (analgesic effect). Progression (PROG): Eccentric PF on a step. Regimen (REG): Isometric PF 30 seconds x 6.

Late Management

Progress when there is no morning stiffness, pain is stable, and movement is unaffected.

  • Plyometrics: E.g., pogo hops into acceleration (start at 70%). PROG: SL jump + increase speed. REG: Banded hops + 50% speed.
  • Skill Specific (SS): Agility in/out of cones (rapid change of direction – COD). PROG: External cues (shoot, verbal). REG: Wider COD, figure 8, slower speed.

Re-injury Risk Mitigation

Gradual increase in load (no more than 10% per week). Monitor training load (RPE, diary, Acute:Chronic Workload Ratio – ACR). Ensure adequate recovery and nutrition. Warm-up should include hops, gradual acceleration, SL landing, COD, core work, and dynamic PF stretch.

Stakeholders: Patient, family, coach, team, previous Physical Therapist (PT).

Outcome Measure: Victorian Institute of Sport Assessment (VISA-A), scored out of 100 (higher = better function). Tendinopathy score should be no more than 70%.

Monitoring: A:C Workload Ratio (WR), aim for 0.8–1.3 (1.5 indicates re-injury risk).

Work Specific: Education on ergonomic adjustments, breaks, work-specific training, functional capacity areas in Achilles Tendinopathy Rehabilitation (AHTRs).

2: Non-Specific Low Back Pain (Lumbar Strain?)

Pathology: Muscle fibers are damaged, leading to an inflammatory response and chemical mediators sensitizing local nociceptors. Follows stages of tissue healing.

Contributing Factors:

  • Psychosocial: Financial and team pressure, tournament constraints, decreased support system, stress/poor recovery.
  • Biomechanical: Decreased injury threshold (increased workload, no rest, tennis to cricket change), posture change (study to cricket), improper equipment, decreased core strength.

Assessment (AX)

Confirms diagnosis, establishes baseline measure, and guides exercise prescription:

  1. Active Range of Motion (AROM): Flexion, extension, lateral flexion (LF), rotation.
  2. Palpation and Passive Accessory Intervertebral Movement (PAVIM) for swelling, asymmetry, ruling out joint issues.
  3. Functional observations: Sit-to-stand (STS), walking while picking something up, single-leg stance (SS).

Early Management

  1. Education: Require rest for 2 days; if no rest, batting load > bowling load.
  2. Pain Management: Heat or massage.
  3. Exercise: Pelvic tuck (5 minutes per day). PROG: Cat/cow stretch. REG: Abdominal bracing 3 x 30 seconds.

Late Management

Ready to progress when there is no muscle guarding, core can be engaged, pain is <3/10, and there is no movement restriction.

  • Wood chopper 3 x 10. PROG: Medicine ball throws 3 x 10. REG: Pallof press 3 x 10.
  • Sports re-introduction, technique correction?
  • Education on proper gym program, referral to an Exercise Physiologist (EP) for financial issues.

Re-injury Risk Mitigation

Gradual increase in load (no more than 10% per week). Monitor training load (RPE). Ensure adequate recovery and nutrition. Warm-up should include dynamic mobility, core work, and shadow batting at low intensity. Fatigue increases risk. Use the box taping method for Return to Sport (RTS). Use a supportive chair when studying. Equipment modifications, e.g., weight of the bat.

Stakeholders: Patient, coach, team, support network.

Outcome Measure: Oswestry Disability Index (subjective % score of level of function in Activities of Daily Living (ADLs), 0–5, higher % = higher disability) OR Roland Morris Disability Questionnaire (higher score = higher disability).

Monitoring: A:C WR, aim 0.8–1.3 (1.5 = re-injury risk) or diary/app tracking duration, intensity, frequency.

Work Specific: (Involve PT, case manager, GP, employer). Slow re-introduction, workers’ compensation funding (e.g., EP referral), adjustments, breaks.

3: Concussion

Note: The pathology, psychosocial, biomechanical factors, assessment, early management, late management, re-injury risk, stakeholders, outcome measures, monitoring, and work-specific sections provided for Injury 3 are identical to those listed for Injury 2 (NSLBP). This suggests a potential copy-paste error in the original document, as concussion pathology differs significantly from muscle strain. The following structure maintains the original content structure but notes the discrepancy.

Pathology: Muscle fibers are damaged leading to inflammatory response + chemical mediators sensitize local nociceptors. Follows stages of tissue healing.

Contributing Factors:

  • Psychosocial: Financial and team pressure, tournament constraints, decreased support system, stress/poor recovery.
  • Biomechanical: Decreased injury threshold (increased WL, no rest, tennis to cricket change), posture change (study to cricket), improper equip, decreased core strength.

Assessment (AX)

  1. AROM: Flexion, extension, LF, rotation.
  2. Palpation + PAVIM for swelling, asymmetry, rule out joint issue.
  3. Functional obs: STS, walking picking something up, SS.

Early Management

  1. Education: Require rest now 2 days, if no rest batting > bowling.
  2. Pain Management: Heat or massage.
  3. Exercise: Pelvic tuck (5 minutes per day). PROG: Cat/cow. REG: Abdominal bracing 3x30s.

Late Management

Ready to progress when no muscle guarding, can engage core, pain <3/10, no movement restriction.

  • Wood chopper 3×10. PROG: Medicine ball throws 3×10. REG: Pallof press 3×10.
  • Sports re-introduction, technique correction?
  • Education on proper gym program, refer to EP (financial issues).

Re-injury Risk

Gradual increase in load (no more than 10% per week), monitor training load (RPE), adequate recovery + nutrition, warm-up (dynamic mob, core, shadow batting at low intensity). Fatigue increases risk, box taping method for RTS, supportive chair when studying, equip mods e.g., weight of bat.

Stakeholders: PT, coach, team, support network.

Outcome Measure: Oswestry Disability Index (subjective % score of level of function in ADLs, 0–5, higher %=higher disability) OR Roland Morris Disability Questionnaire (higher score= higher disability).

Monitoring: A:C WR, aim 0.8–1.3 (1.5= re-injury risk) or diary/app tracking duration, intensity, frequency.

Work Specific: (PT, case manager, GP, employer), slow re-introduction, workers comp funding e.g., EP referral, adjustments, breaks.