What happens after the first 48 to 72 hours of an Achilles tendon injury? When any damage occurs to the soft tissue (muscles, tendons, ligaments), the body immediately goes into a process of repair. Where the individual fibers have been ruptured, or torn, the body begins to bind the damaged fibers 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 new tendon. In reality, this doesn't happen. The tear or rupture is repaired with scar tissue.

Deterring the Formation of Scar Tissue

There are two vital treatments that can be used to remove most of the unwanted scar tissue. The first is commonly used by PTs and primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.

The Achilles tendon receives very little blood supply compared to a muscle, for example. Therefore, it is vitally important to increase the blood flow to the injured area. This will help supply the tendon with the oxygen and nutrients it needs for a speedy recovery.

PTs accomplish this aim by using a number of activities to stimulate the injured area. The most common methods used are ultrasound and heat. Ultrasound, or transcutaneous electrical nerve stimulation, uses a light electrical pulse to stimulate the affected area. Heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues.

Second, to remove the unwanted scar tissue, it is vital that you 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.

The Achilles tendon may be quite tender. Therefore, start with a light stroke and gradually increase the pressure until firm strokes can be used. Concentrate the effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue.

I also recommend the use of Arnica for massaging the injured area. This ointment is extremely effective in treating soft-tissue injuries like sprains and tears.

Active Rehabilitation

Most people will refer to this phase of recovery as the active-rehabilitation phase, which involves performing exercises and activities required to speed up for full recovery. The aim of this phase of rehabilitation will be to regain all the fitness components that were lost because of the injury. Regaining flexibility, strength, power, muscular endurance, balance, and coordination are the primary focuses. Without this phase of rehabilitation, there is no hope of completely and permanently making a full recovery.

Range of Motion

Regaining a full range of motion of the Achilles and ankle joint is the first priority in this phase of the rehabilitation process. A full range of motion is extremely important, because it lays the foundation for more intense and challenging exercises later in the active rehabilitation process.

Through the initial stages of recovery as the Achilles begins to heal, start to introduce some very gentle movements. First, bend and straighten the ankle. Then, as this simple movement begins to be comfortable, start to incorporate some rotation exercises. Turn your ankle from side to side, and rotate clockwise and counterclockwise.

When these range-of-motion exercises are comfortable and can be performed relatively pain-free, it is time to move on to the next phase of the active-rehabilitation process.

Stretch and Strengthen

Now it is time to add some intensity to the range-of-motion exercises. The aim here is to gradually reintroduce some strength back into the injured muscles, ligaments, and tendons.

When attempting to increase the strength of the Achilles, be sure to approach this in a gradual, systematic way of lightly overloading the muscles and tendons. Be careful not to overdo this type of training. Patience is required.

An effective and relatively safe way to start is to begin with isometric exercises. These are exercises in which the ankle joint itself does not move, yet force is applied and the calf muscles and Achilles are contracted.

For example: Imagine sitting in a chair while facing a wall and then placing the ball of one foot against the wall. In this position, push against the wall with the foot; at the same time keep the ankle joint from moving. The muscles contract, but the ankle joint does not move. This is an isometric exercise.

The above example can be used to strengthen the Achilles and ankle joint in all directions. Push the foot to the left or right against something immoveable, and push down (as above) and pull up.

Balance and Proprioception

This phase of the rehabilitation process is often overlooked and is one of the main reasons why old injuries keep reoccurring. Once some strength returns to the Achilles, it is time to incorporate some balancing drills and exercises.

When muscles and tendons are torn, nerves are also damaged. These nerves send vital information to the brain about the specific position and location of the Achilles tendon and ankle joint in relation to the rest of the body.

Without this information, the muscles, tendons, and ligaments are constantly second-guessing the position of the Achilles and ankle joint. This lack of awareness about the position of the lower leg can lead to a reoccurrence of the same injury long after one thinks it had completely healed. Balancing exercises are important to help retrain the damaged nerves around the lower leg and ankle joint. Start with simple balancing exercises like walking along a straight line or balancing on a beam. Progress to one-leg exercises like balancing on one foot, and then try the same exercises the your eyes closed.

When comfortable with the above activities, try some of the more advanced exercises like wobble or rocker boards, Swiss balls, stability cushions, and foam rollers.

Brad Walker is a stretching and sports-injury consultant with more than 15 years experience in the health and fitness industry. He has published numerous articles stretching, flexibility, and sports injury in The Stretching & Sports Injury Newsletter, www.thestretchinghandbook.com/newsletter.htm. For more information, contact .