Achilles pain is common amongst runners. It is sometimes referred to as achilles tendonitis (tendinitis), tendinosis, tenosynovitis, tenovaginitis and a few others which are technically all slightly different conditions, but the term achilles tendinopathy is used as an umbrella term to encapsulate all achilles overuse injuries.
What are the Symptoms?
Achilles tendinopathies tend to start as an aching and stiffness in the tendon at the back of the ankle, especially in the mornings and after periods of inactivity. If you continue to run, pain may start to develop during the run and the area may become tender to touch. You may start to notice that the tendon appears thicker and sometime redder in colour compared to the tendon on the other leg. Pain then becomes more frequent during daily activites and develops earlier in your run.
What is it?
The achilles tendon is the thick tendon at the back of the heel. Tendonitis is an inflammatory, overuse condition. However, recent research has shown that there are rarely inflammatory cells present in the tendons of those with gradual onset achilles pain. Instead, the condition is believed to be degenerative in nature with small microtears in the tendon and collagen disarray.
All of the term mentioned above actually mean something very slightly different – for example tenosynovitis is actually inflammation of the sheath surrounding the achilles tendon. However, in a clinical setting it is virtually impossible to tell the difference between each of these specific types of achilles injury and so they tend to be grouped together under the term tendinopathies. Only imaging studies such as an MRI scan or ultrasound will be able to determine the exact cause of pain. The treatment for these conditions is all much the same so in most cases, it is not necessary to distinguish between the forms.
What causes achilles tendinopathy?
As with most running injuries there are multiple potential causes. With achilles tendon pain the most common causes I come across are tight calf muscles and overpronation. Often there are also training errors or another activity which has caused a flare up.
It’s all very well saying that tight calf muscles cause achilles tendonitis, but why are the calf muscles tight? You can loosen the calf muscles with stretching and massage, but when you return to running the pain will return as the calf muscles gradually tighten again in response to whatever caused them to tighten in the first place!
Again there can be many causes. Wearing high heeled shoes all day; A previous injury to the ankle or lower leg and a muscle imbalance around the hip are the most common problems I come across. Whilst the first two make sense, the last statement here may sound a little crazy. How come something in your hip cause your calf muscles to be tight? Here’s an example:
Tight hip flexors mean the stride length is shortened; Because of this the heel lifts up earlier; This means there is less eccentric loading of the calf muscles; This means the leg swings forwards with less force; This forward swing is required to naturally supinate the other foot; Less natural supination means the supinating muscles must work harder = tight calf muscles!
Oversupination can cause tight calf muscles but overpronation can place additional torsional forces on the achilles tendon as well. So making sure you have good arch supporting shoes and suitable orthotics if required is very important in avoiding this condition.
The treatment of achilles tendonitis / tendinopathy, as with most running injuries, starts with rest from running and excessive walking. Ensure you wear good supportive shoes at all times and initially ones with a small heel are ideal to raise the heel and reduce the stretch on the tendon. Altenatively a small heel raise can be added to the shoes.
Applying ice to the tendon will help ease pain, swelling and inflammation in the early stages. A Doctor may also recommend anti-inflammatory meds.
As long as it is comfortable to do so, start stretching the calf muscles. Ensure you stretch both the Gastrocnemius and Soleus muscles. You do this as follows:
- Standing facing a wall, with the leg to be stretched behind and the front leg about a 2 feet from the wall.
- Keep the back knee straight and heel on the floor as you lean forwards, pushing against the wall with both hands.
- If you can’t feel a stretch in the calf, either move the back footfurther back or try pushing the knee backwards as if trying to overstraighten it.
- After holding this stretch, then move the back leg a bit closer in towards the front leg and bend both knees.
- Squat down as low as possible, again keeping the heels down, but shifting the weight towards the front of the foot.
- This should feel like a stretch lower down – near the tendon.
These stretches can also be performed on a step as shown here to increase the stretch by lowering the heel:
Stretching should be held for 30 seconds for each muscle and repeated 2-3 times, 3-5 times a day. It is really important to stretch these muscles regularly as increasing the flexibility of a muscle group takes a lot of hard work.
If you have access to a sports therapist, sports massage is great for the calf muscles and can also be applied directly to the achilles tendon. This is known as frictioning and is good for increasing blood flow and breaking down adhesions in the tendon. Electrotherapy such as Ultrasound in also often used and whilst there is limited evidence to confirm its effectiveness, many therapist, myself included, find it effective in a clinical setting.
The strengthening protocol recommended for achilles tendonitis is known as Alfredsons eccentric loading protocol. This uses eccentric heel drop exercises to strengthen and stretch the achilles tendon. This has been shown as the most effective way of increasing the tensile strength of the tendon.
To perform a heel drop:
- Stand on a step on one leg, with the heel hanging off the back of the step.
- Start in a heel raise position, up on the tip toes.
- Slowly lower the heel down to below the level of the step.
- Then place the other leg on the step and raise back onto tip toes using both legs.
- Return to one leg and repeat the heel drop.
Alfredsons protocol involves a large number of reps and working through pain, which personally I have not had a lot of luck with and find clients reluctant to continue through the pain. I would personally advise starting with just 10 reps every other day and gradually increasing the reps / sets performed.
If you haven’t had a gait analysis, this is worth doing as it will check if you have the right running shoes and day-to-day shoes for your foot shape and movement pattern. If necessary, change running shoes or insert insoles or orthotics to reduce overpronation.
Return to running
Continue with stretching / strengthening / massage until day-to-day symptoms disappear. Only at that point can you consider returning to running. When you do, start with a very short run, 10 minutes max. Stretch the calf muscles before and after and rest for 3 days following exercise. If ther is no pain at the time of run or in the three days after, try another short run and repeat the 3 day rest period. If again this is ok, add another 5 minutes to your run. Gradually increase in this manner, always continuing with stretching and strengthening exercises, maintaining regular sports massage treatments and wearing supportive footwear and appropriate running shoes.