Despite being the largest tendon in our body, the achilles tendon is one of the most commonly injured tendons in athletes whose sports involve running and jumping. Achilles tendinopathy is an overuse injury characterized by pain, stiffness, swelling and impaired performance; runners typically report pain during running which worsens with distance as well as stiffness in the mornings or with activities that require the ankle to bend such as going down the stairs. Unfortunately, achilles tendon injuries can persist for a while and has a higher re-occurrence rate than most other running injuries, especially when not treated properly. […]
Role Of The Achilles Tendon In Running
The achilles tendon is made up of 2 muscles that come together – the gastrocnemius and the soleus – and combine into one strong tendon attaching to the back of your heel. When the muscle contracts, it pulls the tendon, and therefore your foot, into a downwards or plantarflexed position. The tendon is used in practically any activity that involves using your foot, from as simple as driving your car and using the gas pedal, to more complex activities such as walking, running and jumping.
This tendon plays an especially important role when running. When our foot lands during the gait pattern, the achilles is put onto stretch that creates “potential energy,” similar to a rubber band that is stretched out. As we quickly move towards push-off, this energy is released helping propel us into our next step. The force required during gait is mostly transmitted through the achilles tendon during the “toe-off” phase of gait, which has been shown to be 2-3x your body weight each step!
What Causes Achilles Tendinopathy?
Achilles tendinopathy is typically an overuse injury; this results when the demands placed on the achilles is greater than its ability to function or tolerate it. This can happen in an acute incident (trauma), or more commonly from chronic stress (repetitive microtauma) leading to gradual breakdown of the tissue. Pain, swelling and tenderness to the touch is most commonly felt in 2 places: where the tendon attaches to your heel (insertional tendinopathy), or 2-6cm more proximal in the tendon (midportional tendinopathy). Several factors that may contribute to this excessive stress include:
How To Rehabilitate Achilles Tendinopathy
First and foremost, we recommend seeing a specialist to help accurately diagnose you; it can be your orthopedist, your podiatrist or your physical therapist, but an accurate diagnosis helps determine treatment options. Achilles tendinopathy is most commonly diagnosed through an orthopedic examination and review of medical history; imaging is not often needed except in severe cases.
In acute cases of achilles tendinopathy (recent onset within <3 months), training modifications should be made in order to decrease the amount of stress placed on the achilles; this helps stop the process of overuse and inflammation, and allows pain to calm down. Training modifications includes decreasing your overall mileage, the frequency each week you run, or even just slowing down your pace. Complete rest is rarely recommended as it can be damaging to tendon health; tendons require load to maintain its structure. There is strong evidence in the literature that currently supports exercise as the best intervention for someone dealing with achilles tendinopathy. When pain is significant and acute, runners should start with heavy load (near maximal effort) isometric exercises for the achilles tendon, which has been reported to decrease pain sensation. One good isometric exercise can be performed as follows: while sitting on the floor, place a ball between your foot and the wall, and like pressing the gas pedal, push your foot into the ball as hard as you can tolerate and hold that position for 30-60 seconds. Perform this exercise 3-5 repetition’s for 1-3 sets twice per day as pain is tolerable. Variations of this exercise can include changing the ankle into different angles as well as performing the exercise with your knee straight vs knee bent. Modalities can also be used including ice after pain and inflammation or heat for tightness/stiffness, although not much research supports its benefits. As pain begins to decrease, exercises should become gradually more stressful to promote healing of a tendinopathy. It is thought that heavy load exercises help “reorganize” the messy collagen fiber alignment that develops when your body attempts to heal from the repetitive damage caused over time. Exercises that gradual load the tendon can be performed 2 ways – heavy load eccentric exercise program or heavy-load, slow speed (concentric/eccentric) exercise program. Both of these exercise programs has good support in the literature, similar results shown in athletes although the heavy-load slow speed program has greater patient adherence and satisfaction. For an eccentric calf-strengthening program, athletes should be aiming to perform 3 sets of 15 repetition’s 1-2x/day with both the knee straight and knee bent with as much weight as tolerated. For the heavy-load, slow speed exercise program, athletes should start with 3 sets of 15 repetition max and gradually work their way up to 4 sets of 6 repetition max; each repetition should take ~6 seconds to complete with bilateral equal weight bearing. It is generally recommended to give at least 3 months of exercise before considering other treatment options, although most athletes can recover even sooner. While performing exercises, it is also recommended that athletes continue participating in their recreational activities as long as there is only mild discomfort or no pain. Other treatment option’s such as injections, taping techniques, massage and electrotherapy at the very best may have short-term relief, but have not been show in the research to help long-term for athlete’s. There are many individual factors that will change how exercise recommendations will be prescribed including age, exercise experience, activity level, severity and chronicity of symptoms, and other injuries or co-morbidities. What is important is that in the acute and painful stages, goals should be to decrease pain and stress to the tendon, and then as pain becomes more tolerable, gradually reload that tendon in ways that help promote healing rather than over stress. Again, it is recommended to first get an accurate diagnosis, and then work with your local physical therapist that can help guide you through the exercises and programs while also identifying other risk factors that may be contributing to your diagnosis.