This event’s injury article looks at the Achilles tendon. Pain in this region is extremely common, especially for distance runners, and while there are a number of problems that can cause this pain, tendinopathy is by far the most frequent. Previously known as Achilles tendinitis, we’ve come to realise that there is often no inflammation involved, and as such the condition is more properly labelled tendinopathy. This may include partial tears of the tendon, degeneration of the tendon, or inflammation of the adjacent structures, and can present slowly over a period of time or quite suddenly after a particularly tough training session. Most often, we notice pain and stiffness in the Achilles region when getting out of bed in the morning, which decreases with warming up. Similarly, pain is experienced at the beginning of a training session, lessens with activity, then returns as we cool down…your classic overuse Achilles tendinopathy.
It’s worth mentioning that this problem is reasonably uncommon in adolescents, and pain in the Achilles region is often attributable to Sever’s disease, an aggravation of the tendon’s attachment to the calcaneus (heel) in skeletally immature individuals.
The Achilles tendon joins the gastrocnemius, soleus, and plantaris muscles (the calf) with the calcaneus. It is the thickest and strongest tendon in the body. There are two important bursa (fluid-filled sacks which help protect the tendon) close to its attachment point, and these may also become inflamed and symptomatic in cases of bursitis (see figure).
Problems with the Achilles and surrounding structures occur when the load applied is greater than the tissue can tolerate. This may occur with a single, high intensity load, or gradually over a period of time. When the healing of the tendon, which has poor blood supply, is unable to maintain pace with the wear and tear placed on it, tendinopathy results.
A number of factors have been proposed to contribute to Achilles tendon problems by either increasing the load, or decreasing the ability of the tendon to tolerate it. These may include:
Excessive or abnormal foot pronation, which causes the Achilles to “bow-string” and increases the load on the tendon when pushing off
Footwear
- inadequate medial arch support allows excessive pronation
- too much resistance through the forefoot means the calf has to work harder to push off
- inadequate heel counter or lower heel than the athlete is used to, placing more stress on the tendon
Training variables
- increased speed or mileage
- change of terrain
- decreased recovery between sessions
- greater number of years running
Calf weakness and/or inflexibility
Calf-dominant running style, with increased use of calf muscles for propulsion
Genetics – not much we can do about this one (yet!)
Prevention should address each of the potential causative factors. Every runner should ensure they are wearing appropriate footwear, according to their foot type. Generally, shoes are suitable for about 6 months or 500 km. A thorough prevention programme will also include a general core and gluteal strengthening regime. For the more serious or “at-risk” athlete, I recommend an evaluation of running style by a skilled, biomechanically-trained sports physiotherapist. Also, the heavy-load eccentric strengthening exercise, outlined below, should become part of the prehabilitation routine. Finally, early recognition of a problem is paramount to the quick resolution of symptoms. Achilles tendinopathy has the potential to become a frustratingly chronic problem, so seek help early on and get it sorted out!
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Raise up on toes of both feet through a full range of motion, then slowly lower yourself down off the edge of a step using only 1 leg. Repeat 3 x 12 times daily, using a backpack loaded with weight to add resistance.
Phase I (Acute)
Activity modification!
- stop running temporarily
- arm bike, swimming, water running, upper body weights, core strengthening for general conditioning
Ice massage
Heel raises in shoes
NSAID’s (eg. ibuprofen, topical creams)
Taping (consult physio)
Phase II (Sub-acute)
Soft tissue massage (calf muscles)
Stretches
- Gastrocnemius
- Soleus
Phase III (Recovery)
Deep friction massage (Achilles tendon)
Strengthening/endurance
- Heavy-resistance eccentric loading (see exercise section)
- Hamstrings (see previous articles)
- Gluteus medius and maximus (see previous articles)
Orthotics/footwear modification as required
Phase IV (Return to Running)
Heavy-resistance eccentric loading continues
Plyometric jumps
Gradual PAIN-FREE increase in speed/distance/frequency/hills
Modification of running style and training errors
- Keep centre of gravity low
- Use gluteals and hamstrings for propulsion, rather than calves
