If there is an Achilles heel for runners, it is probably, well, their Achilles heel (or, to be more accurate, tendon). One unscientific study puts it as the second most common injury among runners. And unlike a few of the other more typical injuries (knee problems, IT band, hamstring strains, and the like), even doing disciplined work on your core and leg strength doesn’t help you avoid issues. Furthermore, it can creep up on you over time, and, if you aren’t paying attention, get to the point where it forces a layoff that can become quite extended.
As always, let me first state that I am not a healthcare professional of any sort, and the best advice for managing a condition like Achilles tendinitis (or other issues related to the Achilles, more generally classified as “tedninopathy”) would come from such an appropriately-trained professional. That being said, I learned a bit about treating this condition in its early to middle stages of development through researching approaches to deal with my own recent Achilles issue, and seem to have had some success in applying these treatments, at (most importantly here) minimal costs.
Since it is usually pretty obvious that the Achilles is the issue, and many of the treatments proposed below are relatively low risk (i.e., you aren’t going to get “worse” by doing them), this may serve as a good starting point in addressing issues with your Achilles, while either waiting for an appointment with a professional or in lieu of one. Note that I did see a professional about this condition, and her advice was largely in line with what I mention below, though her diagnosis was more along the lines of a retrocalcaneal bursitis. The Achilles happened to be cooperative that day, but I have little doubt that it had its own issues, and the two conditions are anyway highly related.
Causes of Achilles Tendinitis (sometimes spelled Achilles Tendonitis)
For a detailed review of the causes and treatments of Achilles issues, this article provides great depth. In a nutshell, the biggest cause other than the usual suspects of increasing mileage and getting older (undoubtedly contributors to my own condition) is having calves that are too tight and, as more of a root cause, too weak. If the calf muscles are stronger, they can bear some of the load that that the Achilles tendon often has to, which can, during running, reach seven times body weight.
As with most running injuries, shoe selection is also believed to play a role, and the impact is still debated. What seems likely is that the use of traditional shoes with “normal” heel lifts (specified as being in the 12mm range for heel-to-toe drop), both for running and everyday use, shortens the calf muscle and Achilles tendon, thus making it more vulnerable to injury. However, too rapid of a move to “minimalist” shoes (with a heel drop of 6mm or less) or barefoot running may stress the Achilles tendon, promoting an injury.
Symptoms of Achilles Tendinitis
The main symptom is pretty easy to detect – pain in the back of the ankle or heel that increases over time. Note that this pain is most typical when the Achilles is tight, such as first thing in the morning or early in your run. The Achilles may well start feeling better a mile into your run. It is important to note that this does not mean your Achilles is not getting worse. It is important to note the trend in the pain when you aren’t running on a daily basis.
If ignored, Achilles tendon issues can turn into a tear. While this is rare, it is certainly true that the further the condition progresses, the longer it will take to heal, so this is one condition to be sensitive to and exercise caution.
Potential Treatments of Achilles Tendinitis
If the pain is minor or emerging, it may be possible to reduce your running by 50% over a week or two period (preferably by shortening longer runs and taking an extra day or two off), and apply some of the other treatments below, then resume your training. Achilles injuries can be exacerbated by running on a lot of hills and by speed work, so these types of activities should also be avoided during this feeling-out period. If the pain doesn’t diminish or gets worse, then it is time for an all-out cessation of running.
The unfortunate news about Achilles issues is that it can take a long time for them to heal. The area is poorly served by blood flow, thus limiting the rate at which tissue repairs can occur. It is important during this time period to limit stresses on the Achilles, thus certain activities should be avoided.
Specifically, various cross-training techniques that runners turn to for other injuries such as cycling and using the elliptical may present some risks with Achilles tendinitis. One must be careful to avoid putting pressure on the ankle during dorsiflexion (i.e., the motion of moving the toes up towards the shin). One must be sensitive to this while using this equipment, and stop if there is pain in the Achilles – certain models and modes of exercise (riding high in the saddle on the bike, or having little support for the foot on the elliptical) may increase the risk of further damage. It may well be that swimming is your only resort for aerobic activity during recovery.
There are a range of other approaches you should consider to try and get back to health as soon as possible:
Apply ice: While inflammation tends to fade quickly after healing begins, there is no harm in an ongoing icing regime, between two and four times / day, up to twenty minutes each session. This would be particularly important after any exercise (walking or cross training) performed.
Take ibuprofen: Anti-inflammatories are also recommended early in the recovery – my doctor recommended a normal dose of ibuprofen 3 times per day for the first week.
Avoid going barefoot: While I generally advocate walking around barefoot to help with strengthening of foot muscles, now is not the time to do so. It is best to wear shoes with a “normal” amount of heel lift as much as possible. However, you should also avoid wearing high heels as this also places stress on the Achilles.
Wear a night brace: This is a piece of advice that you don’t often see mentioned, but my wife, who has a minor in sports medicine, highly recommended it (in fact, she ordered me one) as it helped her recover from her own issues. The point of such a brace is to allow the ankle to remain in a state of “relaxed dorsiflexion” overnight, thus providing a gentle stretch with no risk of over-stressing the tendon. There are two options:
A sock (like the[amazon_link id="B001AW3O00" target="_blank" container="" container_class="" ] Strassburg Sock[/amazon_link]): This functions by pulling upward on the toes – it may be less intrusive, but also less supportive (though, surprisingly, it can be more expensive).
A [amazon_link id="B001PAWOX0" target="_blank" container="" container_class="" ]heel splint or brace[/amazon_link]: This functions by pushing upwards from the base of the foot. It is a bit bulkier and, by my experience, can make for a rougher night’s sleep at times.
Both options provide for adjustment to create the needed tension. It is worth trying one of these options and continuing to use it for a period of time after recovery, if you can tolerate it.
Eccentric Calf Strengthening
By many accounts, the Alfredson heel-drop protocol is the most successful treatment for Achilles tendinitis, presenting both short-term and long-term benefits in healing and preventing the condition. In fact, it is such an important prevention step that it deserves it’s own section.
Ironically, it apparently came about as an attempt by Dr. Alfredson to make his Achilles tendinitis sufficiently painful that he could receive surgery to repair his condition. On paper, this exercise does what you shouldn’t do to an injured Achilles – place it under stress during dorsiflexion. As he now states, what he discovered was that this “mechanotherapy” approach, in which movements stimulated repair in the tissues, seems to accelerate healing.
The exercise is performed on a step, and involves raising up on to the toes, removing the support of the healthy leg, and slowly “dropping” the ailing heel as low and slow as possible. The healthy leg is then used to provide the force to raise back to your tiptoes. Note that it is mandatory to have a healthy calf for this exercise – if both Achilles are damaged, then you are back to rest. The “eccentric” nature comes from the fact that you are only exerting force as the muscle extends – which is opposite of the usual “concentric” approach (applying force as the muscle contracts).
The protocol calls for 3 sets each of straight leg (for the gastrocnemius) and bent-knee (for the soleus) exercises, 15 reps each, twice a day. Note that this is technically called the “Alfredson painful heel drop protocol” – so pain is mandatory too. Once the pain stops occurring, it is time to add some weight, best carried in a backpack. I do recommend wearing shoes also while performing this exercise, as I believe that the stress placed on my foot while attempting to do so barefoot led to some early symptoms of plantar fascitis (the evil step-sister of Achilles tendinitis).
This summarizes the non-professional treatments of Achilles tendinopathy. If the condition is more severe or you wish to accelerate the healing and can afford the time and cost, a physical therapist can apply ultrasound (the benefits of which are debatable) or electric stimulation (with or without the application of a steroid). A chiropractor may be able to help via active release technique, which may actually focus on treatments all the way up the “kinetic chain” to the hamstring (you may need to stretch your thinking a bit). A physical therapist or podiatrist may also be able to prescribe and provide orthotics to provide improved heel lift – though you may want to consider whether such a step is helpful to your long-term running efforts to improve your form and reduce your risk of other injuries.
As far as the time required to heal, it can vary widely. Often four to six weeks is typical for a not-to-serious case of Achilles tendinopathy, but more advanced conditions can require three months or more. If you aren’t seeing improvements within three to four weeks, it may well be time to see (or revisit) a professional, unless one previously advised you that recovery would take longer.
Returning to Training from Achilles Tendinitis
As with recovery from most injuries, one must be patient and build back up the mileage slowly. Obviously the “starting point” may differ broadly, based on how long you were unable to train. Over four to six weeks, you will see a significant degradation of fitness, unfortunately, even with cross-training. It is best to be conservative in initial run frequency and mileage as you return, starting with every other day, and ramping only as it feels comfortable.
Beyond managing the build-up of mileage carefully, one must also be careful to avoid more stressful workouts such as speed work or running on hills during the early recovery phase. These types of workouts place the foot in greater degrees of dorsiflexion, so be certain that the tendon is capable of such work before trying it. It may take over a month to return to speed-intense or hilly workouts.
Ongoing Prevention of Achilles Tendinitis
The best approach for preventing further issues with the Achilles is continued strengthening and stretching. For the former, the eccentric heel strengthening can be supplemented with more tradition (concentric) calf raises once healing is complete. The value of traditional static stretching is debatable; one approach I intend to pursue (and write about, of course) is Active Isolated Stretching, which involves quick pulsing of the addresses muscle, ligament, or tendon under light force.
Modifying your shoe selection is another approach to consider. While you will want to stick to (or move back to) traditional heel-to-toe drop shoes during your recovery and initial outings, you may well want to plan a strategy for incorporating shoes with lower heel-to-toe drops – or barefoot strides in the grass – to help build calf strength and flexibility over time. Even if they don’t become your primary shoe of choice, such options can provide the strength needed to reduce ongoing injury risk.
Otherwise, typical injury-avoidance advice applies:
- Increase your mileage and intensity intelligently – train within your limits and expand those limits patiently and gradually.
- Improve your form through working out imbalances – this often involves strengthening your glutes, hips, and the rest of your core to better maintain running form under fatigue.
- Build overall strength and flexibility through body-weight or other strength training exercises that are appropriate for runners.
- Utilize appropriate warm-up and cool-down techniques to simultaneously reduce stress on muscles during running and improve overall mobility.
At present, I am in the early stages of being able to run again after 2-1/2 weeks of down time. The treatments listed above have been sufficient to get me back to running, though I will continue to apply them and maintain lower and easier mileage for at least a month while verifying the fact that I am healed. I have, for now, avoided the cost and hassle in visiting a physical therapist or chiropractor, and it’s doubtful that doing so would have accelerated this recovery.
The attempt to begin running again fizzled after three weeks, and I took a further six weeks off. During this six weeks, I shelved the eccentric calf strengthening and experimented (with no success) with orthotics and heel lifts for everyday use. Ultimately, it was the combination of gentle stretching of the calf muscles and active release technique (ART) massage therapy that seems to have brought me back to good health.