By Boulder Sports Physiotherapy / April 08, 2022

Achilles Tendonitis

Running Injuries

It starts off as stiffness - an aggravating tightness and pain that can lead you to believe walking will never feel normal again. For the first few steps in the morning, it feels as if someone from above has just struck you with an arrow. You limp as if you just gained 30 years of age overnight and it takes you twice as long to get downstairs just for a cup of coffee. By the time you’ve finished the cup of coffee, eaten a bowl of cereal, and hobbled around the house to get ready for work - your pain is almost nonexistent. Whoever speared you with their arrow has now become bored or miraculously decided another is too cruel. Phew! You move on with your day by rushing to work, settling into your perfectly ergonomic desk chair, crossing your legs, and beginning the slow slump into bad posture and eye strain. 

It’s been two and a half hours of working, and your body - like a coffee pot - has filtered all of your morning brew from your kidneys to your bladder. The pot is full, and nature calls. You uncross your legs, push the chair away from your desk and begin the adventure to the bathroom. AH! Another arrow has been shot into your ankle - maybe as a way to say “Hey, would you mind NOT crossing your legs for that long? Have you HEARD of a foot stool?” 

Fast forward 5 hours to the end of your work day - when you finally arrive at the track for a tempo workout with your team. The ankle feels a little stiff, but warm up drills do not cause sharp pain and in fact it might be feeling better. You start the first mile at an easy pace and pain is minimal - nonexistent even. Conversation with friends distracts you from any symptoms lingering in the background and pace picks up at mile two to marathon pace. Still - no pain. Amazing! You’ve defeated the injury!
Hahahahha - ahhhhhhh. Wouldn’t that be nice. 
Speed continues to increase and by mile 6 you play with 5K pace. You can feel the presence of another arrow being aimed at you as your achilles begins to slowly sting. Shoot. You bring down the pace to enter an early cool down and that seems to diminish the pain. The workout ends, you say your goodbyes (which last for at least 10 minutes - or more if you are from the midwest), and as you begin to walk to the car the pain returns. BUT,  it isn’t until you get home and step out of your car that the final arrow strikes your achilles as you try to walk to your front door. Now, your ankle is angry, and concern fills your thoughts. Why won’t this go away? What am I doing wrong? Will it ever get better?
Yes - it will get better, it will go away, and the powers above will stop aiming their arrows at you someday. But when? How? 

How Does This Happen?
Injury to the Achilles tendon can happen for a variety of reasons; however, in runners it is likely due to overuse, over training, poor shoes or old shoes, and weaknesses in the muscles surrounding the tendon as well as above the chain. 

Side bar - the “chain” refers to your lower extremity. So, up the chain means closer to your waist, down the chain means closer to your ankles. End side bar.

AND - let’s be honest - it is typically a combination of the reasons listed above. Am I right?? We overtrain in old shoes and are too tired to do our “band exercises” in addition to high mileage weeks. I get it. Just because I am a physical therapist doesn’t mean I am doing exercises all day - or every day! Don’t get it twisted my friend. I much, like you, prefer to end my nights with the ol’ Netflix and Chill. I’ll get to my exercises “later.” 

First of all, I want you all to know that this injury is extremely common especially for runners. According to the latest research, achilles tendonitis occurs in 1 of every 20 runners. Although Achilles tendinopathy affects both active and inactive individuals, 24% of athletes develop the condition, and an estimated 50% of runners will experience Achilles tendon pain in their running careers (1). 

WHHAATT???? That’s quite a bit. So, if you’re running group has twenty people in it, you better start rolling your calves and doing heel raises - because it is coming for one of you…….

What Does it Feel Like?
Everyone will describe their aches, pains, and injuries somewhat differently because pain is so multifaceted and often attached to emotions. BUT - here is a list of fairly common symptoms those with achilles tendonitis will report: 

Pain in the morning that gets better after movement.
Pain that worsens with activity like running, biking, hopping.
Pain that is worse after activity (but sometimes hurts during as well). 
Symptoms typically feel sharp, aching, and localized to the achilles tendon. 

What CAN You Do?
Again - injury is not something to fear, but to be prepared for and understand so you can take care of business and jump right back into life as soon as possible. Here are some tips, pointers, notes, and puns for prevention and rehabilitation of achilles tendon pain. 

1. Stretch your calves. you have 2 calf muscles: the gastrocnemius and soleus - both of which attach to your achilles. If these muscles are tight (or too “short”), they will pull on the achilles tendon and eventually cause irritation to the calcaneus (ankle bone) and underlying bursa (fluid sack underneath the tendon). 

Sidebar - the word “sack” is about as weird and gross to me as the word “moist.” End sidebar. 

When the muscles are too short, they cannot function - just like an accordion not pulled out far enough to produce noise once you push it back together. If muscles cannot function or contract to produce enough power against the force applied to them, then tendons are called upon to transmit or absorb force. SO - by stretching your calves, foam rolling the area, and increasing the flexibility and length of the tightened calves, you can ensure less irritation will occur at the tendon because your muscles are now doing all of the work assigned to them.

2. Strengthen your calves. I have many patients ask me “so do I stretch it, strengthen it, which should I do?” Well - the answer is both! Overall performance depends upon having enough mobility, stability, and strength to do any task. While increasing the length of the muscle to a proper amount, you want to make sure it is then strong enough to produce and absorb enough force for your sport! ANNNNDDD - because exercise in itself can be medicinal, there is a very specific way you can strengthen your calf that also helps in healing the achilles tendon. These are called ECCENTRICS!! Or also - ISOMETRICS! If you have gone to physical therapy in the past, you know exactly what I am talking about. “Heel raises” are a standard exercise where you stand on two feet or one foot, raise your body up on the ball of your feet, then lower yourself down. Eccentrics simple means you prolong the lowering phase of the exercises. SO - you stand on one foot, raise up on the ball of your foot, and SLLLOOOOOWWLLLYY lower yourself back down. This can be performed on the floor (easy) or on a step (harder). Typically, these are more beneficial for someone who has pain along the middle portion of their tendon. If you have pain along the heel bone (just below the achilles), then you are better off doing Isometrics in order to reduce risk of further injury. All this means is you place that same foot on the ground, push the ball of your foot into the ground with 50-75% of your force (without lifting your heel) and hold for 10 seconds. By doing this, you bring more blood and nutrients to the area and activate the muscle for strengthening while reducing the stress applied to the tendon. BUT - there are of course other exercises and areas that need strengthening, of course.
3. Strengthen everything else. Our bodies are machines, and machines have multiple moving parts that work together to carry out specific tasks and functions. Your ankle is not the only part of your body at fault here. I bet the farm that someone with achilles pain may also have weakness in their glutes, in their core, and potentially in their hamstrings and quads. 

“Sarah - that is literally everything else.”
“PRECISELY!!! Man - you’re good.”

The calf/achilles is active in very specific “phases” of the running cycle.  One moment occurs during the last part of the stance phase when your foot is behind you and pushing off the ground to swing forward. It is also active when you first hit the ground (and this can vary depending on where along your foot you strike the ground). However, it is not the only muscle turned on at these moments. Your glutes and hamstrings must also be active to generate force for propulsion as well as to decelerate the leg upon landing. It is very important to make sure your body can activate these muscles in the right pattern so as to take up the force from the ground, transmit it properly, and produce a force that results in fast efficient forward progression. WITHOUT causing too much harm to tendons, ligaments, etc. 

4. Take rest days. This will be a common theme and general recommendation for most injuries. Overuse injuries come from - well - overuse. If you never let dough sit for a few hours, the dough will never rise. It will never grow to its full potential and produce the delicious loaf of bread you’ve been dreaming of all day. Give your body time to rest, for during recovery is when your muscles/joints grow and repair for better performance the next time. And this holds true with and without injury. We require more days of “rest” with injury of course; however, rest days are also great ways to prevent injury. Pick any day during the week that works best for you, your schedule, and your training goals. I love Sunday or Monday rest days. Sundays because I can take full advantage of sleeping in and participating in all things brunch. Monday’s because I can sleep in, ease into the work week, and use the day to meditate on what the focus is for the week. 

How Long Does It Take?
How long does it take to heal? Well, that all depends of course - on age, activity level, lifestyle, diet, if it is chronic or acute, stress, hydration, etc. Personally, it seems somewhat irrelevant to put a specific time frame on the healing process because we are ultimately trying to rehabilitate this tendon towards better performance and resilience for the rest of your life. Often, we are preparing it to be better than it was before you were injured, so it is likely you obtain some of these habits (i.e. strength, stretching, training parameters) and practice them even after your pain is gone. HOWEVER - for my people who like numbers and time schedules - and believe you me I am very much that person - I would give it at minimum 8-12 weeks before you are pain free with all activity. Remember, most injuries (especially repetitive, overuse injuries) happened from several months of improper training, weakness, bad shoes, etc. This is part of the reason why the rehabilitative process seems long. We all want a quick fix, but a quick fix most often leads to re-injury. Trust the process, and remember any time spent away from being active or tolerating normal movement is time you are spending getting stronger, increasing mobility, improving your health, etc. It is one of the few moments where we can enjoy a slower-pace, both in life and in training. Sometimes we need this for more than just our bodies, so take advantage of it and allow yourself to feel all the emotions. That is why the second word of the rehabilitation process is “therapy.” 



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