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20 Mar 2014 - 07:53:52 am

How to manage achilles tendinopathy | RunningPhysio




How to manage achilles tendinopathy | RunningPhysio

Written by Tom Goom, senior Physio at The Physio Rooms Brighton. Follow Tom on Twitter.

The Achilles Tendon is a common sore spot for runners and can be a difficult area to treat. Here we'll look at common diagnoses, causes and treatments.

What is a Tendinopathy?

Tendinopathies are not limited just to the Achilles. They can be a problem in a number of areas throughout the body and runners might suffer patella tendinopathy, posterior tibial tendinopathy or peroneal tendinopathy to name but a few. Much of our bodies are in a constant state of building new tissue (synthesis) or breaking down tissue. It happens in muscle, bone, ligaments and tendons. How much stress or load we put on a structure plays a huge role in how much synthesis and breakdown of tissue there is. It's a balance.

If the load we put on a tendon is too much and we continue to do this frequently then the amount of tissue breakdown starts to exceed tissue synthesis. The structure of the tendon then starts to change and becomes less efficient at dealing with load and you have a vicious circle.

Tendinopathy is usually divided into stages. Initially you have a reactive stage. This is usually a response to rapid increase in loading. The tendon may visibly swell and will be painful. In more chronic cases there is often a more degenerate tendinopathy and the tendon's structure is changed considerably - it may be thickened and develop nodules. If untreated the degeneration of the tendon can reach a level where it really can't handle any load, as a result it fails and you develop a partial or total Achilles tendon rupture. This is a gradual process and usually a painful one but sometimes it can occur without pain with the first sign of a tendon problem being a sudden unexpected rupture. Working out the stage of the condition is important to determine the best treatment - see our article on staging tendinopathy.

Sounds like a bleak picture doesn't it?! It needn't be. If the problem is identified and treated early it often fully resolves but it is something that needs acting on. It probably won't go away on it's own.

Symptoms

Runners usually describe a gradual onset of achilles pain during or after a run. Gradually the pain becomes more frequent and can start to be a problem on a daily basis when not running.

Usually the tendon itself is painful if you squeeze it between 2 and 6 cm from the heel bone. There may be swelling initially or thickening of the tendon.

Activities that load the tendon will increase pain, this can include going up or down stairs, walking on tip toes, squatting and of course running.

There might be tightness in the calf and pain on taking weight first thing in the morning.

What else could it be?

Part of the reason that this is now called tendinopathy and not "tendinitis" is because of the ongoing debate as to what this condition entails. It's a bit more complex than you might think! We no longer believe the condition involves inflammation which is why we've changed the "itis" at the end (a word ending in "itis" usually suggests inflammation). We now know that instead of inflammation the tendon has a reactive response which thickens and stiffens it and acts as a "stress shield" to reduce load.

There are other issues around the tendon that can be involved. These include the insertion of Achilles into the heel bone (insertional tendinopathy) or inflammation of the bursa at the base of the achilles (retrocalcaneal bursitis). There is also another tendon, called plantaris that is sometimes embedded within the Achilles and can cause irritation. Insertional tendinopathy usually presents with more pain at the attachment of the Achilles to the heel bone rather than the mid section. It's management is quite different from mid Achilles tendinopathy - for example it is often aggravated by stretching or "heel drops". We will tackle insertional Achilles tendinopathy in a separate article.

The other condition that can be misdiagnosed as Achilles Tendinopathy is Posterior Tibial Tendon Dysfunction (PTTD). The pain tends to be more on the inside of the Achilles tendon and the Achilles won't be sore when you pinch it. A lot of the treatment principles are similar though so you might find the treatment you would use for the Achilles will work for PTTD.

Managing a reactive Achilles tendinopathy

Generally speaking if you have acute mid achilles pain after an increase or change in training it's likely you have a reactive tendinopathy. Your inital aim is simply to calm it down and settle symptoms. The most important treatment is simply load management. Reduce the stress on the achilles to a level that the tendon can manage and the tendon may settle in as little as 5-10 days. For mild cases you may be able to continue some running as long as you're able to keep it pain free. Bare in mind though that a tendon may take 24 hours to respond to load so may not hurt until the next day. If you can't find a way to run pain free then it's usually sensible to rest for a few days until you can. Other treatments may also settle symptoms;
Anti-inflammatory medication - ibuprofen has been recommended for reactive tendinopathy. Although there may not be inflammation present it can help reduce the tendon's reactive response and decrease tendon swelling. As with any medication consult your GP or pharmacist first.Isometric calf exercises - in standing slowly push up onto your toes on both feet, use support if needed. Hold this position for around 5-10 seconds. Slowly lower again. Start with around 5 reps and gradually build up to 10. As you progress try to place more of your body weight on the weaker leg during the 'hold' part of this exercise. In too painful pushing up or coming down do this part with more weight on the weaker leg.Ice - for maximum of 15 minutes at a time to reduce pain - see our article on ice application.Offload the tendon with a gel heel raise in your shoe all the time, not just for running. They're easily available online or from shoe shops, the idea is to use it as a temporary measure when things are sore in the early stagesOffload the tendon with kinesiology tape (details below). Again the aim is to reduce load on the tendon in the early stages, we mentioned above that this can be used when running but, like the heel raise, you may need to use it when walking if things are very sore. Long term though you want to wean off it as you gradually increase the load on the tendon.Massage or foam roller the calf muscle to reduce tightness. Avoid massaging the tendon itself if it's sore.See a Physio for acupuncture or ultrasound? The jury is out on this, if you've responded well to ultrasound or acupuncture in the past it may be an option for you. Personally I would try the methods mentioned above and consider these two if the others don't work.
Yep. That there is my skinny little ankle!


Once symptoms have settled ensure your return to running is gradual and follow the guidance of your health professional. Tendons are sensitive to load for some time after a reactive tendinopathy and can react painfully again if you increase mileage too rapidly. Make sure you explore the causes of your tendinopathy to prevent recurrence or progression to a more degenerate tendon.

Managing a degenerative Achilles tendinopathy


If you're an older athlete and have had a grumbling tendon for some time with periods of flare ups in your pain it's likely you have a more degenerate tendinopathy. Your Achilles may be chronically thickened with 'nodules' you can feel within the tendon. That said this condition is more of a scale from reactive, through into tendon dysrepair and then degeneration rather than a case of either a reactive or degenerate tendon. In fact a flare up in symptoms from a chronic tendon problem can be a reactive response from non-degenerate parts of the tendon. If you're in one of these flare ups then first settle symptoms with the advice in for reactive tendinopathy above.

There are aspects of degenerate tendinopathy that are irreversible. Some of the structural changes won't resolve with exercise. That said, symptoms may well improve even despite this. If you've had chronic Achilles' tendon problems it's likely you'll need an ongoing management plan to keep the symptoms under control.

Load management is an important part of degenerate tendinopathy - if you continue to overload the tendon it will remain painful and may potentially lead to severe degeneration or tendon rupture - see below for details of avoiding overload through training error.

Improve your tendon's ability to handle load - this can be achieved through eccentric loading and strength and conditioning work as well dealing with what has caused the initial problem.

The idea behind eccentric loading is that it actually helps to reverse some of the effects of a tendinopathy. The tendon seems to respond to this type of exercise by reorganising the structure of the tissue so that it's more capable of dealing with load. Excellent. The original research showed promising results and recent research suggests that this type of exercise is effective both in the short term and at 5 year follow up.



Taken from Alfredson et al 1998.

These "heel drops" involve pushing up onto the toes of both feet, then lower over the edge of a step on the weaker foot. The exercise is done with the knee straight and repeated with the knee flexed, so there are essentially 2 exercises. The original research recommends doing both with 3 sets of 15 reps of twice per day. However this isn't set in stone, Many people will need to start by doing the lowering part on both legs too as it may be too sore to work just the weaker leg. Also you may need to do lower reps and sets, for example starting with 3 sets of 5 on both legs and building up to 3 sets of 10 on both before progressing to onto 3 sets of 5 on just your weaker side. Be guided by your pain and gradually increase as able. Unlike many exercises it is usually ok to have some pain during eccentric loading. If you rate your pain out of 10, where 10 is the worse possible pain and 0 no pain, it shouldn't be more than 5.

Strengthening the calf muscles is also likely to help. With guidance from your health professional you can also progress to high load eccentric work, isometrics and plyometrics all of which can help to improve muscle and tendon function.

Causes of Achilles Tendinopathy

As with many running injuries establishing the cause is essential for recovery and prevention of recurrence. If you just focus on treating the pain then there is a risk the problem will come back once you run again. This is a challenging area of rehab and you may need guidance from a Physio for this. There are many factors that you can work on but I would recommend finding the key issue and focussing on that first. To watch a very detailed assessment of a runner and treatment of his Achilles issues check out this Running Times article here.

Usually the cause of Achilles tendinopathy is continually putting too much load on the tendon and not allowing enough time for the tendon to recover. Its not just about distance otherwise all marathon runners would have achilles issues which they don't. Several factors will lead to a runner putting more load on the Achilles than it can cope with;

Training error

The classic too much, too soon.

Research suggests that training error is involved in 60-80% of cases of runners with tendon problems.

A rapid increase in mileage doesn't allow the tendon time to adapt to deal with the load and as a result it starts to breakdown. Hill work also places greater stress on the Achilles and doing too much can also also cause this issue. Increasing speed, changing stride length and not having enough rest can also play a part. Commonly it's not just doing one of these things but a combination of a couple of factors that lead to a problem.

Solution

Stick to the usual recommendation of only increasing your weekly mileage by 10%. Be cautious when doing hill or speed work not to over do it. Work on just one training modality at a time. By this I mean if you're doing endurance work do just that. Don't try and do your long runs quickly in an attempt to improve fitness. Likewise with speed work these are not meant to be long workouts. Either work speed or endurance not both together. For long runs you should be comfortable and easily able to chat, it should be around 60-90 seconds per mile slower than your race pace.

You can use a recent race time to approximate speeds for each run using the Macmillan Calculator. I know people have mixed views on this but it just gives you a little guidance. RW's training schedules also include recommended paces so you can use those too.

What I've found is that sometimes you feel great running and you just want to go for it. Sometimes you worry that you've not ran any real distance at race pace and that anxiety makes you push yourself on the long run. I've done it myself, I ran a 20 miler at 7:27. My race pace for the marathon is around 7:15 (hopefully!). I felt great at the time, the last 3 miles I pushed close to 7:00 per mile. What's the problem then? It took my legs nearly 3 weeks to recover and I had to drop a few runs here and there to prevent injury. I've learned from it that training for a marathon is about the whole programme not each individual run.

Another part of this which is really important is have a rest day. I can't stress how important rest is for this condition. Research has shown that if you don't have at least 24 hours between each run that the tendon doesn't have enough time to rebuild new tissue. The balance between tissue synthesis and breakdown is lost and you have a greater amount of breakdown. That isn't to say you need a rest day between each run but if you can plan your running to prevent multiple consecutive days of running it will help. Some programmes "bracket" the long runs with rest days before and after, this makes sense to me. I sometimes wonder about the wisdom of a "recovery run" loading fatigued tissues the day after a long run.

For some simply amending any clear training errors may be enough to allow your Achilles to settle and for you to continue running. You may not even need specific rehab if your training was the sole cause. For others you may need to adjust your running to find a way to do it pain free. You can try offloading the tendon when you run using a gel heel raise or taping technique (details above). Try varying running surface, speed, distance, stride length or running form (aim for quiet, controlled running). Try and find a level that you can manage without pain during running or for 24-48 hours after.

What if you can't do this? If there is no way you can find to run pain free then I'm afraid you'll need to rest until you can and aim to settle your symptoms. It may take a few days or a couple of weeks depending on severity. During this time you can cross train following the same guidance as you're running - it should be pain free during and 24-48 hours after.

Continuing with the causes...

Biomechanics

Lots of potential causes here, they include leg length difference, over pronation, high foot arch and poor mobility in the foot and ankle. Running "form" plays a part here, in theory if a runner heel strikes and then the foot overpronates then this places "whipping action" on the Achilles.

Solution

This excellent piece of research recommends video gait analysis and provision of the correct footwear to support the foot, ankle and Achilles tendon. It's a long read but if you've got a spare 30 mins or so it covers everything from achilles tendon to stress fractures (man alive, I'm such a geek!).

So, if you haven't already, get a running shop or health professional to assess your gait. I would suggest that simply watching you run without the aid of slow mo video is probably not enough. A lot of running shops will assess you on a treadmill with slow mo video for free, but bare in mind their ultimate goal is to sell shoes. The only way to really find out if it's the right shoe for you is to run in it, some shops will give you a 30 day running trial with a money back guarantee which gives you the opportunity to properly test it out.

In theory a shoe with a higher heel drop (the difference in height between the heel and the middle of the shoe) should have less stress on the Achilles. I say in theory as there is very little research evidence to support this idea. Some shoes are designed to encourage you to mid foot strike and again in theory this should help. A stability or motion control shoe or orthotic insole to reduce overpronation should also help but again the evidence here is far from conclusive.

Poor movement control

Hand in hand with biomechanics comes movement control. If you have poor control of movement then that can lead to increase stress on the Achilles tendon. "Eccentric" control is often thought of as very important. This essentially means how well you control how a muscle lowers your body weight. Think of a squat, that's eccentric control of the quads (among other things). Each time your foot lands a host of muscles including the calf have to control the impact and utilise the force to propel you forward. The whole leg is involved at different levels so an issue at the hip or knee can affect the ankle and Achilles.

Solution

Identifying your own control issues isn't easy. A Physio assessment is certainly helpful here. There are a few things you can look at, see how easy each one is, how well you can control it and how it compares to your non-painful side (if you have one!).

Single leg balance - can you do this and keep the leg and trunk steady? What about with your eyes closed or on a pillow?

Single knee dip - your knee should move fluidly over your second toe without drifting in towards the other leg.

Calf raise - you should be able to do this with knee straight and knee bent. You should be able to lift the heel the same height off the ground on both sides and control lowering the heel too. Note; if you have pain this may well limit this test.

If you find a balance difference work on it. With control work the focus is on quality not quantity there is little point doing hundreds of wobbly single knee dips, it's better to do 5-10 controlled movements. Details here on assessing balance and movement control.

Muscle Strength/ Endurance

The main culprits here are usually the 2 calf muscles gastrocnemius and soleus. You can test the endurance of each by doing repeated single calf raises to fatigue. First though ensure that your pain has settled otherwise you can flare up your symptoms and it's unlikely the test will reveal much as pain will stop you before fatigue does.

Use a little support for balance and do repeated calf raise with the leg straight first with your good leg, then your weaker side. Count how many it takes to reach fatigue and note the effort needed. Repeat with the knee bent 30-40 degrees.

Solution

Once your symptoms are under control you can strengthen any weakness you've found. To improve endurance the recommended dosage is usually 15-25 reps (or to fatigue) 3 sets each separated by a rest period of 1-2 minutes. This can be done around 3 times a week with a rest day between. Of course this isn't set in stone, there are a host of different programmes recommended and you will need to stop if you get pain. More here on calf strengthening for runners.

Tissue Flexibility/ joint range of movement

It's important that the ankle has a full range of movement to prevent excessive stress on the Achilles. Ankle movement is a combination of 4 main directions - upwards (dorsiflexion) downwards (plantarflexion) inwards (inversion) and outwards (eversion). Compare your range of movement between both sides and again work on any deficit. Particularly important is dorsiflexion. When your foot hits the ground the ankle has to dorsiflex first, any loss in range can increase stress on the Achilles. Dorsiflexion range is commonly lost after ankle fracture or sprain or due to calf muscle tightness. Try stretching your gastroc and soleus, see if one side feels tighter. You can also do the knee to wall test and compare left and right.

Solution

Regularly stretch gastroc and soleus. Nice video from on stretches from RW here. Ensure the calf is stretched dynamically pre-run. Video of this coming soon, until then I like these dynamic calf stretches. If the ankle range of movement is restricted, some simple ankle range of movement exercises may be adequate to loosen it up.




Final summary: managing Achilles tendinopathy can be a challenge. First determine what stage of the condition you have as this will effect treatment. Load management is key at any stage and identifying the cause is important to prevent relapse. Eccentric loading and strength exercises can be useful in helping the tendon deal with load.

Many runners will try and self treat tendon problems but some guidance from a Physio can be really helpful. As with any condition on RunningPhysio if in doubt get it checked out!
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