Do not let your Achilles be your “Achilles Heel”!

 

Moving up so to speak from the plantar fascia is the Achilles tendon also known as the tendo Achilles (TA). The TA is a special tendon. Without this we would not be able to have a bipedal existence. The TA allows us to walk, run and jump at full velocity. The TA can absorb up to ten times our body weight. If the TA becomes painful considering its exceptional weight-bearing capabilities you can assume that your running will become dysfunctional.

 

A TA tendinopathy is an injury of the bands of tissue (tendon) which are formed from the two main muscles in the calf compartment. These are the soleus and gastrocnemius muscle. This tendon inserts directly on to the heel bone or calcanium. The correct terminology for a problem with the TA is an acute TA tendinopathy. TA pain accounts for 5-12% of running injuries. Considering this injury effects around 150,000 people each year it is important to understand and regrettably, it is commonly mistreated. Our understanding of the mechanics and physiology of the TA has changed over the years. There are many ways of trying to treat the disorder and the various tendinopathies that can arise. Treatment should reflect up to date research but most physiotherapists will tend to apply what works from their own experience together with what has been tried and tested protocols.

Early Warning Signs

There are early warning signs including the following:

  1. Early morning stiffness in the TA which rapidly subsides after a few steps.
  2. A pinch test on the mid portion of the TA or by the heel which if irritated will cause local sharp pain which is not found on the other side.
  3. Beginning to get a tight calf. This is not in itself a symptom of TA tendinopathy however it may well become a huge contributing factor.

What brings TA pain on?

  1. Trigger points in the calf compartment pull up on the TA which subsequently pulls away from the bone and generates pain.
  2. General poor calf range puts load on the TA.
  3. Poor biomechanics.
  4. A sudden increase in hill training, volume or speed.
  5. Running back to back days too frequently.
  6. Just bad luck!

It has now been identified that with most injuries there is a hereditary weakness in the Achilles tendon which predisposes to injury. It may be that the tissue that makes up the TA is weaker in some individuals. Regrettably, there are also a number of antibiotics particularly the tetracycline group, often used in the treatment of acne that can also contribute towards a tendinopathy and that should always be discussed.

What should the physiotherapist look for?

When seeing a physiotherapist with a pain in and around the Achilles tendon you should be provided with a clear diagnosis that is a definite cause of the pain. The particular tests by the physiotherapists should include:

  1. All of the above as discussed.
  2. Palpable trigger points or knots in gastrocnemius and soleus.
  3. Early signs of thickening in the tendon.
  4. Neural tightness in the calf compartment.
  5. The exclusion of any other diagnosis such as a partial tear or even rupture of the TA
  6. A consideration of the history of the injury, how the pain came on and any recent changes in training.
  7. The posture of the foot.

What happens if the pain is ignored?

I have discussed in previous articles and I will continue to discuss in future articles and I know I have been guilty of this myself as a 400m hurdler in the past. We leave niggling pains to develop and hence injury emerges. Runners and athletes at all levels are stubborn creatures. Pain is an accepted part of our craft. We will persist until our leg is hanging off and then seek attention. If needed re-read article two to see how you initially handle niggles. If the pain does not subside do not keep running. This is only going to aggravate the injury. The TA is unique. It has no sheath therefore calling it a tendonitis is not correct. Other tendons do not follow this pattern.

What is the mechanism of chronic TA?

Acute inflamed tendons generating tendinitis leads to an acute pain syndrome that settles if appropriate treatment is applied as will be discussed in a future article. The tissue which makes up the TA is very strong. If repeated load is put through the tendon when irritated it begins, over time to change its actual structure. The body responds to such repetitive injury by causing the tendon to thicken which in turn generates local stiffness within the tendon itself. Perhaps the biggest mistake with this type of injury is that because the pain and stiffness subsides initially it is assumed that it is better or not a mistake to keep running on the injury. The tissue may have adapted but microscopic changes continue to take place as the tendon keeps being loaded by running. This leads to more microscopic damage which in turn causes more thickening, greater stiffness and increased problems with the normal action of the calf muscles. The athlete then finds they are running on a dysfunctional calf and tendon unit. Subsequently the early morning stiffness doesn’t go or the pain will be present on walking alone. When that happens this means the tendon has entered in to a chronic phase and the tissue has now altered and is potentially irreversible.  

Current treatment for acute TA tendinopathy

A physiotherapist should identify with you whether this is an acute tendinopathy or whether you have entered in to a more chronic phase. The greatest problem is to stop running. Active recovery is both appropriate and should be encouraged. Swimming for instance is an excellent activity but all impact exercise needs to be stopped with medical attention being sought. The protocol for stretching the calf compartment as described in last month’s article on plantar fasciitis needs to be introduced again. The reality with TA tendinopathy is that it can only be self-managed to a certain degree and an experienced physiotherapist will need to work with any injured individual in order to loosen the muscles and limit any further damage. I do not personally perceive that ultra sound or any other form of electrotherapy does anything in this particular situation though it is often used at significant expense.

The current treatments recommended include the following:

 

  1. Deep tissue and trigger point release of the soleus and gastrocnemius muscles.
  2. Gentle stretching but do note not to excessively stretch the tendon as this in itself can cause irritation (hence a greater need for physiotherapy input).
  3. Acupuncture in to the trigger points.
  4. Actually leaving the TA alone so that it isn’t irritated in the acute phase.
  5. A podiatry assessment if necessary.
  6. Even leaving calf raises if the tendon itself is within the acute phase.

The Rehabilitation Phase

Once the acute phase is managed effectively then rehabilitation needs to continue, this will include the following:

  1. Strengthening the hips and legs generally with a standard series of exercises for each muscle group.
  2. Eccentric loading of the calf muscles (calf raises).
  3. A running biomechanics assessment.
  4. A change of footwear.
  5. An analysis of the training programme that led to the problem in the first place.
  6. Regular maintenance treatment on calves 

Conclusions

TA tendinopathy is a frustrating injury for runners and also for therapists, particularly if the athlete presents late. Always treat the TA with respect and it will look after you. If you have any signs which have been discussed seek advice. There is nothing wrong with taking a low intensity or rest week to allow all tissues to settle down. Protecting runners from themselves is one of the key components of good coaching and treatment. With a week of rest or low intensity then it is easier to determine where there is localised stiffness.

 

An interesting technique that I was taught by a sports psychologist was of self-scanning your own body. This should be built in to your training but not before or just after running so as to avoid distraction. Sit quietly in a room and in your mind go head to toe. Work out where there is stiffness, where there is pain and what feels relatively normal. Use the results of that analysis and self-audit to either spend more time stretching on problem areas or seek advice and build a self-management programme around your own subjective analysis. Thanks again for taking the time to read these thoughts.