Achillies tendonitis - Triathlon & Multisport magazine

Achilles tendonitis is a common and debilitating condition among runners. We take a look at some of the symptoms of this affliction and, more importantly, ways to both treat and prevent it.

Does this sound familiar? You’re approaching your fittest condition and are poised to run your best ever racing times. Then, while out running one day, you feel a low-level, nagging pain pinching at your Achilles tendon. You limp home and ice the tendon. While running the next day it feels ok when you start, but after a while it becomes even more painful. This continues for several days until you grind to a painful halt.

Well, you’re not alone if you’ve had Achilles tendonitis – it’s one of the five most frequent running injuries and has crocked many a runner in their prime, even sidelining runners from Olympic games finals. The chances are you’ll experience Achilles tendonitis several times during your running career.

Symptoms of Achilles tendonitis
The symptoms are unpleasant: the tendon or its sheath may be stiff or sore when you wake up in the morning, or after you’ve been sitting or lying around for a while. Often you’ll feel a creaking or grinding sensation. With continued training, the tendon may become swollen, red and puffy. If this has been building up for a long time, there may be a nodule or lump of scar tissue around the sore area of the tendon.

Pain ranges from dull to sharp. Apply the ‘pinch test’: you’ll know you’ve got a problem if it hurts when you pinch the tendon about two-to-six centimetres above the insertion of the tendon into the heel bone, where it is narrowest. These symptoms indicate advanced inflammation and micro-tears in the tendon or sheath, and are warning signs that trouble is brewing in the largest and strongest tendon in your body. And be cautious because inflamed Achilles tendons are at high risk of complete rupture if stressed continually for several weeks. If you feel sharp pain – an indicator that the injury is severe – stop immediately.

The degree of Achilles tendonitis varies greatly, anywhere from a slight inflammation to a complete rupture, which will feel like you’ve been shot. The majority of cases of Achilles tendonitis are low-level complaints, easily remedied with self-treatment, but the worst thing you can do is to ignore it and hope it will go away.

Achilles tendonitis does not fade quietly into the sunset – it prefers to slowly creep up on you until one day you can’t walk properly without feeling pain, let alone run a few steps. Sometimes, though, Achilles tendonitis can be a wily foe. It will hurt briefly during a workout, and then disappear as you warm up. And the soreness returns again the next morning.

Recovery time from Achilles tendonitis
Achilles tendonitis can become a chronic, insidious injury that will force you to stop running for several months unless you address it early. This is because the Achilles tendon does not have a good blood supply, so it takes a while to heal.

How long are you likely to be sidelined if you damage your Achilles tendon? Obviously, the time it will take for you to return to running will depend on the severity of the injury.
The idea is to address Achilles tendonitis before it progresses past stiffness in the morning, and before it becomes chronic. If you catch it early, in the first few days, and follow some of the recommended self-treatments, you can be back running within a week or two, or a month at the longest.

Causes of Achilles tendonitis
Physiotherapists report that this affliction affects male runners between 35 and 45 years old more than other demographics. Not much we can do about that except realise that this population is at higher risk, and train with more caution.

Your chances of getting Achilles tendonitis increases with every year you’ve been running, the faster you train, and as you suddenly increase your mileage. Fortunately, we can do something about these risk factors. Programming rest and recovery days into our training schedules and doing some low impact or non-impact cross training such as swimming, cycling, or elliptical training at our fitness club will ensure that our musculo-skeletal system has recovered adequately from workouts. We can also increase our mileage gradually instead of suddenly piling the miles on.

The biomechanical cause of Achilles tendonitis has been traced to excessive rear foot pronation and weak ankle muscles (gastrocnemius, soleus, anterior tibialis). Slow-motion video footage of runners with severe pronation shows a rather nasty whipping or twisting movement of the Achilles tendon when their foot lands and then absorbs the impact.
For a split second when your foot lands, the tendon absorbs the strain of three to 12 times your body weight (depending on your speed). This strain is then transmitted to the thick, bulky calf muscles through this half-inch thick cord.

This repeated shock combined with the knee rolling too far forward over the foot places tremendous stress on the Achilles tendon and may eventually cause inflammation. It’s no wonder that this tendon occasionally rebels against this abuse – it can only take so much repeated trauma.

Treatment and rehabilitation of Achilles tendonitis
Treatment revolves around settling down the pain and inflammation, strengthening the muscles around the ankle, and regaining joint proprioception (joint position sense) to regain power and coordination of the ankle.

We use several treatments to achieve these goals: rest, anti-inflammatory medications, physiotherapy, icing, orthotic inserts, heel inserts, better footwear, eccentric calf stretching, and when all else fails, steroidal cortisone injections. In chronic cases where the runner is incapacitated or has a rupture, surgery has proven effective (fortunately very few progress this far). One study found that 85 per cent of 86 runners who underwent an Achilles injury rehabilitation program built around these modalities were able to resume regular sporting activities.

Self-treatment for Achilles tendonitis
There are many things you can do if you start feeling symptoms of Achilles tendonitis. If done early enough, and diligently, they will heal up your Achilles tendon quickly. However, if the symptoms persist for more than two-to-three weeks, see your sports medicine physician.                                                                        

First, you need a rest period, so reduce or stop running (my sports medicine physician once told me that for low level Achilles tendonitis – meaning without pain – to train every second day, instead of daily). Cut your running back to a slow jog, and cut your running distance down to a few kilometres. Definitely avoid hill running and speed work!
And this is certainly not the time to play basketball, soccer, tennis, or any sport that involves sudden twisting or changing direction.

Ice the tendon immediately after running for 10-to-20 minutes and avoid excessive stretching. Next, ice the tendon consistently (10 minutes every two hours) for the first two-to-three days after getting injured until the pain has receded. Then start heat application, using heat packs or a hot water bottle with a damp towel wrapped around it.

If you’re worried about losing your fitness while you’ve stopped running, try some non weight-bearing exercises like swimming or deep water running. Then, progress to non-impact cross-training such as the elliptical trainer machine or cycling with low resistance.  

Take a course (five-to-seven days) of non-steroidal anti-inflammatory drugs available from your general practitioner or pharmacist.
Avoid day-to-day weight-bearing activities and keep your foot elevated when possible. Do not walk barefoot around your house and avoid wearing excessively flat shoes, such as tennis shoes, cross trainers, etc.

Self-massage the Achilles tendon and calf muscle using arnica oil or anti-inflammatory gel. Rub in semi-circles in all directions away from the knotted tissue, three times a day. Once the pain, swelling and scar tissue are gone, stretch the calf muscle gently. And a warning here – if you feel an ‘empty’ spot or gap on your Achilles tendon, get thee to a sports medicine physician immediately – you may have a partial rupture.

Exercises to avoid
Excessive stretching is likely to aggravate an inflamed Achilles tendon. Your goal is to settle the inflammation down, so caution is advised. Avoid doing stretches throughout the day and avoid stretches that put high tension or body weight on the Achilles tendon, such as the ‘stair stretch’ and stretching on an incline. A safer stretch is the wall stretch, where you lean into a wall with your leg and knee straight.

Other exercises to strengthen the ankle
Physiotherapists will have you try several exercises to strengthen your ankle and Achilles tendon. Here are some that you can try: heel to toe walking, heel walking, calf raises (with bodyweight first, then adding weights), and one-leg knee bends.

Returning to running
After these treatments, and assuming that the tendon has settled down and is pain free when you walk, you are ready to start your return to running. Try doing some calf raises with no weight as a test. If there is no pain during and after doing several sets of calf raises, you’re ready to start jogging.

Place a quarter-inch heel insert in your shoes (including your street shoes) and start by taking several walks of 15-to-30 minutes. Then start jogging slowly on a soft surface like grass (but not sand), with some mild stretching afterwards. During these early runs, monitor the tendon closely for pain or discomfort. If it flares up again, start the self-treatment process again and visit your local sports medicine physician for possible referral to a physiotherapist.

If all is well, gradually progress with your training program while avoiding excessive hill training and speedwork. And incorporate rest into your training program.

Physiotherapy treatment
Clinical treatment will initially consist of physiotherapy modalities like electrical stimulation (high voltage galvanic stimulation HVGS), ultrasound and gentle massage. Your physiotherapist should also check your running shoes. They’ll look for three things: excessively worn heels, heel shock absorption that is too soft, and if the shoe is too stiff around the ball of the foot.
Preventative measures against Achilles tendonitis

Stretching of the gastrocnemius (keep knee straight) and soleus (keep knee bent) calf muscles will keep the Achilles tendon strong and flexible. Hold each stretch for 30 seconds, relax slowly. Repeat stretches two-to-three times per day. Remember to stretch well before running.

Strengthening exercises for the foot and calf muscles, such as heel raises, are good to incorporate into your strength-training program. Make sure you are using the correct running shoes for your weight and biomechanics, specifically motion-control shoes and orthotics to correct overpronation. 

If you follow these guidelines when you experience the first minor symptoms of Achilles tendon inflammation, you should recover quickly. But there’s a warning here that should be heeded – you’re doing something that is aggravating your Achilles tendon. Follow the advice here to prevent further aggravation and strengthen the tendon before it reoccurs.

Looking for more training advice? Find out how to improve your performance on race day and get all the latest nutrition tips.

Photo credit: Images: Delly Carr/ THINKSTOCK