How to deal with your Achilles heel.
How to deal with your Achilles heel.
The Achilles tendon. A super strong, tough, thick band of fibrous tissue that attaches your calf muscle to the heel bone, a vital part of the running mechanism. When running or walking, the calf contracts and relaxes to propel you forward and the Achilles plays a role in this by stretching and recoiling like an elastic band to help forward propulsion.
It may be easy to take for granted, but neglect your Achilles at your peril. Many an athlete, from top international performers to recreational weekend runners, will shudder at its very mention, reeling off tales of training and racing disrupted by their Achilles heel. Indeed, Achilles injuries are notorious for seemingly coming from nowhere but then hanging around stubbornly - and the longer they’ve been grumpy, the harder it is to get them to shut up. Don’t despair, though. It may take some trial and error but find the correct balance between rest and load level in your physio programme and the chances are that this, too, shall pass, without any need for more invasive treatments. Optimally, catching any problems early can save a lot of time, pain and physio fees in the long run.
Warning signs
How can you tell it’s your Achilles starting to niggle? Usually you can point to one spot on the back of the heel or on the tendon. Typically, they feel sore at the start of the run and then loosen off, only for the soreness to return later in the run, or later that day or the next morning when you get out of bed.
What makes your Achilles grumpy like this? Loading or working the tendon during exercise and activity causes micro damage or tears. When you rest from activity these tears repair themselves. Get the amount of use and rest just right and the tendon will repair itself stronger each time. If, however, the rate of damage becomes greater than the rate of repair, the tendon starts to struggle and will eventually start to produce symptoms like pain, stiffness and swelling. On the other hand if you under-use your tendon it will become weaker and less able to take load, thus making it more vulnerable to problems even at a load that it was quite happy with previously. It is worth noting that there are other factors that can affect the repair rate, including certain antibiotics.
As with all injury problems, prevention is better than cure. A bit of extra thought around planning could save you hassle down the line, particularly where change to your training or exercise routine is concerned. Changes that can cause overload on an Achilles include:
Increased hill running (uphill and downhill)
Increased soft surface running - especially marshes and sand
Increased road running
Increased fast running, especially sprints and hill reps.
Increased volume
Change of shoes (especially the amount of heel drop)
Sometimes, though, even with the most sensible planning you may nevertheless start to feel the tendon complain. What can you do? Managing Achilles injury is based around two elements: calming it down and building it up. The key to successful rehab is understanding which you should be doing when, and how much of each.
Calming it down
When: If the tendon is suddenly painful or significantly more painful, if it is slowly and consistently getting worse or if you’ve slightly overdone building up and it feels grumpier again.
How: reduce the load on the tendon to a level that allows it to start feeling better. This might might just reducing running volume, avoiding speedwork, reducing or stopping Achilles strength exercises etc, or it might be as extreme as reducing walking.
Other things that might help:
Ice
Anti-inflammatories
Heel raise in shoes (reduces the stretch stress on the Achilles)
Night splint
Calf massage
Gentle exercises that work the tendon a little bit.
Or more invasive or expensive treatments (which essentially calm the tendon):
Injections
Surgery
Shockwave therapy
All of the above are aimed at reducing pain and irritability of the tendon, giving you a base to then start building up the tendon’s capacity to take load again. If you jump straight back into normal activity after it has calmed you will probably just flare it straight back up again.
Building it up
When the tendon has calmed down, you then need to start challenging it to get it used to being worked and loaded again. This is partly to reduce the sensitivity in the tissue and partly to strengthen the tendon and calf. This can involve several elements:
Gradually build up the activities that you’ve had to stop or reduce (walking, running, cycling and other sports)
Gradually build up the strength of the calf and Achilles.
Gradually build up the Achilles’ ability to work as a spring (power exercises such as jumping and hopping.)
Each individual will find their tendon is different and the type and amount of building up will be individual. This is based on what it can already take, which areas it struggles most with, and what the end goal is (walking for an hour, park run, marathon etc).
Most Achilles rehab programmes are very prescriptive (e.g. 3*20 reps eccentric calf raises on a step). This might be just the right level for some people but for others the load might be too much or too little.
How do you know you’ve got the load “just right”?
Slight discomfort or awareness of the tendon working during the exercise
No build up of pain during the exercise
The exercise feels challenging but not too hard
No reaction or only a slight reaction after the exercise (same day or next morning), but this has settled after 24 hours.
Frequency of exercises depends on how sensitive the tendon is. If the tendon has no reaction to the exercises and the limiting factor is strength, then exercises should be as challenging as possible and done every 48 hours, which gives time for the tendon and muscle to recover fully between bouts. If tendon sensitivity is still a problem then each bout of exercises should be easier and maybe could be done more frequently to help lessen sensitivity at the same time as building some strength.
Again, everybody is individual and it’s about finding the programme that causes a net improvement, both in terms of reduced pain and improved function (strength).
A Note on Stretching
Many people believe that managing Achilles injuries is all about stretching - they’ve done too little, which caused the problem in the first place, or to solve it they need to stretch. Some people find stretching helps ‘calm down’ the tendon - if this is you then use it as a calming method. But it’s not a cure.
As one might guess, stretching can make the calf and Achilles have more stretch! But it won’t help the tendon become more robust and better able to manage load. It may sound counter-intuitive but stretching can also cause further tendon irritation by creating a compression load, i.e. squashing the sensitised tissue, especially where the tendon inserts into the heel. Depending on your tendon and injury, stretches may be best avoided completely while calming the tissue down and instead form another part of the build-up phase, done with caution to encourage greater range without aggravating the tendon again.
In conclusion, if you can take one thing from all the above it’s that every Achilles and every injury is different. There’s no one solution and programme that fits for everyone and while this can make this a difficult injury to treat, taking action and getting advice quickly is always a good idea. At the practice we’ve seen every kind of Achilles - the angry ones that nevertheless calm down quickly, the stubborn ones, the ones that change their mind from week to week - and we’ve helped many an athlete adapt and build their activities to accommodate an Achilles problem. If you find yourself struggling with stiff and sore heels, we’re ready to help you, too!