Irish international runner and physiotherapist Matt Bergin talks about identifying an Achilles injury and offers advice to help you successfully return to running.
If you’re reading this, there’s a good chance you’ve had a run-in with the dreaded Achilles tendon pain, and you’re wondering ‘is it finally time to have a few days rest’.
You wake up every morning tentative to take those first few steps out of bed. You know the pain and stiffness is ready to greet you. The first 10 minutes of your run is a hobble until finally, it eases out and you feel you can run normally. Then you wake up the next morning, and it all begins again…
The Achilles tendon is the strongest tendon in the body, but one of the most problematic for runners and also one of the most difficult to treat.
Its role is to absorb shock and, through elastic recoil, allow us to push off through our toes. During this movement, the Achilles is subjected to around three to four times our body weight. It’s hardly surprising it’s such a common injury!
Our bodies are constantly building and breaking down tissue. This balancing act is guided by the stresses and loads we place on them. This constant dynamism is what allows our tissues to adapt to the demands placed upon them.
Unlike with muscle the Achilles tendon has very little blood flow of its own, so relies on the supply that exists in the sheath surrounding the tendon.
If we place too much load through a tendon, without adequate recovery tissue breakdown begins to exceed production and we are left with a painful Achilles tendon. The addition of poor biomechanics further overloading the area can exacerbate this even further.
Treating an Achilles injury
In order to effectively treat an Achilles issue, you must look at two aspects.
1) The tendon itself. It needs time to heal. If the problem has become chronic (six weeks plus) it needs to be prompted to heal through a number of techniques.
2) The underpinning cause(s) of the injury. Typically a combination of poor biomechanics, strength deficits, and reduced flexibility. These must all be addressed in patient and activity specific ways. One must allow the tendon to adapt to the demands that will be asked of it.
1) The onset of pain is rarely sudden, but a stiffness that builds. This can be especially in the mornings and at the beginning of a run.
2) If the stiffness eases throughout the morning (less than 10 minutes) and eases as you get into training, then it can be trained on at a level that does not make things worse.
3) If the pain is sharp there is likely to be significant tissue damage and running will cause more problems. Please stop.
4) If the tightness and stiffness does not lessen when running and gets worse throughout the day, you are asking too much of an already damaged tendon. You need to reduce the frequency, duration and intensity of your training.
Some patients complain that their Achilles swells or seems constantly swollen. If the Achilles blows up with swelling after a run please reduce the amount you are doing. You are continuing to damage an already damaged tendon.
If it appears swollen, but it is a thick, solid type swelling that does not fluctuate then this is more likely the result of scar tissue and thickening of the tendon sheath. If the pain is not worsening you can still run on it.
Where does it hurt?
The exact location of your Achilles pain will help guide you to the type of rehabilitation exercises you should undertake. Tendons are inherently tender to poke, so compare with the other leg to see if you have found the right part, there may be an area of lumpiness or it may feel like it’s creaking.
This is felt a few inches above the heel, often more to the inside of the tendon. If it is only a few days old and particularly tender, please rest and ice until symptoms have eased.
If the issue is a few weeks old begin loading the tendon through eccentric heel raises. This is where you rise up on two feet on the edge of a step and lower fully down on the affected leg in a controlled manner. Three sets of 15 reps, two times daily then building up to around 20kg as able.
This is felt within an inch of the heel bone. When the foot is pulled up the heel bone is pushed into the Achilles. Do NOT pursue eccentric exercises with the heel below the toes as this will potentially irritate things further.
If a few weeks old you may do the eccentric lowers but on the flat.
The retrocalcaneal bursa, which is a fluid-filled sack, sits between the Achilles insertion (as above) and the heel bone, and is there to reduce friction. However, it can often become irritated in someone with an insertional Achilles issue.
– With the bursa, the pain will be felt more to the sides of the heel.
– If you suspect a bursa, stick with ice and rest to start with as often any heel raises will irritate it.
This is an extra bit of bone that sits on the outer edge of your heel bone. They can be in response to loading or just genetics.
Some people can have no Achilles problems even with a Haglund’s deformity, however, having one predisposes you to Achilles issues as the bone compresses into the tendon more than a ‘normal’ heel would. For these please seek advice and do not continue exercising while in pain.
What can I do about it?
The history of your Achilles issue will help determine what type of rehabilitation exercises and treatments you should undertake. Is it an acute problem that has developed in the last few days? Or are you suffering from an Achilles that has been giving you issues for weeks, if not months now?
In an acute Achilles issue, the first step is to address the pain.
Running through this might not be the answer. You are obviously operating at a level which the Achilles simply cannot cope with. Tissue breakdown is exceeding tissue generation.
We must reduce the loads being placed through the tendon. This is done by reducing the volume/intensity of runs, avoiding hills, harsher running surfaces, and anything else that aggravated your Achilles which may be specific to you. If you do this early, your tendon may settle in as little as one week.
A general guide in helping to decide whether you need to stop entirely is your level of pain the following day(s) after running. Tendons often ease throughout the course of a run so may feel quite good during your run, however, the following morning, or even up to 48 hours after, is a more realistic time to judge things.
Other treatments to help an acute Achilles issue
– Anti-inflammatory medication – ibuprofen is often recommended for acute tendon issues. Please consult your GP or pharmacist first.
– Ice – 10-15 minutes several times throughout the day.
– Foam rolling – avoiding the tendon itself, massaging or rolling the calf muscle can help to reduce strain on the Achilles.
– Isometric calf raises (should be pain-free).
In standing slowly push up onto your toes on both feet, use support if required. Hold this position for 5-10 seconds, and then slowly lower again. Work up to 10 reps. If you have no problems and find this easy progress to rising up on two feet, transfer the weight onto one leg and then hold. Then slowly lower on two.
Weeks or months of pain
If you have been struggling with your Achilles for a few weeks now, or you’ve had issues for a few months with intermittent flare-ups the approach will be slightly different.
You may find that your Achilles is visibly thicker than the other one or there may be palpable ‘nodules’ and areas of thickening within the tendon. These changes will often not resolve but it does not mean the tendon cannot function well.
As with an acute tendon issue, the load being placed through the Achilles must first be addressed.
If you continue to run on an already weakened tendon it may soon lead to severe degeneration or worst case, tendon rupture. Again be guided by the pain and symptoms (stiffness/creaking etc.) you are experiencing the following morning.
Specific to the Achilles tendon, we can enhance the tissues ability to handle load through an eccentric loading program, which have been shown to produce great results.
Over the edge of a step (mid-tendon) rise up on two feet and slowly lower down on one, coming past the level of the step.
You should aim to initially complete 3 sets of 15 reps, two to three times daily. Work up to 25 reps and building in weight (up to 25kg) using either a Smith Machine in the gym or by popping on a backpack and filling with household objects.
The Achilles needs to be elastic and not stiff, as often happens in a damaged tendon. So mobilization of the whole tendon is essential. All it takes is two minutes several times a day.
As discussed above the Achilles tendon is surrounded by a sheath. This can become stuck down to the tendon, even after the tendon has repaired, and this is often the ‘creaking’ feeling you may experience in the mornings.
Freeing this up can be very beneficial, but can be a little painful during. Pinch the sides of the tendon, and move the foot up and down. This slides the tendon within the sheath and helps loosen these adhesions. Two minutes, a couple times a day.
These exercises will take around two to three weeks to have an initial effect and then a further two to three weeks to get really good. So stick with it!
About the expert
Matt Bergin is an international middle-distance runner for Ireland and physiotherapist at leading UK practice Witty, Pask and Buckingham, specialising in running injuries. You can find out more at www.wpbphysio.co.uk
In his next article, Bergin will take a closer look at the causes of an Achilles injury.