So, tendons are pretty tough and they connect muscle to bone. They can handle being pulled apart (tensile loads) like a champ, but they also get squished against bones at times (compressive forces). Ideally, they should be able to handle both types of stress, but things can go wrong when they're constantly pulled and squished over and over again and they aren’t ready to handle the demand.

What is the Achilles Tendon?

The Achilles tendon connects the calf muscles to the heel bone. It is the largest and strongest tendon in the body, and has to tolerate forces up to 7 times the body weight during running!

The Achilles tendon is a key player during the “push-off” phase of running. Let’s think about the Achilles tendon like a pogo stick:

• Foot hits the ground —> Achilles tendon stretches/stores energy

• Achilles tendon recoils/releases energy —> forward propulsion

PT TIP: The energy created by the Achilles tendon is FREE! We want to capitalize on this and make our Achilles tendons STIFFER by making our calf muscles STRONGER! Cue in heel raises!

Given the important role that the Achilles tendon plays in running, it’s no surprise that runners tend to run into some issues with it, usually resulting in what is called a "tendinopathy.” Tendinopathy is an umbrella term used to refer to pain and dysfunction in the tendon regardless of pathology.

Types of Achilles Tendinopathy—based on location of symptoms

• Mid-Portion: 2-6cm above tendon insertion on the heel (most common type)

• Insertional: where the tendon attaches to the heel

Common Causes/Risk Factors

External: Increased hill running, speed work, footwear, running mechanics, alcohol consumption, Ofloxacin (a quinolone antibiotic for bacterial infections)

Internal: Ankle range of motion, decreased calf strength, age

Signs & Symptoms

• Morning stiffness with initial steps

• Tends to “warm-up” with activity

• Minimal pain at rest

• Swelling and thickness

• Pain with squeezing the tendon (mid- portion) or applying pressure to the heel bone (insertional)

• Pain with progressive loading (example: progressing from a heel raise to single leg hopping)

Typical Presentation in a Runner

Achilles tendinopathy tends to start off as a dull stiffness in the tendon with initial steps, that gradually goes away as the tendon “warms up” with activity. If you continue to train on it, the pain may become sharper and you will feel it more often. It can even creep into your daily life, affecting your ability to do daily tasks such as, stairs!

Why “traditional”recommendations DON’T work?

A quick search of the internet for “Achilles tendinopathy” treatment will provide you with the following recommendations:

• Rest—”If you don’t use it, you lose it.” Tendons lose strength within 2 weeks.

• Calf stretching/Massage—further squishes the tendon against heel bone, which irritates the tendon

• NSAIDs—can impair tendon healing

• Ice—tendons have poor blood flow, as such, ice will further decrease blood flow to the area

How can I get started treating my Achilles tendon pain?

• Avoid positions of compression by wearing a heel lift or wearing running shoes with a higher heel-to-toe drop

  Positions of compression—any position that further presses “compresses” the tendon into the bone. Think “calf stretches, keeping feet in a dorsiflexed position”

• Temporarily remove or reduce energy storage & release activities (i.e. running, skipping, hopping)

• Apply heat for pain relieve 15-20 minutes several times throughout the day

• Exercise should be the main treatment approach for at least 3 months before considering other treatment approaches

In the next blog, we will be discussing how to get started on an exercise program aimed at gradually loading the Achilles tendon in preparation for return to run!

Thank you for taking the time to read! If this sounds like something that you might be dealing with and you’d like to learn more about how to rehab an Achilles tendinopathy and come back a stronger, more resilient runner schedule a complimentary call today!

References

Chan KM, Fu SC. Anti-inflammatory management for tendon injuries - friends or foes? Sports Med Arthrosc Rehabil Ther Technol. 2009 Oct 13;1(1):23. doi: 10.1186/1758-2555-1-23. PMID: 19825161; PMCID: PMC2770552.

Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol. 2007 Apr;21(2):295-316. doi: 10.1016/j.berh.2006.12.003. PMID: 17512484.

Rio E, Moseley L, Purdam C, et al. The pain of tendinopathy: physiological or pathophysiological? Sports Med. 2014;44:9-23.

Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994 Sep;18(3):173-201. doi: 10.2165/00007256-199418030-00004. PMID: 7809555.

Schepsis AA , Jones H , Haas AL . Achilles tendon disorders in athletes. Am J Sports Med 2002 ; 30 : 287-305