Achilles Tendinopathy


Do you notice pain in your heel and the lowest part of your ankle when you get out of bed in the morning?

Does this wear off during the day, only to return with a vengeance the next morning? You may have something called Achilles Tendinopathy.


So why do people get Achilles tendon problems?

A tendinopathy occurs when a tendon is unable to adapt to the strain placed upon it. As we age the tissues in our body become less resilient and more prone to react to overuse. It is very unusual for me to see a 6 year old with an Achilles tendon issue, but quite common to see it in someone over 40.


Achilles tendinopathy is a particularly common issue for older runners. Increasing your running distance, running at a faster pace or adding extra hill work are all changes that can bring on Achilles tendinopathy - I am not saying that you can't run further, faster or over trickier terrain, but you have to build up to it very slowly if you have older legs!


What Kind Of Training Can Bring On Achilles Tendinopathy?

A rapid increase in exercise intensity is a common factor in a lot of running related injuries. This is because many people are tempted to progress our running or walking too fast; older tendons, muscles and bones are unable to accommodate such rapid increases in demand.


Too often we will be tempted to increase our exercise intensity according to our cardiovascular capacity, but this does not take into account how long it takes to make structural changes to tendon tissue and tendon attachments. Tendons and ligaments have limited blood flow, and it takes time to generate any increase in tissue capacity.


Bear in mind that an injury from running normally starts 3 to 6 weeks following a training error, so if you suddenly increased your running distance or speed you probably won’t notice any problems for a few weeks.


What Should You Do If You Notice Achilles Tendinopathy Symptoms

As with most tendon problems, if you notice any signs of Achilles tendinopathy, you need to reduce the intensity of the exercise - run at a slightly slower pace, reduce the length of the runs and try to avoid running up hill if possible while you still have any pain. Continue with this lighter exercise load until you get to a point where any symptoms after a run are settled by the following day.


Some Interesting Science Bits There are three muscles in the calf:

  • Gastrocnemius

  • Plantaris

  • Soleus


These three muscles come together to form the triceps surae, which is what we call the Achilles tendon. Through the action of running, at certain points of the stride the Achilles tendon is subjected to are forces that amount to 8 to 10 times our body weight - these forces are only applied for a short period of time when we are in mid-stance phase, but this level of impact is more than any other group of muscles in the body take at any time - considerably more than the force applied to the glutes or quadriceps.


The Achilles tendon is an energy storage unit, it is like a strong, stiff spring. The problem is that as we age the spring is not quite so stiff, another 'feature' of the more mature body is that we also loose a lot of our strength in our calf muscles.


The Achilles tendon likes load - but it likes just the right level of load

- too little load over time means that the tendon becomes, dysregulated and less adaptable which means that when the demand on it increases, it is easily pushed beyond it's capacity.

- too much load will mean that the tendon will not have a chance to repair and to strengthen, while additional damage is still being incurred so healing will not happen.

But…….. to get a tendon better we need to start loading the tendon. Back in the 1990s Alfredson proposed using eccentric loading exercises for Achilles tendon rehabilitation which proved very successful, however it was an incredibly time intensive approach requiring 5 hours a week of eccentric loading exercises. For a long time, this has been the gold standard advice for Achilles tendonitis rehabilitation.


5 Hours A WEEK!? Is There Another Way?

It looks like there is! New evidence has emerged to suggest 'Heavy Slow' resistance training may be just as beneficial and saves an awful lot of time! 'Heavy Slow' resistance training is a progressive loading regime; initially the exercises are done standing using just your own body weight, and sitting using additional external weights.


The starting point for this kind of exercise approach depends on how sore your Achilles tendon is to start with. Initially this could be isometric exercises such as this one:


stand on the edge of a step, with the ball of your foot on the step and your heel off the step.

lower your heel so it is slightly below the step, hold for 45 seconds. You are not stretching the calf you are trying to hold the weight.

DO NOT BOUNCE!


to progress this exercise, stand with the ball of your foot on a step, raise your heel up above the height of the ball of your foot, and then lower your heel down below the height of the ball of your foot.

Aim to build up to a slow, heavy load - 3 seconds up, 3 seconds down.

If this is too much strain, you can reduce the intensity of this exercise by using both legs for a while before switching to working on a single leg.


Initially do this exercise using just your own body weight but then start to increase the weight you are lifting. With no additional weight, aim for 3 sets of 15 rise/fall movements, as you increase the weight you may find yourself can only manage 6 or 7 reps, with the last of each set being a real struggle.


NB - there is conflicting evidence about whether isometrics are beneficial for Achilles tendon issues, and it appears they are more helpful for some people than for others (isometric exercises appear to work more widely for people with patella tendon issues). If they do not appear to be helping, you will need to change your approach.


'Do I Need To Stop Running?' As long as you reduce the load that your tendon is under while running, you can still continue to run. You will be using your exercises to build up the strength in the tendon, but if you run within your existing tendon ability you should be fine to keep running. I would positively encourage you to keep running, fear of injury has a serious and long term impact on health and fitness - if you reduce the length, speed and intensity of your runs while you work on strengthening your Achilles tendon, you will do no harm and it will improve your confidence in your ability to run.


Prevention is Better than Cure

It is always better to combine strength training exercises alongside your running routine to ensure that the resilience of your Achilles tendon is one step ahead of your running intensity. Improving the strength and resilience of your Achilles tendon takes time, and for the older runner, running alone is not always going to have enough of an impact. Doing the strengthening exercise will give you more capacity in your Achilles tendon, and it is always better to have a bit of extra capacity in the tank. Judging from the feedback of many of the runners that I look after, a stronger, more resilient Achilles tendon reduces their rate of injury and seems to generally improve their running.



I work with runners from all over Essex, but I am also able to advise and support runners from further afield through phone consultations, video analysis and Zoom. If you would like some advice or support to help you to start running safely, keep running safely, or return to running after an injury, please get in touch.


Kind regards

Nick

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