Last updated: 28-Nov-16
I know a weak spot is called an Achilles heel after the great Greek warrior Achilles was shot in his heel with a poisoned arrow by sneaky Paris, but it really could equally have come from the fact that so many runners find it to be their downfall. Karina Teahan (BSc, MMT, MISCP) Chartered Physiotherapist and elite runner sat down with us to answer all our questions about this pesky tendon.
Q. Can you tell me about your running experience and your physiotherapy qualifications, and where you live, work and run now?
A. I started running at a young age at the local parish sports in Sneem, Ireland, and joined a running club age 14. At that time I played lots of different sports; Gaelic Football, soccer, basketball, badminton – basically anything that involved running! I now run with a great club (for both social & running reasons) in Cork called St Finbarr’s AC.
I would suggest to any keen runner regardless of ability to join their local running club, as you get so much more from the running experience this way. I have always found running to be a great leveller in life and this is one of the aspects I really love about it, along with all those running endorphins. I have made lifelong friends though running and my husband Cian is also a runner – tall lean and fast so I always have someone to chase. We are currently in the middle of Cross Country season. I have run with others wherever I have lived: Ireland, UK, New Zealand and back to Ireland. (Editor’s Note: What Karina is too modest to say is that she is incredibly fast and wins many of the races she runs in. She was also crowned “Fastest woman in Salford” while working in Manchester.)
I graduated from University College Dublin in 2002. I did a Masters at the University of Western Australia (finishing in 2010). I have worked in Dublin, Manchester and New Zealand and am now based in a Primary Care Centre in Cork city. The majority of patients I see here present with a musculoskeletal issue.
Q. As a starter for ten – what is the Achilles?
A. The Achilles tendon (heel cord) is a large, tough, rope like band of fibrous tissue in the back of the ankle that connects the powerful calf muscles (gastrocnemius & soleus) to the heel bone (calcaneus). It is the largest tendon in the human body. As the calf muscles contract, the Achilles is tightened pulling the heel. This allows you to point your foot, jump, stand on tip toe and run forwards.
Q. Why does it cause problems for runners?
A. Despite its strength, the Achilles tendon is also vulnerable to injury due to its limited blood supply and the high loads (compressive & tensile) placed on it.
The tendon got its name from Greek Mythology. According to the story Thetis wanted to keep her son Achilles safe for all eternity and in an effort to do so dipped him into the River Styx. However to prevent him from being swept away she held him by his heel hence his heel was never submerged. He grew up to be a strong fierce warrior but in battle he was eventually killed as his enemy who knew of his vulnerable spot shot him with a poisoned arrow in his heel.
The Achilles can cause problems for runners due to the repetitive forces and stress we put on it through running. This can be anything from 3-8 times our body weight depending on the speed we are running.
Q. What are the most common problems for the Achilles?
A. Tendinopathy is a process which describes injury to the tendon that is a result of overload beyond the capacity of that tendon. Each athlete will be different in terms of what load (volume, frequency & intensity of training) their tendons can tolerate. Factors such as gender, age, percentage visceral fat, current physical activity, medication use, medical history, post menopause/hormonal influences and lifestyle will all influence our tendon health and their capacity to support certain loads.
Compressive or tensile overload of the Achilles Tendon can occur in three ways: rapid overload, repetitive overload or abusive overload (blunt trauma).
In the past the term Achilles “tendinitis” was used a lot to describe tendon injuries. This is actually a misnomer as there is no inflammation present. A better way to view Achilles tendon injuries/pathology is to categorise them into a continuum of three stages, these being:
- The Reactive Tendinopathy
- Tendon Dysrepair
- Degenerative Tendinopathy
Clinically reactive tendinopathy occurs from acute overload and the tendon will become swollen. This is the result of changes at a cellular level. In this proliferative response there is an increase in protein production, mainly proteoglycans which imbibe water to cause the swelling. The collagen remains intact and not torn. The cells become over active and can start to produce pain chemicals and the tendon becomes highly sensitised.
A reactive tendon will be tender to touch with your sock or the back of your shoe and even with gentle loading. The tendon will be painful locally, tendons generally do not refer pain so if your pain is very diffuse around the area, the Achilles may not be the source of your problem. Most injuries are mid portion of the tendon (insertional tendinopathies are for another article!). Brufen can help in this phase at a cellular level but not for its anti-inflammatory properties. Other generic anti-inflammatories may not work.
The next stage is tendon dysrepair. The tendon is attempting to heal itself but it does so in a disorganised fashion resulting in an altered (weaker) load capacity of the tendon. This stage isn’t quite as painful as the reactive stage. You may find it quite stiff and painful in the mornings for the first few steps. It will be sore as you start to run, ease as you warm up but may get sore again later after you stop and cool down, they may even take a few days to settle.
The final stage is degenerative tendinopathy which is a failed healing phase, the tendon is even more disorganised. The collagen fibres are of a weaker type and there is less overall collagen. The capacity of the tendon to repair itself is very poor hence it becomes very vulnerable to further strain/rupture. It won’t necessarily be painful but it will be a bit grumbly!
Q. What should you do for the above?
A. You need to identify what brought on your injury. It is usually a sudden increase in training intensity or volume or load of some sort. In the early reactive stage stop running to avoid making it worse. Ice, a heel raise, Brufen (once cleared by your GP due to its side effects) are useful.
However a tendon should never be fully unloaded or it cannot heal. It is the stimulus that drives the tendon forwards or backwards along the continuum so if you adequately load it in the early stage the tendon will revert to normal. If you overload it or ignore it you risk it developing into dysrepair.
Isometric exercises are very useful in the painful stage and help both reduce pain and allow some strength work to continue while you are off running. You can exercise your tendon through some discomfort / pain and a more accurate guideline to see how it is the following day (latent response), it should not feel worse.
In the past the focus was purely on an eccentric programme but now we realise that optimum treatment will involve both eccentric & concentric work as both are needed for proper functioning of the calf & ankle and ultimately enjoyable running.
Here are some guidelines to help you along the road to recovery of your Achilles tendon problem. I suggest you get your Chartered Physiotherapist to assess you first in order to stage it for you. It is very difficult to be objective about ourselves and sometimes we need someone else to tell us to stop running as we as runners never want to stop running!
Phase 1
Ice, isometrics, Brufen (as GP allows), small 3-5mm heel raises in your shoes (temporary), avoid wearing shoes/runners that catch the sore part of your tendon and irritate it further. Deep dry needling of your calf muscles.
Phase 2
- Exercises once/day.
- Double leg calf raise standing on floor 3 x 10-15.
- Single leg calf raise standing on floor 3 x 10-15.
- Seated calf raise 3 x 10-15.
- Eccentric calf raise standing on the floor 3 x 10 (up on 2 feet and down on one).
Phase 3
- Exercises once/day.
- Exercises 2 & 3 as above but on a step.
- Seated calf raise 3 x 15.
- Exercise 5 as above but on a step.
- Quick rebounding: double leg calf raise 3 x 20 (do quick calf raises as if you are jumping without toes leaving the floor. Go back up when the heel is 1cm from the floor).
Phase 4
- Exercise intensity can be increased by increasing the speed of loading or adding load using a back back/weights.
- Exercises once/day or if using weights 2-3 times/week.
- Single leg calf raise standing on edge of step with added weight 3 x 15.
- Eccentric calf raise with added weight ((up on 2 feet and down on one).
- Quick rebounding 20 x 3 sets, progress to single leg as able (do quick calf raises as if you are jumping without toes leaving the floor. Go back up when the heel is 1cm from the floor).
- Plyometric work – approach with caution and under guidance of your physiotherapist due to the very high loads this type of exercise puts on your Achilles. Examples include: skipping, hopping, bounding, jumping.
Phase 5
- Maintenance.
- Return to sport.
- Exercises 2-3 times/week: single leg calf raise with weight 3 x 15, eccentric calf raise with weight 3 x 15 and quick rebounding calf raise 3 x 20.
- Avoid making the same mistake that led you to get injured in the first place – keep a training diary and do not increase your training load by more than 10% per week.
The weights you chose above will be decided by your own strength and your experience with weights. Start low and build up. Get advice from your physiotherapist or a trainer at your local gym.
There is some evidence for shockwave therapy for a tendon injury that hasn’t responded to the conservative type treatment above.
Q. What precautions should we take to avoid problems in the Achilles?
A. Remember (all) tendons hate a sudden change in load. So in spite of wanting to up our training suddenly due to return from injury or an upcoming race, we cannot trick our tendons. They need time to adapt to increasing load so abide by the 10% rule. Only increase your training load (frequency or volume or intensity but not all three) by 10% per week.
Do not dive straight into a plyometric (skipping, hopping, bounding, jumping) programme if you do not already have a good underlying strength base. Remember to incorporate strength training into your weekly training plan (for legs, arms & core). Even 10 minutes three times/week. As runners we tend to swap strength sessions for that extra run but strength training will make you faster, run with better form and help keep those injuries at bay. Develop a mini circuit for yourself that you get in the habit of doing three mornings a week or at a time that suits you. Invest in a set of dumbbells –they will last you forever! You can also use body resistance.
Keep your calf muscles flexible and maintain good range in your ankle joints. Pilates & yoga classes can offer really good dynamic stretches & joint mobility exercises for these areas.
Change your runners when they start to lose their support and bounce! Guidelines suggest that running shoes should last 300-500 miles but this is also dependent on factors such as the type of running shoe, your running style & bodyweight. Buy the correct runners for your foot type.
There is no evidence to suggest that people who over pronate are more likely to get an Achilles tendon injury. A high arch (excessively supinated foot) may be more vulnerable to this injury so get the runner to suit your foot type. Avoid training in your flats/racers, save them for race day or the odd occasion to get used to the feel of them. I only wear my spikes & flats the day of my race. Try varying the training surface you run on. Those who do a lot of speed work, uphill running or a forefoot striking running style may be slightly more predisposed to this injury. Respect the warning signs of your tendon starts to become sore. Take your rest days, cross train (swim/cycle) be patient and diligent with your rehab programme.
Q. What are your top three Achilles stretches?
A. As a physiotherapist I get slightly nervous when people suggest stretching their painful tendons, in fact I possibly wince! I suggest you keep your calf muscles stretched as a runner and your ankle joints flexible but do not stretch an injured tendon or you will make it worse. Use the STICK or foam roller or knobbly ball to loosen out those tight runner’s calf muscles. Deep Dry Needling is a great way to manage tight calf muscles. I tape two tennis balls together with sports tape and find it a very effective way to loosen out my calf muscles (in a supine plank position) yet not put excessive load on the Achilles tendon.
I recently heard that Green Tea has protective elements for tendons and help in their healing but I think you would need to drink quite a lot to get this benefit. However it might be no harm to add to your daily fluid intake!
Factors that can put you at higher risk of developing a tendinopathy (unrelated to running) include:
- Smoking
- Diabetes
- Obesity/increased visceral fat
- Certain antibiotics (fluoroquinolones) have been linked to tendon rupture in some patients
- Corticosteroid injections – again caution to having your Achilles injected as it is a major load bearing tendon and you risk rupture.
So my top tips involve lots of useful bits……but no stretching of your sore tendon!!
Thanks Karina for this comprehensive guide and those ideas for exercises. Off to do an eccentric calf raise right now!
