By James Gucciardi
Myth has it that the mother of Achilles dipped the infant in the River Styx, which supposedly offered powers of invulnerability. Holding him by his heel his whole body was submerged in the magical water making him invincible. That is, his whole body except for his heel where his mother held him.
Achilles tendinitis is one of the most frequent injuries suffered by runners. If you run long enough, there is a good chance you’ll suffer from Achilles pain at some point. There can be many reasons for this, but one clearly stands out the most among the rest and that is over-use. Let’s take a look into greater detail of the anatomy of the Achilles, how it breaks down, and what you can do to have more resilient ankles.
Understanding How Stress & Adaptation Works
Running, or any type of exercise, stresses tissues. Your body will adapt to the demands placed on it as long as the applied stress isn’t greater than your body’s ability to adapt. So a gradual and progressive training stimulus (work) combined with adequate recovery (rest) elicits increased strength in tissue and muscle hypertrophy (bigger muscles). However, too much stress performed too soon with too little recovery causes a breakdown in tissue, and if it persists long enough you’re headed towards injury. A weak training stimulus produces next to nothing is terms of adaptation. This is the person that exercises but never really gets much stronger, faster, flexible, etc. Your porridge can’t be too hot or too cold if you want to make progress. It has to be just right!
Tendinitis vs. Tendinosis
This is semantics here, but it’s important to note so bear with me. Tendinitis has the connotation that the Achilles tendon is inflamed. However, this isn’t what actually happens to tendons. What does happen is the cumulative stress of running causes the collagen fibers that make up the tendon to break down faster than your body can repair them. So instead of laying down the specific collagen that makes the Achilles so strong in the first place, your body is forced to use weaker collagen to repair the tendon. Kind of like hiring a bad carpenter that uses inferior materials. Consequently, the Achilles tendon’s structure begins to change for the worse.
Now, your brain receives constant updates about everything going on inside your body through your nervous system. At some point, the brain may interpret these structural changes to the Achilles as dangerous and you’ll feel pain. That’s your body’s way of telling you that something is wrong and you should address it. So these pathological structural changes occurring to the tendon make tendinopathy or tendinosis a more appropriate term than tendinitis.
Anatomy of the Achilles Tendon
The Achilles is the thickest and strongest tendon in the human body. It is the common tendon of the gastrocnemius and soleus muscles. The gastrocnemius is the more superficial calf muscle and is easily seen contracting when you stand on your toes. It has a medial and lateral head and attaches above the knee joint. To stretch it your knee must remain straight. The soleus is the deeper muscle and does not cross the knee, therefore, to stretch it effectively you should bend the knee to take tension off gastrocnemius and isolate soleus. These two muscles act to plantar flex the foot, like when you point your foot down, stand on your tippy toes, or propel you when you jump, among other things.
When we run, there are periods of time when one foot is in contact with the ground, and there are moments when neither foot is touching the ground. The foot is in contact with the ground for one tenth to five tenths of a second while the runner is landing with 2 ½ to 3 times their body weight with each stride.¹ The Achilles acts like a spring storing that force as elastic energy and releases it at toe off. This is extremely efficient since your calf muscles don’t have to work nearly as hard.
In fact, research has found that your calf muscles perform significantly less work than is commonly thought during the propulsive portion of running. Normally, you shouldn’t be pushing off with the back foot. Excessive push-off could lead to running injuries affecting the foot & ankle. What should happen is your calf muscles contract isometrically during late midstance, which forces your Achilles tendon to stretch and return energy.²
The Achilles tendon has a poor blood supply. That’s an important detail to be aware of because blood is needed to transport the cells that repair and remodel tissue damage. So minor Achilles injuries can become major problems if you ignore them and continue to run through pain.
Contributing Factors Leading to Achilles Tendinosis
- Running too much, too soon, without adequate rest between runs. I’ve seen this a lot with new runners.
- Sudden increases in training intensity like a big jump in mileage or pace.
- Changing your running gait and not adjusting your mileage to allow enough time to adapt.
- Drastic changes to footwear, especially switching to a shoe with a significantly lower heel-toe drop, and not allowing your body time to acclimate.
- Excessive hill running. It pains me to say this to the Selden Hills Warriors, but it’s true. While hill work is an important way to improve your running, you’re at a greater risk of developing an Achilles injury if you’re not ready for the workload.
Signs Your Achilles is Breaking Down
The most frequent cause of Achilles tendinosis is running through pain. When the check-engine light comes on— you can ignore it and hope your car doesn’t break down. But, that’s usually how minor issues become major problems. When your body talks to you, it’s wise to pay attention. So here are some hallmarks of Achilles tendon injuries:
- Initially, the first symptom might be stiffness in the Achilles or sides of your heel. It’s often worse in the morning when you take those first few steps.
- Pain when you gently squeeze the tendon.
- A creaking or cracking sensation when you move your ankle or press on the Achilles.
- Sometimes a lump will form on the sides of the Achilles. This is evident in someone who ignored the check engine light.
Too Late | It Hurts | Now What?
So now that you have a basic understanding of how tendons break-down, you can appreciate that when you feel pain, it is essentially too late. Pathological changes are likely occurring in the Achilles tendon at the cellular level. The first thing you can do to nip it in the bud is cut back on training with less mileage and/or more rest. However, cutting back on training doesn’t necessarily have to mean complete rest, which rarely works when dealing with tendon injuries. Tendons seem to heal better when gently loaded. Research has shown benefit with performing Alfredson’s eccentric exercise,³ which is basically the lowering phase of a calf raise. Hakan Alfredson is a Swedish orthopedic surgeon. The original protocol called for performing 3 sets of 15 reps with the knee straight and 3 sets with the knee bent twice a day on the affected leg. That’s a total of 180 repetitions daily! If that’s too strenuous or painful then just do as many as you can tolerate. That’s how I teach people to do them and the results are generally positive. You should do the exercise daily for 12 weeks. Here’s how you do them:
Additionally, gently mobilize the Achilles on a daily basis. This doesn’t mean crank the hell out of an already injured tendon. Instead, try self-massage and gentle calf stretches throughout the day. If you are particularly tight, the best thing to do is enlist the aid of a healthcare professional who is experienced in soft-tissue & joint work. They can often accelerate your progress by targeting muscles that are difficult for you to work on by yourself.
Cortisone is a great anti-inflammatory, however, it’s known to weaken tendons. Repeated cortisone injections make the Achilles more prone to rupturing. It’s not an inflammatory condition to begin with so I don’t think this should be your first option. However, other structures like bursa are often inflamed, so a cortisone injection may help reduce symptoms.
Preventing Achilles Injuries
Preventing athletic injuries is damn near impossible. If you play, you pay for it eventually. But that shouldn’t scare you away from pushing yourself. It’s the only way to progress.
The most obvious risk factor for Achilles injuries is running too much too soon so first things first— be consistent with your training and gradually buildup mileage and pace. Rome wasn’t built in a day and your great athlete has spent years of methodical training to get to where they’re at. If you’re going to start running hills or start running period, give yourself adequate recovery. There are too many variables on how much recovery is necessary. No two peoples’ make-up and lifestyle are alike. Nonetheless, here are some general rules to help recovery and try to prevent injury:
- Make sure you warm-up adequately before you run.
- If your calves are tight, and most peoples’ surely are, perform self-massage with a stick, foam roll, lacrosse ball, or see an Active Release Technique® Provider (ahem).
- Follow up self-massage with some static and dynamic stretching. Static stretching is ideally done on off days or after your run. If you want to know the details why then read this.
- Wearing a shoe with a higher heel-toe drop for a period of time will reduce some strain on your Achilles and sometimes helps alleviate symptoms. Also, make sure the heel counter of your shoe isn’t rubbing against the Achilles.
- Start cross-training if you aren’t already. Ideally, it should include a combination of strength training and stability work customized to your needs.
- Consider having your running gait analyzed by a professional or running coach.
Your body will adapt to the stress placed on it as long as the stress isn’t greater than your body’s ability to adapt; in which case you will likely develop an over-use injury
Running is great exercise and while we can’t predict injury with great accuracy, being proactive is your best option at staying healthy. Having a basic understanding of how Achilles injuries occur in the first place and taking your time to build a strong resilient body will make your running efficient and fun. It’s also prudent to think you’ll reduce your risk of injury too. So enjoy the process and don’t fall into the trap of beating the hell out of your tendons and joints. Think about the long haul.
¹ Paul Langer, DPM. Dartfish Video Gait Analysis Guide.
² Thomas Michaud, DC. Dynamic Chiropractic – February 26, 2012, Vol. 30, Issue 05
³ Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sp Med 1998;26(3):360-6.
Dr. James Gucciardi is a Chiropractic Sports Practitioner and co-owner of Champion Performance Chiropractic Rehab in East Setauket, New York. With a background in exercise physiology and movement science, he has a keen, first-hand sense of how your body works and understands the paths to pain-free function, flexibility, and strength. You can send him a message here with any questions.