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Apr 2020
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Achilles Tendonitis

What increases the risks or tendinitis, tendinopathy or rupture? How can we treat and prevent?

Achilles Tendonitis

Foot Care, Health , , , , , , solefit

THE LEGEND OF ACHILLES

According to Greek legend, the unstoppable greek warrior Achilles was shot with an arrow in his left heel during battle.  This just so happened to be the one vulnerable part of his body not dipped into the River Styx, which led to his demise.  His injury, located where the primary tendon of our principal calf muscle attaches to the heel bone (calcaneus), was excruciating enough that the legendary warrior fell and couldn’t fight off his adversaries.  While modern day achilles injuries are common, they fortunately have quite different outcomes!  So far, we have yet to treat a client with an achilles problem from being shot with an arrow, but hey, you never know!

Although our demise is likely not going to be caused by an arrow to the heel like the poor Greek warrior Achilles, achilles tendon issues can put a real limitation on your activity levels. 

A tendon is a thick matrix of strong fibrous tissue that connects a muscle to a bone.  As the muscle contracts (shortens or lengthens,) the tendon acts as a cord that manages the forces of contraction within a movement to stay connected to the bone.  Heavy stress on a tendon can cause damage to the tissue, no matter how strong.  Tendons are protected by strong and functional muscles and proper mechanics.  This means that our muscles must be both strong and mobile, and require good range of motion, functionality and stability.  Limited calf function causes tightness in the muscles which effectively ‘shortens’ the length of the calf/tendon putting added tension against it.  Tendons are also nourished by muscles via blood flow and circulation of fluids.  Unfortunately, this is a major flaw of the achilles tendon: it has low vascularity from blood vessels, which means it is dependent on the muscle pump of the calf to nourish it.  For optimal function, the achilles must be supple in order to work well, along with the calf muscles and rest of the lower extremity.

A tendon is a thick matrix of strong fibrous tissue that connects a muscle to a bone.

The achilles tendon attaches the calf muscles of your lower legs to the base of your heel bone (calcaneous).  Often the weak link along the chain of muscle, tendon, and bone is where the tendon attaches to the bone.  Thus many achilles tendonitis sufferers feel pain at the base of the heel even though the source of the problem may be coming from up above.  Like most tendon issues, the key is catching things early.

The pain associated with achilles tendinitis often begins as a mild ache in the back of the lower leg or above the heel after activity.  Episodes of severe pain can occur after prolonged strain or explosive movement such as during distance running, stair climbing or sprinting.  Overuse repetitive strain injury is common, as with walking and easy jogging.  Typical symptoms also include tenderness or stiffness in the morning, which usually improves with mild movement/activity.

Comparatively, achilles tendinopathy is degeneration of the tendon from acute or repeated injury.  Many small injuries can occur over time, which breaks down the tissue integrity and strength, ultimately causing degraded function or tendon failure in severe cases.  Many attributes can cause long term issues: poor foot posture, improper footwear stability (or too much!), and compromised circulation are major factors in chronic tendinopathy.

An achilles tendon rupture is a sudden acute tear of the tendon itself.  This happens mostly to people between the ages of 30 and 50, and is most commonly caused by intense sports activity such as tennis.  This catastrophic injury typically requires immediate surgical care, and can potentially cause long term tendon dysfunction.

What increases the risks or tendinitis, tendinopathy or rupture? How can we treat and prevent?

COMMON CAUSES OF ACHILLES TENDINOPATHY

A sudden increase in activity (too much, too soon).

Sports that have quick starts and stops, which can cause inadequate exposure to high levels of demand or intensity.

Poor fitting shoes/inappropriate footwear (poor shapes, poor features, worn out shoes).

Running or exercising on uneven ground or uphill running (when not accustomed to it).

Highly stiff specialty footwear like cleats, ski boots.

Tight calf muscles, excess tension in the hips, legs and feet.

Bone spurs (extra bone growth in the heel that rubs the tendon and causes pain).

Weakness or instability associated with various foot types, as well as weak calf muscles.

Insufficient warm up before exercising.

Limited stretching and lack of activity which can cause stiffness of the calves and achilles tendon.

Long periods of time in the same kind of footwear, especially very stiff shoes and those with elevated heels or high heels.

Prior injuries in the foot or ankle.

Dehydration, or excess inflammation in the body (high stress, poor nutrition).

WAYS TO TREAT AND PREVENT ACHILLES TENDINOPATHY

We should always treat problems on a continuum: from the onset of pain and injury, through comfortable movement and rehab, to strengthening to optimal function.  We present this continuum regularly to our clients to help them see it’s a process and we don’t want to stop at short term pain relief, but want to go after the root causes and long term objective.

TREATMENT CONTINUUM

  • 1

    (A) Protect Damage

  • 2

    (B) Restore Function

  • 3

    (C) Adapt Strength

SHORT TERM MEASURES

Mobilize!  Warm up tissues before getting up in the morning/after sitting long periods or pre/post exercise.  Mobilization via self massage, gentle joint circles, and heat can all help prepare the tissues to load with less strain and pain. (A,B)

Avoid barefoot.  Step directly into footwear with elevation in the heel while pain is still acute and noticeable in order to protect the length of the tendon.  Avoid barefoot during the painful phase of achilles tendinitis.  (A)

Lift and support.  Short term use of bilateral therapeutic lifts in shoes.  Couple this with additional support around the foot via custom foot orthotics or structured shoes as needed. (A)

Light therapy (photobiomodulation).  Infra-red light  helps to decrease inflammation and promote a cellular healing response via collagen production. (B/C)

Provide adjunct therapy.  Kinesio-taping, acupuncture or dry-needling, massage therapy, physiotherapy, modalities such as ultrasound, TENS devices or other professional treatment can all help with pain relief and healing depending on the individual. (B/C)

Treat the source.  Work on releasing tension from the calves, increasing tissue circulation and removing waste products around the injury.  Help improve the quality of movement through manual therapy, mobility tools, self massage and stretching often. (B)

Use therapeutic tools as needed.  Night splints, Strassburg sock, short term heel lifts and taping can all be complementary to increasing positive Achilles function. (B)

Reduce load and intensity, but keep moving.  Based on current research, total rest appears to be detrimental for Achilles Achilles issues.  Reducing load amounts and/or volume of activity is beneficial.  Try to keep moving and working the area but not over-stressing the tissue. (B/C)

LONG TERM MEASURES AND OBJECTIVES

Adapt foot and ankle range of motion.  Gradually adapt the length of the tendon back to full capacity by using lower heeled, or completely flat heeled shoes.

Work on overall mobility.  Many gait issues arise from poor patterns of movement between the hip and ankle.  Consider daily mobility work as essential, especially if you sit often.

Adaptive strength protocols.  Various scales of demand via eccentric exercises and resistance training can gradually load the tendon and increase its strength over time.

Increase barefoot strength.  Gradually decrease need and dependency on support around the ankle and feet via barefoot strength exercises as it becomes possible.  Check out our short video on improving foot health here.

Hydrate!  Most people are guilty of not drinking enough water.  Aim for best quality, filtered water ideally, with intake of ½ your bodyweight in ounces per day.  More may be needed when engaging in intense intense activity.

Lower inflammation.  Any words that end with ‘itis’ means ‘inflammation of’.  Lowering inflammation is supported by lowered blood sugars, less pro-inflammatory foods (such as sugar and processed oils/foods).  Choose foods that have an anti-inflammatory effect.

Provide building blocks.  Tendon and most connective tissue consist of collagen fibres.  Provide bioavailable sources of collagen to encourage healing effects.

Achilles problems can really set us back, but the good news is that there are many things that you can do to facilitate a quicker return to activity.  Making good choices based on mobilization, lowering intensity but still moving, and frequent exercises to help rebuild can all make a big difference.  That being said, because blood flow is limited to this area, it is a slower injury to heal.  Our bodies can only heal at a certain rate so the last necessary component is patience (and one of the most difficult components for many of us!).  The body requires up to ~27 weeks to fully repair damage to ligament and tendon so we have to give it the proper care, attention and loving patience to get the job done.  Work with the body and it will work with you!

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