If only I knew…
How to Get Rid of my Achille’s Tendonitis.
by Marie-Catherine Bruno, B.Sc.P.T,; M.O.P.Q.; RPT
The idea to write about the Achille’s tendon came to me when one of the US top orienteers (whose identity will remain confidential), asked me for some advice on his tendon that was acting up on him. It made me realise that with all the running we do in those low cut, poor arch support shoes of ours, that it is actually quite surprising we don’t hear of more Achille’s tendonitis amongst orienteers. Anyway, for those unlucky ones of ours, here is a bit of anatomy on the subject:
The Anatomy of Sir Achille
The Achillle’s tendon runs on the back of the lower leg, from about mid-leg to the heel. It is a thick and wide tendon that anchors two muscles to the heel: the gastrocnemius and the soleus. The gastrocnemius runs from the lower part of the femur (just above the knee), while the soleus starts from just below the knee, on the tibial plateau. The two muscle bulks work individually; the gastrocnemius is mainly active when your knee is extended (e.g. walking), while the soleus works more when your knee is bent (e.g. riding a bicycle). The tendons though work together as they join further down to form the Achille’s tendon. The tendon then attaches on the heel bone (calcaneus), and unlike most tendons, has a very wide attachment (1-1 ½ inches).
What can go wrong?
Because of its location, the Achille’s tendon is very prone to get damaged. It supports a great load (half of the entire body weight pretty much) and it is very exposed to friction (shoes). Here are a few things that can go wrong:
- Direct friction/pressure on the tendon from high top shoes, ankle taping, ankle brace or badly designed heel cup in a low cut shoe;
- Lack of flexibility: like any muscle, the more you exercise a muscle, the bigger it gets. And the bigger a muscle gets, the shorter it becomes. Failure to stretch routinely makes your muscle an easy target for injury - a weak link - because it then is constantly under tension. And we all know that anything constantly put under tension will eventually collapse (or even snap).
- Malalignment of the calcaneus: if you are a pronator or a supinator (refer to ONA, October 2001), then you are constantly stretching and straining one side of your tendon more than the other (your heel is side bent, so imagine the angle of pull created on the tendon). This tends to get even worse running on uneven ground like orienteering or running in shoes that do not provide a lot of support (like orienteering shoes!).
- Muscle imbalance: your calves should be no more than 300% of the strength of your anterior leg muscles (the tibialis brothers and company). When you are running, if your calves are strong and tight, they will keep the calcaneus (heel bone) in a plantarflexed position when your foot is up in the air (meaning your toes will drop down a lot), so when you hit the ground, especially at lower speeds where you really hit with your heel, you will then over stretch the tendon on every step. This could potentially create some microscopic damage in the tendon, a weakness eventually leading to a tendonitis or a rupture. So in a well balanced leg, the foot remains in a better position while up in the air and therefore hits the ground in a much less threatening position.
- High heel shoes: because your foot is constantly in plantarflexion (toes down), your calves slowly adapt to the shortened position and shrink. Not only you will get flexibility problems (see above), but you create a lot of strain when running around in regular shoes because, all of a sudden, your calves get stretched. It is a bit like walking on your heels for a person that does not regularly wear high heels; it would become fairly uncomfortable after only a few minutes!
- Hill training: for most orienteers, this should not be a problem!!! But for those of you out there that are training to improve your hill running speed, be aware of those high intensity workouts. Too much too soon is very destructive; calves work particularly hard and are at great risk during hills since they are working on a stretch (the steeper the worse, since your heel drops down even lower). Too many of those hard training sessions with inappropriate warm up or rest in between repetitions and/or training sessions might create some micro damage and further make your calves very fatigued and unable to recover. Eventually, the muscle and its tendon become weak and prone to injury.
- Poor warm up: imagine your muscle like a piece of silly putty. When it is cool, it is very hard to stretch, mould or deform. The more you play with it, the warmer it gets and the easier it becomes to shape it. Well, your muscles are like that too. If you start running fast or jumping over logs without any warm up, your muscles will not be able to elongate to meet the sudden demand and will snap. As simple as that! (refer to ONA August 2001 for tips on warming up).
What to do, what to do…
You have been bad and managed to get an Achille’s tendonitis? Well, it will for sure keep you out of running for a while, but follow these steps to get rid of it.
First of all, make sure you have eliminated ALL of the above causes. Your shoes leave a red mark on your tendon? Maybe it is time to get better fitted ones. Your ankle brace or taping job puts a lot of pressure on the tendon? It is probably because you get it done when your foot is relaxed. Make sure you bring your foot and toes towards you when you get the tape or the cast done, so that the tendon is already poking out in the back. This will give it more room when you stand up and put your weight on it. Adding a little pad with some ointment like petroleum gel will also help.
You wear high heels regularly? Try to gradually lower down. If you still really feel like you really need the extra height (who doesn’t?!), platform shoes might be the answer: they still give you the height with a much more gentle slope!
If you are a pronator or supinator, make sure you buy running shoes that are appropriate for you. Most shoes these days are designed to keep your heel in a neutral position; you just have to make sure you pick the right ones!
If you are not flexible, refer to ONA May 2002 and start stretching! If you have weakness in your calves, consult your personal trainer at the gym and look at ways to change that.
Are you pushing too hard at training? You should avoid doing 2 days in a row of high intensity workout (unless specified by your trainer). During the workout, make sure you give yourself enough rest between the repetitions and that you are not doing too many repetitions; if you start feeling uncoordinated and slow, you are pushing too much. Cool down and go home. You think maybe the hill you use for your hill repeats is too steep? Well, try a slightly flatter one and see for yourself!
You don’t warm up properly – you know what I am going to say!
Once you have pinpointed the cause, you still have to deal with the injured tendon. Let’s see what you can do with it.
First of all, you have to give the fibres a chance to heal, and this takes 3-4 weeks. This means rest. Imagine the ruptured/damaged fibres like a cut on a finger: every time you bend your finger, you reopen the cut. It takes for ever to heal. Same for the tendon; every time you exercise and put pressure on it, you will reopen the wound. So take a break.
The first few days (when you first feel some discomfort in the area), you want to ice and ice and ice. It is fairly superficial, so ice for about 10-12 minutes, every 2 hours. At this point, the electrotherapy used in physiotherapy is very useful to help reducing the inflammation and promote the healing. Avoid walking if it is painful (crutches are always fun anyway!). You can try a temporary solution if walking is painful: put a heel lift in your shoe (as simple as a piece of blue foam used for camping, about 1 ½ to 2 inches long). This will slightly lift up your heel and therefore shorten the distance between the 2 attachments of the muscle, giving it some release. I say temporary solution here because the relief from this little heel lift is quite spectacular and makes you want to exercise again. It is still too soon, do not start exercising yet Plus, who would want to become dependent on that little piece of foam?!
When you can finally walk without any pain, it is time to start working on the fibres. You have to be very gentle still, because they are still very fragile at this point. You can start massaging the tendon gently. This will help getting rid of the excessive scar tissue. You can also deeply massage the calf to promote relaxation and circulation, therefore taking some of the load off the tendon. As it gets better, you can start stretching, but it has to be painless. Stretch lots, and stretch both the soleus and the gastrocnemius. Ice is still effective at this point, as long as you ice after the massage, and not before (silly putty, remember?).
You are now pain free and feel like you can start exercising. Begin with low weight and many repetitions (something like 3 x 15). Progress to more resistance, making sure that it is still pain free. When you feel like your muscle and tendon are strong again, you can try to go for an easy jog. Keep it short and easy. Increase the pace and the time progressively, making sure it still feels good. At this point, stretching becomes critical. Not only you want to recover full flexibility, but you want to increase it (keep in mind why you got the tendonitis in the first time!). You may still experience some discomfort (no pain allowed though) due to spasm or scar tissue.
It is now the last part of the treatment where you can start the deep tissue massage. Warm up the muscle (short jog, hot tub, hot pack), massage its tendon deeply, stretch it, and then ice it. This should take care of the final phase of the rehab. Try to ice the tendon when it is stretched (and in a stretched position), as it will retain its flexibility for a longer time. Within 4 weeks (depending how far into the process you already were of course), you should be back to where you were in your training. Enjoy running pain free again!
Note: now I know you will wonder if you should keep using orienteering shoes since I’ve referred to their bad arch and ankle support in this article Ô so many times! Truth is, nothing beats the studs and spikes of a real orienteering shoe to run in the forest. So keep using them, but maybe think of adding some support to them, like custom made orthotics or footbeds.
See you in the woods!