If you’ve been a distance runner for any reasonable period of time, then you’ve probably experienced heel or achilles pain of some degree! The fact is the calf achilles complex undergoes a lot of load/stress from running. In fact, with all the attention these days on strengthening gluteals (which absorb 1.5 – 3.5 x body weight load in running) it is surprising that the poor old calves do not get more of a mention in strength regimes, as this critical muscle group  absorbs 6 – 8 x body weight loads!   

With these sorts of loads going through the calf/achilles region, it makes sense that after a lot of running there tends to be some permanent changes to the internal structure of your achilles tendon. What is really interesting is the poor correlation between scans and pain – I regularly see runners with essentially normal scans but lots of tendon pain, and probably even more of runners with scan results (taken for some other reason) that show tendon damage but that person has never had issues with that tendon. What actually makes you feel pain we do not actually know. What we do know is that we can get two athletes or runners with almost identical investigation findings, and one will have pain and the other won’t and never has. The scan is not relevant, the pain is!

What I can say is that scanning a painful achilles is largely useless, especially in early stages, so save your money. What I can’t answer with such clarity is the question “What is causing your pain”! Most people are probably more used to the word tendonitis when describing Achilles injuries, but this term is factually incorrect. There is little to no inflammation involved in tendon issues (note to all those taking anti-inflammatories for tendon pain!) so tendinopathy better defines “pathology in the tendon”.  Along with true tendon pain, there are several other conditions that may be responsible for your Achilles/ heel pain: paratenon (sheath issues), sural nerve entrapment issues, bursitis and Haglunds Syndrome to name a few.

Achilles tendinopathy is characterised by several key symptoms and without them you really need more investigation to ensure you have the correct diagnosis. These symptoms include:

1. A warm up phenomenon (they don’t get worse the longer you run, they often feel better)

2. Morning stiffness

3. 24 hour response period. They can get quite sore after your run when the tendon has cooled down, but then feel great by the next day.

So, what do I do to fix my tendinopathy?

In a nutshell, any sort of true tendinopathy is fixed with a good load management program. Sounds simple, but it ain’t quite that easy unfortunately.

So far I’ve knocked the effectiveness of scans out of the equation, and also anti-inflammatories, so I might as well add injections to this list. It’s such a common question to a physio that treats runners: “Can you get this injected”? Given the difficulty of simply knowing what is causing your pain recommending an injection to try and change that pain behaviour is largely guess work. We do know from research and clinical experience that cortisone can be dangerous with tendons, and that the other common injection – bloods, platelet rich plasma, or PRP, wahtever you want to call it – has very low percentage success and comes at a reasonably significant cost.

Exercise for tendons is best practice and that in particular means strength/load. The only thing that changes the capacity of a tendon (its ability to tolerate loads) is load itself, but make sure that load is within its current capacity. One thing that we know is that load (read that as strength) is good for tendinopathy and rest is not. It is all a matter of managing that load. Virtually every person suffering with achilles tendinopathy will have been given some calf raises by someone as part of their treatment. If this is not helping, we really need to assess your technique of doing them, what amount you are doing or whether you have true tendinopathy. If your problem is more one involving the tendon sheath, calf raises will actually be making it worse rather than better. As mentioned above, if you have achilles tendon pain and you stop exercising, that will result in further loss of tissue capacity to withstand load. All of a sudden even less activity will result in overload of your tendon and the cycle will continue. The very first thing that you need to do after having it confirmed that you have an achilles tendinopathy is work out the maximum capacity that your tendon has, and start building load from there. It is all about a balance between the load you are placing on the tendon structure and its capacity to cope with that load. If you place more load on the tendon structure than it has a capacity to cope with you will likely experience pain or aggravate your injury. The key is to build capacity through exercise but load the tendon at a level below the tissue capacity and build both progressively. If you don’t load the tissue (eg rest it), its capacity to cope with load will become even lower, meaning even simpler aggravations as you continue to load it beyond its reducing capacity.

So how do I work out how much load my tendon will cope with?  This can often be worked out from your subjective assessment of your own achilles. Eg – if your achilles is coping with 3k run but not 5k run or if you can do 10 single leg calf raises and not pull up sore then we get a good picture of where the capacity of your tendon is at. One of the typical characteristics of tendinopathy mentioned above is warm up phenomena. That is, a tendon will usually respond and feel better with exercise. To monitor whether or not the tendon is tolerating the load, the best measure we have is morning stiffness (the day after your exercise session) and 24hr response. If you feel considerably worse the next day after exercise, then the load you have placed on that tendon is probably more than its current capacity. As you add load and then assess how it feels the next day you want to see that the tendon pain is ideally improving but at the very least remaining low and stable, indicating that it is coping or adapting to the load that you are putting through it.

The old adage of listening to your body is one of the keys to preventing injury: Typically, if aggravated by the session before, that just means that your following session needs to involve less reps or weights (decreased load). Your tendon does not need to be pain free but the key is the pain is low or very tolerable and is not pulling up any worse 24 hours after exercise. If you have low and very tolerable pain that is not getting any worse as you increase load then you have a tendon that is tolerating those increases and you can safely continue to slowly progress as long as your continue monitoring your response and react accordingly.

 If in fact your achilles gets progressively worse with exercise and is not warming up, you again may need to be alert that it is possibly not a true tendinopathy.

If I have been doing progressive strength work for a while but still can’t get back running what do I need to do?

Our tendons basically act as springs in our bodies. We therefore need to ensure that our rehabilitation involves more than just pure strength as described above with single leg calf raises or even seated calf raises. Typically, a healthy tendon needs to be stiff so that it can compress when absorbing impact, store that energy and then be used to spring you off and propel you forward at the toe off phase of gait.  A tendon which is showing signs of poorer capacity will lose some of this stiffness. To get that stiffness back, you need to not only get stronger in your calf/achilles complex but learn to jump/hop again.

Take Home message

The key to recovering from achilles tendinopathy is make sure you see an experienced sports physiotherapist ( ideally one that knows running) to ensure you have the correct diagnosis.

Once you have your accurate diagnosis of tendinopathy, be assured that complete rest does not help. Exercise is needed.

Design and follow a progressive strength program progressively adding more load to the tendon and progressively re assessing your response to that load 24 hours after and adapting to that response.

Don’t be afraid if you flare up from adding too much load. In fact this is nearly inevitable as you add more load. Just respond appropriately by modifying the load in your next session.

You must add some more dynamic load like skipping to your program before resuming running. Don’t just jump from pure strength work to running – the gap in rehab is too great!

Tendinopathies are one of the most researched injuries in our field meaning that we have great knowledge on what works and doesn’t work.

All my learnings come from some great experts in our medical field and if you want to learn more some names worth looking up are Craig Purdam, Jill Cook, Peter Malliaras, Ebonie Rio and Lorimer Moseley.

Rob O’Donnell

SSPC Physiotherapist