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Achilles tendinopathy
This is a precarious time of year for triathletes. Many of you are emerging from your long hibernation of indoor training into the cold spring sunshine. Now’s the time you get to stretch your legs and start building some proper speed work into your routine. Now’s also the time that I start to see athlete’s break down and pick up those niggly injuries that if not dealt with properly can last all season.One of the biggies is an achilles tendinopathy. So I thought I’d use this month’s newsletter to tell you a little more about it with some practical tips to help avoid picking up this and other common running injuries.
The achilles tendon is an amalgamation of tendon fibres from four muscles located in the back of your leg. The two we worry about most are the two headed Gastrocnemius and the shorter, fatter Soleus muscle just underneath it. These huge muscles contribute fibres to the achilles tendon that follows a course down the back of your leg inserting just at the very back of your heel.
Achilles tendinopathy frequently involves heel or lower calf pain that comes on gradually over the course of weeks. Generally, there is pain and stiffness during the initial stages of exercise (or when you get out of bed) and as you carry on the pain will often disappear only to return with a vengeance when you stop again. You may after a short period of time develop some thickening of the affected tendon.
So, why does it happen? Well there are a number of factors that can affect whether you get a tendinopathy. The biggest risk factor is a dramatic change in training load. That load can be divided into volume and intensity. Load also carries a certain component from the environment, so temperature and surface need to be considered. For example, if your coach has written a progression of hill sessions and you’re unable to complete the first couple then discuss with them whether you should start the progression again. Don’t just jump into the 3rd week of the progression without thinking.
Similarly, be aware if you’re transitioning to a new running surface, i.e. from x-country to running track for your speed sessions. Keep an eye on how tight your calves are becoming, make sure that you stay supple perhaps consider some soft tissue therapy to keep everything moving nicely.
Make sure that you’re wearing appropriate footwear. Going straight from your big chunky, cushioned trail shoe to a lightweight racer you haven’t worn since last August is also a no no. Racing flats tend to have less of a heel to toe drop, which increases the stress on your calf complex and increases the chances of causing damage to the achilles tendon.
So by increasing load and changing surfaces gradually we should be able to avoid a tendinopathy. But for an unlucky few their time will come. Thankfully, dealing with achilles tendinopathy is fairly well researched and with a little bit of patience doesn’t have to mean the end of your season. Inevitably there will be a period of protecting the tendon so the running load may have to be reduced and push off the swimming pool wall with care!
Firstly, achilles tendinopathy is NOT an inflammatory condition. At a cellular level the tenocytes (tendon cells) are not inflammed, so although drugs like ibuprofen may help the pain, they won’t help healing. In fact there is some research to show that non-steroidal anti-inflammatory drugs (Ibuprofen, diclofenac etc) actually inhibit your body’s own healing mechanisms. My advice would be to stick with simple analgesia such as paracetamol and ice.
Tenocytes respond best to load. In order to encourage organised healing of the damaged tissue you need to load it. An eccentric loading programme has been proven to be the most effective way to improve achilles healing time. Eccentric muscle work refers to a muscle that is lengthening while contracting. Maximum tension is generated in the muscle and tendon during the eccentric contraction. Gradually increasing the load by increasing the number of sets and reps of eccentric Calf contractions causes the achilles tendon to adapt and get stronger.
A rehabilitation programme known as the Alfredsson protocol is widely regarded as the gold standard for achilles tendinopathy. His program involves completing approximately 180 repetitions per day of eccentric loading. This is painful, and in many respects impractical. Here are some ways to replicate the Alfredsson protocol at home:
1. Stand about 40 cm away from a wall and put both hands on the wall at shoulder height, feet slightly apart, with one foot in front of the other. Bend your front knee but keep your back knee straight and lean in towards the wall to stretch. You should feel your calf muscle tighten. Keep this position for several seconds, then relax. Do this about 10 times and then switch to the other leg. Now repeat the same exercise for both legs but, this time, bring your back foot forward slightly so that your back knee is also slightly bent. Lean against the wall as before, keep the position, relax and then repeat 10 times before switching to the other leg. Repeat this routine twice a day.
2. Stand on both feet. Use your unaffected leg to raise up on to tiptoes. Transfer your weight across to your affected leg and lower yourself down. Repeat and aim for 3 sets of 15 repetitions twice each day. The standing on tiptoe exercise can be performed with your knees straight and with your knees bent.
3. Stand on the bottom step of some stairs (facing upstairs) with your legs slightly apart and with your heels just off the end of the step. Hold the stair rail for support. Lower your heels, keeping your knees straight. Again you should feel the stretch in your calves. Keep the position for 20-60 seconds, then relax. Repeat six times. Try to do this exercise twice a day.
4. Keep a towel (or a long piece of elastic) by the side of your bed. First thing in the morning, before you get out of bed, loop the towel around the ball of one of your feet. Then pull the towel towards you, keeping your knee straight. Hold the pull for about 30 seconds. This exercise will pull your toes and the upper part of your foot towards you. Repeat this exercise three times for each foot.
5. Sit on a chair with your knees bent at right angles and your feet and heels flat on the floor. Lift your foot upwards, keeping your heel on the floor. Hold the position for a few seconds and then relax. Repeat about 10 times. Try to do this exercise five to six times a day.
Continue these exercises for 4-8 weeks and then start slowly re-introducing running to your program. If your problem persists or gets worse make sure you arrange to see a sports therapist, physio or doctor.
Remember, prevention is better than cure – if you feel like something is hurting stop what you’re doing and get some advice. Better to DNF one session or warm-up race than push through and potentially give yourself an injury!
