Ultimate Guide to Achilles Tendon Health in runners: Injury Prevention, Rehabilitation, and Performance
As a Physiotherapist working with runners for almost 20 years, the most common presenting problem we see is Achilles Tendinopathy or tendinitis. In this article I wont to write about the condition in detail. Achilles tendon injuries are among the most common and frustrating ailments for runners. Named after the Greek hero Achilles, who according to myth was vulnerable only at his heel, this tendon is the largest and strongest in the human body. It connects the calf muscles to the heel bone and plays a critical role in walking, running, and jumping. However, its unique structure and function make it susceptible to injury, particularly among athletes. This comprehensive guide will delve into Achilles tendon health, providing detailed insights into injury prevention, rehabilitation strategies, and exercises to improve performance.
Understanding Achilles Tendon Injuries
Achilles tendon injuries range from mild inflammation to complete ruptures. The two most common forms are:
Reactive Tendinopathy
Definition:
Reactive tendinopathy is the initial stage of tendinopathy that represents a non-inflammatory response to acute overload or sudden increase in mechanical stress on the tendon.
Key Characteristics:
Acute Response: Occurs due to a sudden increase in loading, such as a significant change in training volume or intensity.
Tendon Swelling: Swelling within the tendon structure leads to a thickened appearance, which can be observed on ultrasound imaging.
Pain: Acute pain is often felt during or after the activity that caused the overload.
Reversible: With appropriate load management and rest, this stage is reversible.
Histological Changes:
Increased proteoglycan content, which leads to tendon thickening.
Non-inflammatory cell response, primarily involving tenocytes (tendon cells).
Minimal structural disruption of collagen fibers.
Management Approach:
Reduce the load on the tendon through rest or modified activity.
Use of NSAIDs (non-steroidal anti-inflammatory drugs) may be beneficial for pain management.
Eccentric exercises should be approached cautiously in this stage due to the tendon’s sensitivity to load.
Degenerative Tendinopathy
Definition:
Degenerative tendinopathy is the advanced stage of tendinopathy characterised by chronic degeneration of the tendon tissue due to prolonged overuse.
Key Characteristics:
Chronic Response: Represents a cumulative response to chronic overloading and microtrauma over time.
Tendon Degeneration: Structural changes in the tendon include collagen breakdown and the presence of abnormal blood vessels.
Pain and Stiffness: Chronic pain is often present, typically during or after activity, with notable stiffness in the morning.
Irreversible Damage: Complete reversal of degeneration is unlikely, but symptoms can be managed.
Histological Changes:
Collagen fiber disorganisation and reduced collagen synthesis.
Increased presence of type III collagen (weaker than type I collagen).
Hypercellularity with abnormal tenocytes.
Neovascularisation (growth of new blood vessels) and nerve proliferation.
Summary Table
Reactive tendinopathy and degenerative tendinopathy represent different stages of the same pathological process affecting the Achilles tendon. Recognising the differences between these stages helps in tailoring treatment strategies to effectively manage the condition and promote optimal tendon health. You can see from the images above the difference in the tissue structure when we look closer. note the amount of white area’s between the three different images, and also the considerable lack of organisation of the fibers from the first “healthy” image to the last “degenerative” image.
Causes and Risk Factors
Understanding the causes and risk factors associated with Achilles injuries is vital for effective prevention and rehabilitation.
Overuse: Repeated runs one after the other that are beyond the current “load capacity” of the tendon.
Sudden Changes in Activity: Rapid increases in running distance or intensity can strain the tendon.
Improper Footwear: Worn-out or unsupportive shoes fail to absorb shock, placing extra stress on the tendon.
Biomechanical Issues: Overpronation, flat feet (debatable), and weak calf muscles contribute to excessive stress on the tendon.
Age: Tendon flexibility and blood flow decrease with age, increasing the risk of injury.
Previous Injuries: Prior injuries or surgeries to the lower limb elevate the risk of new Achilles problems.
Symptoms
Achilles tendon injuries typically present with the following symptoms:
Pain or stiffness along the tendon, especially in the morning or after physical activity.
Swelling and tenderness at the back of the heel.
Limited range of motion.
A "squeaking" sensation when moving the ankle.
Sudden, severe pain (in the case of significant tears or ruptures).
Achilles Injury Prevention: Exercises and Strategies
Preventing Achilles tendon injuries involves a combination of strengthening, rolling, and training modifications. Here are essential exercises and strategies:
Strengthening Exercises
Eccentric Heel Drops
How to do it: Stand on the edge of a step with the heels hanging off, rise up onto both toes, and slowly lower the injured heel below the step.
Reps: 3 sets of 15 reps twice daily.
Benefits: Strengthens the calf muscles and Achilles tendon while improving flexibility.
Single-Leg Calf Raises
How to do it: Stand on one leg and raise up onto the toes, then slowly lower.
Reps: 3 sets of 15 reps.
Benefits: Increases calf muscle strength and tendon resilience.
Seated Heel Raises
How to do it: Sit with your feet flat on the ground and a weight placed on your knees. Raise your heels as high as possible, then lower slowly.
Reps: 3 sets of 15 reps.
Benefits: Targets the soleus muscle, which connects to the Achilles tendon.
Toe Walking
How to do it: Walk on your toes for 20-30 seconds.
Reps: 3-5 sets.
Benefits: Enhances balance, coordination, and strengthens calf muscles.
Skipping
How to do it: Use a skipping rope alternating between feet
Reps: 3 times 2 minutes.
Benefits: Endorses colleges synthesis and cross linking through plymotric load to increase tendon overall strength
What are the Best Stretching Exercises?
None, after being a Physio for almost 20 years I can guarantee you, don’t stretch your achilles tendon when you have achilles tendinopathy. The difficult thing is, this goes against everything that you think, because the area feels sore and “tight”. However, there is limited to no evidence that stretching is effective.
Training Modifications
Gradual Progression
Increase training volume and intensity gradually (no more than 10% per week).
Cross-Training
Incorporate low-impact activities like swimming or cycling to reduce stress on the Achilles.
Proper Footwear
Replace worn-out shoes and use models that provide adequate support and cushioning. Especially consider shoes with a greater drop in them. Generally greater than 8mm.
Warm-Up and Cool-Down
Always warm up before running and cool down afterward with light stretching.
Managing Achilles Tendon Injuries: Rehabilitation
If you suspect an Achilles tendon injury, prompt action can prevent further damage and promote faster recovery. Here’s a step-by-step rehabilitation guide:
Rest and Ice
Avoid activities that exacerbate pain above a 4/10 and apply ice for 15-20 minutes several times daily to reduce inflammation. Note that I didn’t say don’t run. It’s a common error amoung inexperienced Physio’s. Firstly, best of luck telling a runner to stop running, secondly, it’s actually not in the tendon’s best interst. Keep running without aggravating the pain above a 4/10 and you will actually recover faster. With this said I would strongly encourage you to follow this with the guidance of an experienced Physio.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Use NSAIDs like ibuprofen to manage pain and inflammation. Another note, this wont fix anything, it will only reduce down the inflammation and more often than not I dont endorse this unless 100% required.
Physiotherapy
Consult a physiotherapist for personalised rehabilitation program and management. But try and find a Physio experienced with working with runners.
Orthotic Devices
Consider heel lifts, shoes with a greater drop or custom orthotics to offload the tendon in the short term, again, your Physio or Podiatrist will be able to suggest if this is appropriate for you.
Gradual Return to Activity
Slowly reintroduce greater levels of running and especially running uphill.
Isometric and Eccentric Loading Exercises
Gradually incorporate isometric/eccentric heel drops to strengthen the tendon and prevent re-injury. I would strongly endorse Collagen supplementation also. More about that HERE.
Advanced Treatment Options
For severe cases, especially ruptures or persistent tendinosis, advanced treatment options include:
Platelet-Rich Plasma (PRP) Therapy
Injecting PRP (a concentration of platelets from the patient's blood) into the tendon to accelerate healing.
Extracorporeal Shock Wave Therapy (ESWT)
Using high-energy sound waves to stimulate tendon healing.
Surgery
Reserved for complete ruptures or chronic tendinosis unresponsive to conservative treatment.
Additional Tips for Achilles Tendon Health
Listen to Your Body: Don't ignore pain, especially persistent discomfort in the heel or calf.
Regular Massage or foam rolling: Massaging and rolling the calves and Achilles tendon can improve blood flow and flexibility.
Hydration and Nutrition: Stay hydrated and consume a balanced diet rich in anti-inflammatory foods (e.g., fatty fish, nuts, leafy greens).
Achilles tendon health is crucial for runners and athletes of all levels. By understanding the anatomy and function of this vital structure, along with implementing effective injury prevention, rehabilitation exercises, and advanced treatment options, athletes can significantly reduce their risk of injury and enhance their performance. Remember, patience and consistency are key in both preventing and recovering from Achilles tendon injuries. Stay informed, proactive, and disciplined, and you'll be able to overcome these challenges with strength and resilience. If you need support with your recovery, let us know HERE.