Updated: Feb 5, 2019
This a post I did last year but I decided to post it again as I have been seeing several people with this issue lately.
Achilles tendinitis (sometimes spelled tendonitis-I will use them interchangeably) is one of the most common injuries in runners that I treat as a sports medicine physical therapist. Usually, by the time the patient gets to me, it is no longer tendinitis but is the chronic form called tendinosis. It is very rare for me to see someone with actual Achilles tendinitis because it only lasts for a week to 3 weeks if treated appropriately. If not treated right away and it becomes chronic then the usual methods to treat tendinitis (rest, ice, anti-inflammatories, easy stretching) no longer work and the person ends up on my schedule.
Some of the symptoms of Achilles tendonitis are:
pain and stiffness along the posterior aspect of the calf/ankle especially in the morning or after sitting for a while
pain along the tendon or heel that worsens with activity
severe pain the day after exercises
a bump/knot in the tendon or at the heel where it inserts
swelling that is present all the time and worsens with activity.
Tendinitis is when the tendon (and often tendon sheath) is acutely inflamed, or in other words, it just recently began hurting. If you begin to get pain in your Achilles you should do something about it immediately. You should not let it go and keep ignoring it because once it becomes chronic (tendinosis), it is much harder to treat and you will have to change what you are doing activity-wise.
If you continue to ignore it and keep running it can progress to something even worse, tenosynovitis. We are not going to discuss tenosynovitis in this post as it is not as common to see in the Achilles and the diagnosis between tendinosis and tenosynovitis is by MRI and likely somewhat subjective. In both cases, changes in the tendon itself have occurred. In tendinitis, there is just inflammation, an annoyance. In the chronic stage, degenerative changes have actually occurred in the tendon as well as some small tearing possibly. The tendon may not glide in is sheath (paratenon in the case of the Achilles) well anymore and you may notice a bump either at the insertion on the heel (insertional) or in the middle of the tendon (non-insertional or mid-substance). Once the bump is there you know you are in for a longer treatment/healing time.
Some of the suspected causes of Achilles issues are:
Sudden increase in the amount or intensity of activity (increasing your daily mileage by a few miles without letting your body adjust to it; increasing your hill running such as doing hill repeats too much or too soon in training; doing speed workouts too much or too soon)
Tight calf muscles causing an abnormal pull of the Achilles at its insertion
These are the two most commonly cited causes for Achilles issues. Some other theories are a decreased blood supply and flexibility to the tendon predisposing it to injury especially with age; malalignment such as excessive pronation; and one that I believe is a cause is muscle imbalances.
I frequently see weakness on one side in the hips/glutes in my patients that present with Achilles issues. It is said that there is a link between tight hamstrings and Achilles issues as well.
I personally believe some or all of the above-mentioned issues can lead to Achilles problems but I am convinced after years of treating patients that having weakness at the hips/glutes is related. Most patients do not come in with Achilles tendinitis/tendinosis on both ankles at the same time. It is almost always (90% of the time in my practice) on one side. Why? What is causing this one side to have the problem and not the other side?
I think you must look for the root of the problem. It may be true that there is decreased blood supply to the tendon as we age and less flexibility but why only one side in my runners? Are they always running the same route and creating imbalances? Do they have “dead” butt on one side and their glutes aren’t working properly causing them to overuse other muscle groups/tendons to compensate? I cannot tell you how many runners I have treated with this condition that cannot even fire their glutes on the side of the Achilles issue.
So, what can you do about this problem? Well, first off, don’t get it! If you begin to feel pain along the back of your calf in the area of the tendon or at the back of the heel do something about it immediately (as soon as you get home from your run). Start with easy stretching and see if this is enough. If it hurts again during or after your next run then you could look into whether you may want to try over the counter anti-inflammatories, ice, a few days rest and easy stretching.
Keep in mind that it has been said that anti-inflammatories are only helpful in tendinitis (the first 1-3 weeks after first getting the symptoms, especially the first week). If it goes on longer than this then there are not signs of acute/active inflammation in the tendon and it has been said that anti-inflammatories are no longer helpful. Now, there is always a possibility of an acute flare-up on top of a chronic condition but that is going deeper than this post.
If you are doing speed work and hill repeats stop both of these and do all of your runs at easy paces. If it does not resolve you should see a professional to be checked for muscle imbalances before it can progress further.
If you already have the chronic form it does not mean for sure that you have to stop running. If you feel and/or see a bump in your tendon or at its insertion at the heel then you should stop running and see a professional. Do not do aggressive stretching as this can sometimes make this worse as it continues to pull at a tendon that may have partial tears in it.
The American Physical Therapy Association has a guide about Achilles tendinitis/osis and the best treatments. The number one treatment for the chronic form is an eccentric program. There are several programs for eccentrics out there but no one program that has been shown to be the absolute best for how many reps, how many days a week, etc. There are a lot of things out there that promise to heal your Achilles tendinitis/osis. Different things work for different people. Here are some of the things I have found helpful in the runners I treat with this issue:
Eccentric calf lowering exercises-I start my clients with 15 reps a day for the first week, 30 reps daily the second week, 30 reps am and pm the 3rd week then we switch to 3-5 days a week, 1-2 sets of 30 and holding weight if body weight is no longer difficult. I also customize it for clients as needed based on their fitness and if they are returning to running
Foam rolling the the calf and IT band
Corrective exercises to correct any muscle imbalances; strength or flexibility or both (frequently gluteus maximus and medius need to be strengthened, hips, hamstrings, quads, hip flexors, and calves should be checked for flexibility differences; core should be strengthened); this list is not all-inclusive and should be customized for your specific weakness/tightness
Manual therapy such as deep tissue work, active release techniques, instrument-assisted soft tissue work
Return to run program that is customized for the client and has at least 4 weeks with all runs at easy/conversation pace. No speed work or hills for at least 4 weeks in those with mild symptoms; 8-12 weeks in those with more severe symptoms
Eccentric Calf Lowering:
Here is a YouTube video showing this exercise. I like to have shoes on when I do it but you can do it with or without shoes.
Foam Rolling to Calf:
I do not have clients roll on the tendon, but just above it and all the way to the knee. It is a good idea to do the IT band as well.
Hopefully, you will not get this problem. If you do, just know there are options and it does not have to completely ruin your training program. Frequently you can continue running while being treated depending on how severe your symptoms are and how long you have had the symptoms.
Using some of the above-mentioned techniques are also good for prevention. There is some plyometrics that can be added for prevention as well but I will not put those in this post as I would not want someone with symptoms to perform plyometrics.
References: Most of this information is from my own experience treating runners and my knowledge as an orthopedic physical therapist but I did get some information from the following: