Achilles Tendon Injuries – How to stay away from the surgeon!

I’ve been writing these articles every week for about 2 years now and it surprises me that not once in that time have I dedicated one to the topic of achilles injury.

How is this possible? It is definitely one of the most common and frustrating injuries that plague the running community the world over.

So, I’m here today to tick this box and ensure that you all get a thorough explanation of this injury and how you can manage it.

Firstly, let’s define it.

Achilles tendinopathy is the collective name we give to any injury or condition of the Achilles tendon.

The Achilles tendon acts as a connection between your calf muscles (Gastrocnemius and Soleus) to the calcaneus or heel bone. It is incredibly strong and dense and has a small amount of elasticity. Its blood supply is limited, so healing rates can be quite slow.

Typically there are 4 main diagnoses we would make with a tendon injury and then several sub categories of those 4 things. If you have tendon pain, see if you can work out which one of these matches you.

1) Tendon Strain – this is essentially a tear that happens suddenly. It may be a very small tear (grade 1), mild tear (grade 2) or major/complete tear (grade 3). This will usually happen as a result of a single incident where the person lands hard on one foot, takes off suddenly or is doing something explosive where the tendon cannot withstand the load it is under.

2) Reactive Tendinopathy – until recently, we may have termed this ‘achilles tendonitis’, though research in recent years explains that due to the poor blood supply, tendons don’t really become inflamed (wherever you see ‘itis’ on the end of a word, it means it is inflamed). Instead they draw in and hold onto fluid, become swollen, tender to touch, painful with exercise, weak and shortened. The signs listed here for Reactive Tendinopathy are similar to what we would expect to see with inflammation, but this new classification means the way we treat it is different…. we’ll get to that soon. Reactive Tendinopathy is often triggered by overuse, a sudden increase in training load or intensity or as a follow-on from a tendon strain.

3) Tendon Disrepair – this category describes a process whereby your tendon is injured, the body is trying to heal it but it is failing. Often the problem is that you continue to irritate the tendon by undertaking daily activities that prevent healing. Essentially, the tendon hurts sometimes and feels better at others. It doesn’t really get a lot better but is usually manageable if you don’t push it. It may be a bit sore to touch, but not as swollen as a Reactive Tendinopathy. Often you may start a run with it tender, and it then gets slowly better – but is usually sore again afterwards.

4) Tendon Degeneration – degeneration happens mostly after having tendon pain for an extended period of time. The tendon may feel gritty, rough, thinner in parts or bumpy. It often gives no pain initially but after a short bout of exercise it will begin to complain and then get gradually worse to the point where you can no longer push beyond it. With this the tendon is in a weakened state and is prone to complete rupture (grade 3 strain) if it is pushed too hard. Generally there is little to no swelling, flexibility in the ankle may be reduced, the tendon may be painful to the touch or may not.

Tendinopathies will often start out as a tendon strain and then progress through the other stages to tendon degeneration, or may start as reactive tendinopathy and progress from there. However, the progression through these stages only happens if you don’t manage the injury correctly. Do the right things at the right time and you can often heal it pretty fast.

Now, I’ll describe the basics for rehabilitation from each of these categories, but please keep in mind that each category is part of a continuum and you may swing between one or another. A full and thorough assessment by someone qualified to do so is always the best course of action.

If your tendinopathy presents as swollen, painful to walk or run on and is sore to touch, your main focus should be around unloading the tendon. This can be done by reducing the amount of exercise you are doing back to whatever is manageable for you without pain, you may also try wearing shoes with a bit of heel in them for a few days (shhhhh, don’t tell anyone I said to wear shoes with a heel. It sounds like blasphemy to me when I say it, but can help to shorten and reduce the tension on your achilles). Getting massage on your calves and soles of your feet is an excellent way to reduce the pull on the tendon also, an alternative to the massage is a foam roller or a massage ball.

If the pain and discomfort from your injury is not too bad and you are able to do some running, walking in cold water afterwards can help to remove some of the fluid that will pool in and around the tendon.

Stretching (pain free) is important in all stages of this injury and should be done at least twice per day.

Strengthening the tendon is going to be the most important component of the rehabilitation plan and ideally will begin the minute you can move without pain.

Strength work can start simply with walking (on flat ground) and slowly progress to various types of calf raises. From there, the strength work needs to become more sport specific and dynamic movements such as jumping, bounding and of course running will be progressed through.

The goal at all times is to stay pain free through the rehab exercises, as this gives you a clear indication that what you are doing is not doing any more damage than already exists.

It is difficult for me to give exact guidelines for a do-it-yourself rehab plan here, because everyone will be at a slightly different stage of progression or regression. I am happy however for any runner to email me for advice or guidance on how to manage their particular case.

One thing to remember is that TENDONS LIKE LOAD. By this I mean that you have to challenge your Achilles for it to become and remain strong. If you take your Achilles tendon injury and plonk it on the couch for 4 weeks, chances are it will heal, but the likelihood of it getting reinjured is high. Much better to slowly re-introduce it to the work it needs to do so that it can rise to the challenge and prevent further injury.

Run long,

Shaun Brewster.

Leave A Reply (5 comments so far)

  1. Remedial Massage
    3 years ago

    This tendonitis is actually the inflammation of the Achilles tendon and is caused by repetitive activity in this part of the body. Fortunately, the risk of developing Achilles tendon decreases if the athlete takes some precautionary measures such as warming up before practice, receiving regular remedial massage sessions and making sure that there is a rest between high intensity workouts.

  2. Shaun
    3 years ago

    Hi “Remedial Massage”, we don’t really use the term ‘Tendinitis’ any more because it does not accurately describe what is taking place histologically in the tendon. Current research suggests the Reactive Tendon/Tendon Dysrepair/Degenerative Tendon model published by Craig Purdam and Jill Cook is the best way to describe what is taking place.
    You are right though, appropriate warm up, regular soft tissue therapy and adequate rest will help reduce the incidence.

  3. Mei Williams
    1 year ago

    Hi there

    did a 40 mile ultra yesterday (10/09/16) today feels gritty ? whats the best way to help this ? zero pain though. thanks Mei

  4. Mei Williams
    1 year ago

    Hi Shaun..

    I’m back. :-(. I now have bilateral achilles pain. Doesn’t hurt when you press but the moment you pinch in certain points you know it. I’ve reduced the drop in my trainers and originally had success. I now know I need to get things sorted properly. I’ve been getting regular leg massages but not feet.So in essence, drop the running for a while (was thinking of rest for 4-6 weeks with plenty of stretching and massage) and then build up gently when I’m asymptomatic ?

    your advice greatly appreciated as ever.

    many thanks


  5. Shaun Brewster
    12 months ago

    Hi Mei, sorry I missed your earlier post a few months back.
    Welcome back by the way!
    What you are describing does sound like tendinopathy, the management of that has a very specific protocol, which luckily works REALLY well. It is very difficult to explain in text, so I’d recommend you come and see me if you get a chance (my clinic is in Newport), or see if you can find a Physio or similar who is familiar with the Ebonie Rio approach to managing achilles tendon pain. This is the best approach and will give you the best chance of getting rid of this problem in the shortest time possible.
    In the meantime, it is important that you don’t stop exercising, as tendons needs load to heal. It’s just a matter of only doing what doesn’t flare up the pain for now. Also, avoid stretching the tendons too much and also avoid compression of them, which means taping, massage, etc. I’d probably get into a slightly thicker heeled shoe for the time being, so that there is less stretch on the tendon for now.
    The thing that most people get wrong with this, is thinking that stopping exercise will solve the problem. If you stop, you will have a reduction in pain, but you’ll also see the problem return shortly after commencing exercise again.
    Hopefully this helps point you in the right direction!

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