Achilles Tendonitis: What You’re Doing Wrong
The more recent research is telling us that we’ve been treating Achilles tendonitis improperly. Don’t make the mistake of following the old recommendations. Read on for how to best treat Achilles tendonitis and keep symptoms at bay.
Achiles tendonitis is an inflammation of the Achilles tendon, or heelcord. If you’ve been a runner long enough, you have probably heard of this condition or have, unfortunately, experienced it yourself.
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Disclaimer: Although I am a physical therapist by profession, I am not YOUR physical therapist. This article is for informational and educational purposes only, does not constitute medical advice and does not establish any kind of th erapist-patient relationship with me. I am not liable or responsible for any damages resulting from or related to your use of this information.
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First, some background:
The Achilles tendon connects the heel bone, known as the calcaneus, to the calf muscle. It is a fairly long and strong tendon that originates at the back of the ankle and ends at the myotendinous junction, or where the bulk of your calf muscle begins. It is a shared tendon for the two muscles of the calf: the gastrocnemius and the soleus.
The gastrocnemius, or gastroc, as it’s known, is the more superficial of the two calf muscles. You can usually see the two heads of this muscle in athletes, those who are fit, and those with a lower percentage body fat. This mucles attaches at the calcaneus and then divides, each head attaching above the knee joint. In this regard, the gastroc crosses 2 joints: the ankle and the knee.
The soleus lies deep to the gastroc. This muscle can be seen from a side view of the calf as a vertical line. This muscle attaches at the calcaneus and below the knee joint. So, it crosses only the one joint: the ankle.
Achilles tendonitis symptoms
For runners, symptoms will typically show up during runs, usually the first few minutes to miles of a run. They may then return after you stop running for a brief time.
Relative rest might help. However, if you do nothing to treat it, symptoms will return when you try resuming your activity. Symptoms may also progress to pain and stiffness in the calf as well as the tendon. And symptoms may also begin to trickle into your everyday life, where just standing and walking become painful.
Symptoms typically begin with the feeling of tightness in the Achilles. The first few steps out of bed in the mornings can often times be the worst. Going up or, more particularly, down stairs in the mornings can be quite challenging. After a little while, symptoms seem to ease and may no longer be noticeable.
A word about stretching
Let’s be honest, most runners neglect stretching until an injury starts to rear its ugly head. Most would opt for that extra mile rather than spending the few minutes streching.
With this being said, if you fall into this category and have tight calves or ankles, you most definitely should be stretching.
How to stretch your Achilles tendon
In order to stretch the Achilles tendon, you need to stretch both the gastroc and the soleus since these two muscles come together to form the common tendon.
In a traditional calf stretch in a lunge position, the target leg is the back leg. To stretch gastroc, keep the knee of the back leg straight. (Remember: it crosses two joints and so you need to stretch it over both joints.) You should effectively feel this stretch in the bulk of the calf muscle belly, i.e. higher up on the calf closer toward the knee joint.
To stretch your soleus, slightly bend the back knee. Keep your heel on the ground. If your heel is lifting up, this means that your soleus is tight and is limiting your Achilles tendon flexibility. Bend the knee less if you have to. (Remember soleus only crosses one joint, the ankle, so we’re taking the knee out of the picture by bending it and focusing solely on ankle motion to get the stretch.) You should feel this stretch closer to the heel, more directly in the Achilles tendon itself.
Why stretching shouldn’t be your primary focus for Achilles tenodonitis recovery
Ok, so stretching is a good thing, so make sure you do it. But the goal of stretching is to increase range of motion at a joint or to increase muscle or tendon flexibility/extensibility. Stretching, in and of itself, does not help decrease inflammation.
Now, here’s an exception: if your Achilles is so tight that it’s limiting your range of motion at the knee or ankle and your body is essentially fighting against this loss of range during running gait, this could be causing your inflammation. Stretching will certainly help in this case. But again, stretching is increasing tissue flexibility, it’s not decreasing inflammation directly. Inflammation is being affected secondarily by the stretching.
However, if your flexibility is decent and you’re dealing with Achilles tendonitis (read: inflammation) due to overuse, stretching is not going to help. Not much anyway. You might feel better in the short term, but symptoms will likely keep coming back as you try to increase your training or activity level again.
Strengthen to get rid of your Achilles tendonitis
Strengthening, both concentrically and eccentrically, increases the inherent tensile strength of a muscle or tendon, and it also helps to rearrange disorganized fibers of a tendon.
A tendon that has been overused tries to heal itself. In its attempt to heal, it lays down scar tissue. These fibers are no longer looking nice and organized but are now running every which way. The tendon becomes inflammed and, in some cases, will even thicken as result of this process.
It’s important to gradually build load/resistance when strengthening, especially when working a muscle or tendon that is injured. In this case, it’s going to be important to strengthen both the gastroc and the soleus. So, just as with stretching, some exercises will be done with the knee bent and some with the knee straight.
By doing the following strengthening exercises, you will be able to rehab your Achilles tendonitis.
Phase I strengthening exercises for Achilles tendonitis
Seated heel raises
Start in seated: while at the edge of a chair or couch, simply do a heel raise. Raise your heels up, lower and repeat.
If you can do these without pain during and with minimal to no increase in your stiffness the next morning, then you can progress to standing exercises as below.
Standing heel raises
While standing, rise up onto the balls of both feet. You can use fingertip assistance for balance on a countertop or wall.
Now, perform heel raises with both knees slightly bent. Remember, knees bent will help to target the soleus. This will probably feel a bit awkward, but you only need to bend the knee about 10-20 degrees.
Make sure that you can perform both the above standing exercises without an increase in pain or stiffness during or after (i.e. the next morning).
A note about pain and/or stiffness
So, to rehab your Achilles tendonitis, you do not need to wait until you are symptom free before beginning exercises. You do need to wait until your pain or stiffness is at a manageable or funcitonal level.
This might mean that you still have pain or stiffness but that you can get through a work day or a “regular” activity type day without increasing your pain/stiffness level.
Sometimes, people feel fine during the day or during a more demanding activity, but will notice an increase in their discomfort level the next day. This is why it’s important to observe how you feel upon first waking, not just during an activity.
A good rule of thumb is to use the pain rating scale from 0 to 10, where 0 means no pain at all and a 10 is the worst pain imaginable (think: going to the emergency room pain). On this scale, a 5 would be a moderate level of pain.
When assessing your pain or stiffness levels, you should not have more than a 4-5/10 rating either during activity or exercise or the next day folowing.
Keep this in mind as you progress your exercises and move through the phases of rehab. I can’t tell you how long you might be in one phase or when to move on to the next.
What I can tell you is that if you have been doing the exercises and your rating is a 7/10 when you wake up the next morning for those first few steps out of bed, you are NOT ready to progress.
If you are at a 4-5/10 or lower, then you can certainly move onto the next phase in the series.
Phase II strengthening for Achilles tendonitis: single limb exercises
Do not move on to the second phase of exercise until you can perform Phase I exercises with less than a 4-5/10 pain or stiffness rating either during or after the activity.
Once you have mastered double limb exercises and your symptom rating is at a manageable level, you can progress to more challenging exercises. When your symptom rating is at a 4-5/10 or less, this means that your Achilles tendon is healing and is ready for an increase in load.
Eccentric heel raises
First, perform eccentric heel raises. In order to do this, rise up onto the balls of both feet. Shift your weight slightly over toward the symptomatic or injured side. Now, lift up the good leg, and use the strength in the injured leg to lower the heel back down to the ground.
Single leg heel raises
Next, perform the same standing exercises as above, just now on one leg. So, while holding onto a wall or counter top for support, perform single leg heel raises.
You should still continue your double leg heel raises in this phase as well. The goal is to add increasing load to the Achilles. We are looking to really challenge and load the Achilles in order to help it heal.
Phase III strengthening exercises for Achilles tendonitis: increase range of motion
The same symptom rating rule applies before moving onto this phase. Make sure that your pain/stiffness is a 4-5/10 or less before progressing.
Calf exercises off the edge of a step
In this phase, you will perform all of the above standing exercises, both double and single limb, as well as the eccentric heel raises, off the edge of a step.
You may need to start with just the double limb exercises off the edge of a step and the single leg exercises on the floor until you symptoms accommodate. Once your symptom rating is at an acceptable level, you can progress all of the exercises to be done off the edge of a step.
Phase IV strengthening exercises for Achilles tendonitis: add load
When you can complete all of your exercises off the edge of a step with an acceptable symptom rating, you can begin adding resistance or load to the exercises.
You can either hold a dumbbell in both hands or you can put some weight into a backpack and wear it during the exercises.
Following the same general progression, start with loaded double limb heel raises on the ground while you continue the other exercises off a step.
Gradually progress to using the weight for the single limb exercises on the ground as well.
Finally, progress to weighted double and single limb exercises off the edge of a step.
At the risk of sounding like a broken record, I’ll say it again: do not progress to the next level of exercise unless your symptom rating is at a 4-5/10 or less!
You CAN heal your Achilles tendonitis
It is possible to treat your Achilles tendonitis and return to running pain free!
Follow the outline above for exercise progression. Remember to respect the severity of your symptoms. Don’t push through, but hold back when necessary.
It’s better to spend a little more time rehabbing in order to return to running successfully, than to set yourself back and have it take even longer!
Think you’re ready to return to running? Get The Running (Re)Start Training Plan HERE!
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