Managing and Preventing Achilles Tendinosis

As readers of this blog now understand, the five most common running injuries are plantar fasciitis, runner's knee (PFPS), IT Band pain syndrome, Achilles tendinosis, and tibial strains (felt as shin splints). Today's focus is on Achilles tendinosis.

Achilles tendinosis is usually first observed as pain at the beginning or end of runs. As the injury worsens, the pain does as well and can expand to include the entire run. Fast running and uphill running can become particularly painful, as well as stairs or standing on your toes.

We'll go into what to do momentarily, but let's take a look at what is happening in greater detail first.

The Achilles tendon can face forces equaling eight to ten times our body weight. This strain can cause microtrauma that doesn't always heal between runs or other training sessions. As the tendon becomes injured, the areas of trauma become stiffer scar tissue rather than the more elastic tissue it is helping to protect. This process also happens as we age, which might be why older runners are more susceptible to this particular injury.

Achilles tendinosis is often misunderstood as Achilles tendinitis. However, it is really important to make a distinction between these two. Tendinitis means inflammation of the tendons, which is actually not possible. Tendons do not get inflamed, which means that a corticosteroid injection (or any NSAIDs) is exactly what a runner does not want to do. Corticosteroids are great for reducing inflammation and often come with a numbing drug called lidocaine. However, research shows that these drugs make the tendons weaker and too numb for a runner to know that they are damaging the tendon even more.

Achilles tendinosis is defined as a chronic degeneration of tendon tissue. This degeneration comes without inflammation. I'll use Jay Dicharry's excellent metaphor here: If we imagine the collagen fibers in tendons to be like a handful of straws held together neatly in parallel to make a much thicker straw, then tendinosis can be imagined as individual straws getting pinched (which is scar tissue on collagen fibers) or moved individually too far up or down (changing the orientation of the collagen fibers from neatly parallel to a random orientation). These stiff spots of scar tissue are subject to a great deal of strain and become damaged.

So Achilles tendinosis is best fixed by relative rest, deep scar tissue work, and eccentric strengthening.

Relative rest allows the tendon to heal. It can involve cross training, reduced running or no running in some cases. Keep in mind that total rest can actually disorganize the tissue even more and weaken it from lack of us.

Deep scar work is done to break up the scar tissue fibers that are not parallel. Breaking up the scar tissue is crucial because it is getting rid of the areas that become the most strained. One of the best ways to do this is what Dicharry called “flossing” and there are many massage therapists and bodyworkers out there that have their own version of this. This technique is best used habitually rather than waiting for an injury and then using this tool.

To “floss” position the joint so the tissue you want to work on is loose and relaxed. Apply firm pressure over the restriction and move the joint back and forth to shorten and lengthen it under your fingers and break it up. For the Achilles tendon, holding the tendon in different spots with firm pressure and then flexing your foot towards and away from you (plantarflexion and dorsiflexion) works well.

Eccentric strengthening is done to help organize the fibers back into parallel lines. Eccentric exercise (lengthening under contraction) should be done about 40-60 times a day for 5-6 weeks. Over time, this improves tendon strength and plays a crucial role in recovery for Achilles tendinosis. Do not do these types of exercises until you can do unweighted eccentric hill dips with minimal pain.

The most common version of these exercises is the eccentric calf raise. First on one foot and then the other, rise off the heels onto the balls of your feet, doing the above recommended number of repeats. As the weeks progress, start from doing this on the ground to doing it on stairs so the heel can drop below the ball of the foot at the lowest point, and then begin adding weighs bit by bit.

Another series of useful exercises is with a rocker board. Stand on one foot and tilt the board about 45 degrees to your body to start. You can touch the toe side of the board to the ground, followed by the heel side for about 20 reps to start, and then rotate the board 90 degrees and do the same exercise again. Be sure to do both foot with both rocker board angles, keeping your big toe firmly on the board alongside the outside and inside ball of your foot.

I also recommend checking out other rocker board exercises, which will benefit not only Achilles tendinosis but help with coordination and running technique and strength.

So go forth and run merrily, while flossing, rocking, and raising your way to injury free exercise!