Achilles tendonitis is one of the most frustrating injuries to heal from. Could stretching and rest actually be moving you in the wrong direction?
For those of you that have interacted with me in the past few months, I’ve likely mentioned the grief my right Achilles tendon has been giving me. I’ve been to see osteopaths, physiotherapists, chiropractors, massage therapists, acupuncturists, and fascia workers. While all have offered some benefit, none of the treatments have offered a long-term solution.
Out of frustration, I started doing my own research into Achilles tendon issues.
My findings: the latest medical research varies greatly from most of the recommendations I received from therapists.
- Rest, ice, compression, and elevation (R.I.C.E) will actually prolong recovery.
- There is more than 1 type of Achilles tendonitis. Different types require different approaches to treatment.
- You’re more likely to have Achilles tendinosis than tendonitis. The treatment is different for each.
- Stretching the calf muscles do little to improve the function of the Achilles tendon.
- Shockwave, laser therapy, and other localized treatments do not address the root cause. Resulting in a recurrence of Achilles tendon issues.
So, read on to address the root cause of your nagging Achilles tendon pain.
What is Achilles tendonitis?
The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon of the back of the leg, and the thickest in the human body. It serves to attach the calf and soleus muscles to the heel bone (calcaneus). Approximately 6% of the general population report Achilles tendon pain during their lifetime. (1)
Tendonitis refers to inflammation or swelling of a tendon. Thus, Achilles tendonitis is swelling/inflammation of the Achilles tendon. If you have chronic pain or discomfort in your Achilles tendon, you, or your therapist, have probably referred to it as Achilles tendonitis. However, it’s far more likely that you have Achilles tendinosis. (2)
Tendinosis is often misdiagnosed as tendonitis because of the limited understanding of tendon injuries by the medical community. Classic characteristics of tendinosis include dull, aching pain and tenderness to touch. Often, swelling is not present in tendinosis. (3, 4)
In the late 1990’s sports medicine researchers discovered that the vast majority of people with Achilles tendon pain (aside from those with Achilles tendon ruptures) have Achilles tendinosis, rather than Achilles tendonitis. (5)
Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the tendon is acutely overloaded with a tensile force that is too heavy and/or too sudden. (6)
Tendinosis is a degeneration of the tendon’s collagen in response to chronic overuse. (7)
Tendinosis refers to damage to the tendon at the cellular level. It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tendon strength thus increasing the chance of tendon rupture.
A normal, healthy Achilles tendon will be primarily made up of type I collagen fibers. In tendinosis, the body lays down type III collagen fibers in response to the microtears developed from overuse. (8) Type III collagen is not nearly as elastic or flexible as type I. It’s really not up to the task of going through the intense stretch and contraction needed by a healthy Achilles tendon.
Proper treatment needs to address the root cause of the injury. In tendonitis, that often involves reducing swelling through limiting aggravating activities. In tendinosis, new type I collagen cells need to be rebuilt. This is not done through stretching, icing, rest, or other conventional therapies.
As Achilles tendon problems may involve either tendonitis or tendinosis, I’ll refer to them as tendinopathies for the remainder of the articles. Tendinopathy refers to a disease state of a tendon.
What causes Achilles tendinopathies?
There are both internal and external forces that contribute to Achilles tendinopathies. Internal forces such as high body mass and constitutional factors such as leg-length discrepancies can place tendons under excessive or abnormal patterns of loading. A sedentary lifestyle combined with the particular physical demands of one’s job or recreational activities may account for the increased incidence of tendon rupture in recent times. (9, 10)
External forces such as the amount and intensity of exercise also can be a causative factor in developing Achilles tendinopathies. Below, we’ll explore the most common causes.
- This is the most common cause of an Achilles tendon issues. It is prevalent in both the running and CrossFit communities. However, the athletic activity by itself is not the problem, the problem is doing too much too quickly or resuming too quickly after a layoff. This includes running/exercising for longer durations or at a greater speed/pace.
- This occurs when one leg is longer than the other or if you over or under pronate. In these cases, a custom fitted orthotic is likely all that is needed to correct the issue. Other potential misalignment causes include tight or weak calf muscles that place additional stress on the Achilles tendon.
- Improper footwear
- I’m looking at you, CrossFit athletes. Running, jumping, and other explosive movements done in lifting shoes is a surefire way to place additional stress on both the calf and Achilles tendon. Other footwear issues include worn out shoes and shoes with too little or too much support.
- Medication (11, 12)
- The quinolone group of antibiotics are used to treat a wide range of bacterial infections, but weaken some people’s tendons.
- Examples of the quinolone group of antibiotics include:
- Cortisone injections are commonly done to help alleviate pain felt in the Achilles tendon. Unfortunately, no longer having pain may cause one to overexert the already weakened tendon resulting in more damage or even a rupture.
- Some studies have found links that cortisone steroid injections in general cause a weakening of the tendons. This increases the likelihood for future tendon injuries.
- My general recommendation would be to avoid steroid injections.
- Genetics (13)
- Yes, your genes could actually influence the likelihood of you developing Achilles tendinopathies. Individuals with the single nuclear polymorphism (SNP) TT genotype of the GDF5 rs143383 variant have twice the risk of developing Achilles tendon problems.
These are the most common causes of Achilles tendinopathies. Treatment will differ depending on the potential cause.
Are there different types of Achilles tendinopathies?
You now know the difference between tendinitis and tendinosis. Determining which one you have is an imperative first step. The next step is to determine the location of your Achilles tendon injury. The most common two are:
- Insertional tendinopathy
- Mid-substance tendinopathy
An Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.
Non-insertional Achilles tendon injuries are more common than insertional Achilles tendon injuries. Like the name implies, Midpoint means midway between the top and bottom of the Achilles tendon. A non-insertional Achilles tendon injury can occur to any part of the Achilles tendon except where it inserts into the heel bone.
How to heal from Achilles tendinopathies
Before any treatment begins, a correct diagnosis is essential to successful treatment. See your doctor or a well-trained physiotherapist/sports medicine practitioner to rule out an Achilles tendon rupture/tear.
Your second step should be to replace the footwear you were using prior to developing Achilles tendon pain. If new shoes are not in the budget, consider adding an orthotic like superfeet to your shoes.
Step three is perhaps the most important. You need to determine if you have Achilles tendonitis or Achilles tendinosis. The most important reason to distinguish between tendinitis and tendinosis is the differing treatment goals and timelines. The most prominent treatment goal for tendinitis is to reduce inflammation, a condition that isn’t present in tendinosis. In fact, some treatments to reduce inflammation are contraindicated with tendinosis. (14)
Healing from Achilles tendonitis
The healing time for tendinitis is several days to 6 weeks, depending on whether treatment starts with early presentation or chronic presentation. (15) The overall treatment goal is to reduce inflammation in the tendon. Tendinitis usually comes about through an increase in duration or intensity of the aggravating factor. For example, if you typically run 5km each week and then double that distance the next week (instead of gradually building) you may develop tendinitis.
Reducing inflammation is typically done through rest, ice, compression, and elevation. Unfortunately, this is old information. The new research suggests that icing an injury actually prolongs healing time. A summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone. (16)
Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells. (17) The blood vessels do not open again for many hours after the ice is applied. This decreased blood flow can cause the tissue to die from decreased blood flow and can even cause permanent nerve damage.
Below, are 4 simple tasks to apply when healing from Achilles tendinitis:
- Decrease the aggravating activity
- I don’t recommend stopping completely. But the quantity and intensity should be lowered so as not to aggravate pain levels.
- Check your footwear
- Did pain levels begin after a new shoe purchase?
- Try a new insole or a different pair of shoes.
- Are your current shoes quite old?
- Replace with new, well-cushioned shoes.
- Did pain levels begin after a new shoe purchase?
- Apply heat
- Tendons have minimal amounts of blood flowing to them. This is why icing will likely prolong recovery time – it stops blood from entering the tissue.
- Instead, heat the tendon with warming liniments like tiger balm or magic bags.
- Eccentric calf exercises (video on how to do these here)
- These work wonders for both tendinitis and tendinosis.
- 3 sets of 10 reps are not going to cut it. You need to go until you feel discomfort in the Achilles tendon. For some, that’s 10 reps, for others, that’s well over 100 reps.
Healing from Achilles tendinosis
The treatment for tendinosis recognized at an early stage can be as brief as 6–10 weeks; however, treatment, once the tendinosis has become chronic, can take 3–6 months. It is suggested that effective treatment might take up to 9 months once the tendinosis is chronic. (17)
Tendons require over 100 days to make new collagen fibers. (18) Knowing this, treating chronic tendinosis for a matter of weeks would provide little benefit to the long-term repair of the tendon.
It is not recommended to try to reduce inflammation when healing from Achilles tendinosis. Ibuprofen, a nonsteroidal anti-inflammatory, is associated with inhibited collagen repair. (19) Corticosteroid injections like cortisone inhibited collagen repair in one study and were found to be a predictor of later tendon tears. (20)
Below are 3 activities to help heal from Achilles tendinosis:
- Eccentric calf exercises (video on how to do these here)
- The research on this exercise is astounding. Even after 3.8 years, patients who previously had Achilles tendinopathies reported no recurrence. (21) I don’t think there is any other modality or treatment that can claim such high levels of success.
- Using a proper eccentric regimen has also shown a decrease in tendon thickening, and an increase in type I collagen fibers. Remember, type I fibers are the stretchy ones we want in our Achilles’ tendons.
- While eccentric exercises are commonly prescribed by physiotherapists, the quantity tends to be woefully inadequate. To have success with this, you need to go until the pain in the Achilles tendon is recreated. (22) This can be well over 100 repetitions.
- Improve your nutrition
- Vitamin C, manganese, and zinc are all important for the synthesis of collagen production. (23)
- Adding a collagen or gelatin supplement to your diet will provide the body with additional amino acids needed to rebuild collagen.
- Change your cadence
- For optimal functioning of the Achilles tendon, one needs to be able to correctly manipulate the stretch-shortening cycle of the tendon.
- For example, if a runner runs too fast for his/her ability level, the Achilles tendon gets overloaded. If a runner runs too slow, he/she fights against rather than work in harmony with the natural, elastic rebound of the Achilles tendon. When recovering from an Achilles tendinosis, make sure the pace is neither too fast or too slow. Your Achilles needs to be in the sweet spot to avoid aggravation.
- This is not specific to running. Any activity that creates a rhythmic contraction-relaxation of the calf muscles and the Achilles needs to have a proper cadence. This includes other activities like skipping, jumping, box jumps, dancing etc.
Other remedies to help with Achilles tendinopathies
The above remedies have a lot of science to support their efficacy. This section details other treatments or remedies I’ve used personally or with patients that show promise.
Calf stretching has shown to be of little benefit in Achilles tendinopathies. I believe this is because, much like our organ systems, our muscular system does not work in isolation. Achilles tendon issues are not due solely to tight calves. Instead, our muscles are connected through a dynamic network of fascia.
The fascia found over the calves also runs up the back of our body and onto the soles of our feet. It connects the base of our skull to the plantar fascia. Tension can occur anywhere in this fascial band. Chronic tension could result in Achilles tendon issues or even plantar fasciitis.
With this in mind, stretching and foam rolling should incorporate all of the posterior fascial line. I recommend the following stretches to help stretch the posterior fascial line:
The exercises are best combined with the above activities. Especially important is the eccentric exercises. These cannot be left out.
Ok, now you know as much as I do about fixing chronic Achilles tendon injuries.
Now I want to hear from you!
What have you found to be the most beneficial remedy for healing Achilles tendon pain?
Also published on Medium.