Achilles tendon injuries are one of the most common injuries faced by runners. They can be broken down into the following categories:

  • Tendonopathies (insertional and mid-portion)
      • Tendonopathy is the the term used to describe both tendonitis and tendonosis.
      • Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the calf muscle and achilles tendon is overloaded with a force that is too heavy and/or too sudden.
      • Tendinosis is a degeneration of the tendon in response to chronic overuse.
      • Tendonopathies can occur where the achilles inserts into the heel bone (calcaneous) called insertional tendonopathies, or in the middle part of the achilles called mid-portion tendonopathies.
      • Tendonpathies are the most common achilles tendon issues faced by runners.
  • Partial Thickness Tears
      • As the name suggests this is usually an acute injury where some of the achilles fibres are torn as a result of a sudden increase in force caused by an activity like jumping or sprinting.
      • Symptoms include a sudden sharp pain in the Achilles tendon. Sometimes though, you may not feel pain at the time of the tear but later on or the next day when the tendon has cooled down and stiffened up
  • Retrocalcaneal Bursitis
      • Retrocalcaneal bursitis is inflammation of the bursa (a small, cushioning sac located where tendons pass over areas of bone around the joints), which lies over the heel (calcaneus) where the Achilles tendon inserts.
      • Symptoms include pain and swelling over the back of the actual heel bone which is sensitive to touch or put pressure on.
      • Can be difficult to differentiate from an insertional tendinopathy because the pain occurs in the same area. The biggest difference is the soft sack of swelling that occurs in a bursitis.
  • Kager’s Fat Pad Inflammation
      • This is one of the less well known, less understood and less diagnosed issues that causes achilles tendon pain.
      • Kager’s Fat Pad is thought to help protect the blood vessels that supply the achilles tendon, and also to minimise the pressure changes in the retrocalcaneal bursa
      • It is difficult to diagnose in isolation and is more likely a contributing factor to pain when other conditions are also present.
  • Paratenonitis
      • Paratenonitis refers to inflammation of the paratenon, which is a thin membrane around the tendon. The paratenon helps the tendon glide up and down smoothly as the Achilles tendon contracts and relaxes to move the foot and ankle up and down.
Diagnose your achilles pain

To be 100% certain of exactly which of these conditions is causing your achilles pain you would need to get an MRI scan. BUT, before you rush off for a scan, you should start a rehab program and give yourself at least 2 -3 weeks to try and manage and improve your symptoms. If your symptoms start to improve, then you don’t need a scan, you should continue with the rehab program.

An MRI scan diagnosis is unlikely to change the initial phase of rehabilitation you need to undertake regardless of which of these conditions you have.

If, after 2 -3 weeks, your symptoms have not improved, or have got worse, that would be the time I would recommend a scan. Two examples of achilles pain which might not respond to the following rehab program are a partial thickness tear which might need a period of enforced rest in a boot, or a bursitis which might also need a period of rest, or possibly even a cortisone injection to help it to settle.

If you are careful and diligent with the rehab program, then even if you have one of these two “stubborn” issues, you won’t be causing further damage or injury, so you have nothing to lose in try a rehab program as the first line of defence.

Rehab your achilles pain

The most common achilles tendon pain experienced by runners is tendonosis. The typical symptoms of tendonosis is where the achilles initially starts becoming stiff in the mornings after a run. The symptoms gradually increase, with the morning stiffness lasting longer and longer, and then eventually becoming painful. This pain usually “warms up” during a run, but over time, if it isn’t rehabbed properly it takes longer and longer to “warm up” until one day it doesn’t actually warm up, it hurts with every step and you finally realise that unless you get some help the pain isn’t going to go away!

The typical healthcare (doctor and physio) model for helping achilles pain is to recommend rest. For some conditions like a partial tear a period of rest is beneficial, for tendonosis however, rest will make you worse!

An achilles with tendonosis needs a graduated load applied to the tendon to help it repair and regain strength. This was discovered in the mid 1990’s by Dr Hakan Alfredson, a Swedish orthopaedic surgeon and researcher. He had chronic achilles tendon pain himself and after failed conservative care asked his boss to book him in for surgery. His boss refused because he thought the case wasn’t serious enough. Frustrated with the ongoing pain, Dr. Alfredson decided to load his achilles aggressively to try and rupture it so that he needed surgery. The loading strategy he undertook was called “eccentric heel drops” (raising up on his toes and lowering back down again on the one sore achilles leg). To his surprise, his achilles tendonopathy didn’t rupture, but in fact eventually completely resolved.

Rehab Step 1 – Reducing tension in the calf muscle

Stiff, tight calf muscles can contribute to achilles tendon pain. The easiest way to reduce this tension is to gently stretch both the gastrocnemius and soleus muscles. Insertional tendonopathies can be aggravated by aggressive stretching, so make sure that your stretches are gentle, and that you hold them for quite a long period of time (2 – 5 minutes)

  • Here is my favourite gastrocnemius stretch
  • And my favourite soleus stretch is the Hunter-Gather Squat. Please note: if your achilles tendon hurts while doing the Hunter-Gather Squat, then work on the gastrocnemius stretch and the trigger point ball release for 1 week before trying the Hunter-Gatherer Squat again. Keep applying this same process every week until you can perform the squat pain-free.
  • You should also use a Trigger Point Ball to release the tension in both the gastrocnemius and soleus muscles
Rehab Step 2 – Strengthening the tendon

The typical physiotherapy treatment model for achilles tendon strengthening is to implement the “Alfredson Protocol” where you gradually build up the number of eccentric heel drops you do to strengthen the tendon. If your symptoms are particularly severe, and you have pain on every step when you run, then this is probably a good way to start your rehab for the first 1 – 2 weeks, until your morning stiffness starts to reduce and you feel like the symptoms are starting to improve. Insertional tendonopathies are much more likely to need the heel drops for initial rehab than mid-portion tendonopathies.

Most runners love to run more than anything else, so a program of eccentric heel drops doesn’t quite push their buttons in quite the same way as running does. For this reason, I try to recommend a gentle and graduated return to running program to rehabilitate achilles tendon injuries rather than heel drops.

For an achilles tendonopathy to successfully repair it needs a small amount of load, followed by a small amount of repair in order to regain strength and structural integrity. The key to returning to running is to keep the runs short, so that you cause micro-trauma to the tendon and stimulate a healing response. If you run too far, you cause too much trauma, which needs longer periods of recovery to repair. Meaning that if you run too far, and try to run again the next day, then you are actually making the problem worse rather than better.

You can read this beer drinking analogy article to learn more about how to structure your training when you are recovering from achilles tendonopathies.

Return to Running Program:

Read this article on how to return to running after injury – to make sure you fully understand the process you need to undertake, and how carefully you need to manage your symptoms during the early phase of rehab.

The following interval table should be used as a guideline for you to follow in your achilles tendon rehab. It is structured in a way to prevent any sudden increases in volume or load. One of the biggest mistakes runners make when returning from injury is to jump from walk/run intervals in the first week or two of rehab, straight back to 5km or 10km runs. This is usually the point where injuries recur.

You need to repeat each level of this table twice with no increase in your symptoms, before you progress to the next level.

Some people will be able to move through these levels faster than others. It will depend on the nature and severity of your achilles injury.

It may seem like your progress will be frustratingly slow using this method, but it works. It has worked for thousands of runners I have treated over the last 20 years, and is the most successful way of building back up to a full running volume without re-injuring yourself.

EXPLANATION OF THE LEVELS:

Level 1 – Run for 2 minutes, then walk for 1 minute, run again for 2 minutes and walk for 1 minute. Repeat a total of 5 times, so that the total running volume is 10 minutes.

Level 2 – Same as for level 1 except there are 7 reps (14 minutes of running)

NB: When following this program it is possible to run 7 days/week as long as your base level of pain is not increasing. Be sensible though, and listen to your body. If you feel like you need a day off, then take one.