Runners and the achilles tendon

Injury prevention and treatment for heel and ankle-related injuries

A weak or injured achilles tendon can be a source of misery for many runners. Runners are often advised to rest from exercise whenever an achilles injury strikes. But it is necessary to address the cause of the injury rather than the symptoms, or the injury will return once running is recommenced.

It is thought that the calf muscles are not very active in the push-off phase of the human running action, so this means that the calf muscles and the achilles tendons act like a shock absorber to control the impact with the ground. If the achilles is not strong enough, damage will occur due to this impact.

For runners who overpronate, it may be that the direction in which the tendon is forced to move puts too much of a demand on an otherwise reasonably strong tendon. If the tendon is not healthy, the force of the impact will produce further stresses on the tendon and small tears and areas of damage will accumulate, which over time could lead to an acute tendonitis or even rupture.

So what is achilles tendonditis and tendonosis?

In the past, most achilles tendon injuries were diagnosed as tendonitis — '-itis' meaning inflammation. Treatment would be based on rest and the use of anti-inflammatory drugs or even steroid injections.

As inflammation does not usually occur immediately, but develops several hours after the activity that has caused it, any pain will not usually be felt for several hours after the activity. Typically it will be felt when getting up the following morning. Coming down stairs can be an experience for those affected by it! If inflammation is the problem, rest will settle symptoms, but the pain is likely to recur if the exercise that caused it is not modified.

The perceived wisdom today is that achilles tendon injuries are more usually a form of tendonosis, which essentially means that the tendon is 'unhealthy'. As a result of an imbalance between the strength of the tendon and the strain it is under, small areas of damage appear within the tendon, and this doesn't repair too easily.

Achilles problems are more common in older runners. Depending on the severity of the damage, the pain will come on at different points during a run, and may settle down only to return towards the tail end of a run. The tendon will be sore and tender immediately after the situation, unlike tendonitis where the pain comes much later. The achilles will generally feel stiff and sore the next morning.

Tendonosis left unchecked can lead to partial rupture or complete rupture of the achilles. Pain will appear suddenly, when the tendon is put under additional strain, such as during a sprint or when running up a hill. A complete rupture will feel as though you have been struck on the back of the leg or you may hear a crack. Walking with this type of injury will be near impossible and medical assistance should be sought.

Treating an achilles injury

After signs of an injury first materialize, it is advisable to avoid running for at least one week. The length of the lay-off will very much depend on the grade of injury.

In his book Lore of Running, Dr Tim Noakes describes four grades of injury:

  • Grade 1 — discomfort in the tendon first thing in the morning
  • Grade 2 — pain on running but not affecting performance
  • Grade 3 — pain affecting performance
  • Grade 4 — running is impossible

Regardless of the grade of injury, before returning to training, you should consider the potential causes. Take a look at your running shoes — maybe it's time to get some new ones, or have a gait assessment done to ensure you have the right ones for you. You should also consider whether your calf muscles are too tight.

Here's some suggested recovery solutions for each of the different grades of injury:

  • Grade 1 — after resting for one week, it is probably not necessary to modify training too much.
  • Grade 2 — it will be necessary to cut back on speed and hill work and possibly also mileage.
  • Grade 3 — any running should be restricted to short jogs and cross-training is much preferred.
  • Grade 4 — clearly no running should be attempted.

For all grades of injury, eccentric exercises of the calf muscles and achilles tendon should be carried out. This will, over time, strengthen the achilles tendon and its elasticity will return. In addition, your running ability will improve and you'll have greater protection against injury in the future.

Why can achilles problems suddenly come on?

Achilles problems often emerge when a runner has a sudden increase in training. This can either be due to an increase in the amount of training or an increase in the quality of training. Often, the introduction of hill traning can be a significant factor.

The reasons that this increase presents a problem could be a due to a number of contributing factors, including: overly tight calf muscles, overpronation, stiff-soled shoes, shoes with flatter heels than normal, and stiff ankle joints. Older tendons are also more prone to damage.

Ankle strains

In addition to the threat to the achilles posed by running, the ankle can also be at risk, especially when running on uneven ground. While cross-country and running on trails does give the muscles and tendons some protection from impact, it does however require the ligaments around the ankle to work harder. If the ligaments are not sufficiently strong, or the strain on them is too great (for example, strain caused by going over on an ankle), the ligaments will tear. Occasionally the damage can be severe enough to affect the stability of the ankle, meaning that treatment is required. A less severe injury usually occurs and involves a few fibers in the ligaments on the outside of the ankle tearing, resulting in bruising and swelling and a fair bit of pain.

After sustaining an injury — rest, ice, compression (with Tubigrip bandage) and elevation are the key. As a rule, do not attempt to run until it is possible to walk without a limp. Make sure that the ankle isn't allowed to stiffen, so as soon as you feel able to (even if there is still some discomfort — but not severe pain!), move the ankle joint through a full range of motion.

Sadly, after damaging your ankle ligaments, your chances of sustaining a further similar injury are increased. This is nothing to due with a weakening of the actual strength of the ligaments, but more to do with a reduction in the body's ability to sense what position the foot is in, which would usually allow the muscles to make quick adjustments to take account of uneven surfaces.

This is because sensory nerve endings contained within the ligaments are damaged at the time of the original injury. Thankfully it is possible to 'retrain' the ligaments in their ability to sense the position of the foot by working out on a wobble board.

When an injury occurs, it is often down to more than just poor luck. More often than not there is a clearly identifiable reason why a specific injury has occurred at a particular time. If a period of rest and rehabilitation is what is called for, then do so. Your muscles will hopefully be better prepared for the challenges that lie ahead provided you have tackled the root cause.

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