A Runner's Achilles Heel
Preventing Achilles injuries
A common and sometimes chronic grievance, Achilles tendinopathies can be, both literally and figuratively, a runner's Achilles heel. The media's constant chatter about Achilles injuries only serves to highlight their prevalence. Reporters recently speculated that Usain Bolt's loss to Tyson Gay at the Diamond League Meet in Stockholm was the result of a slow recovery from an Achilles injury. David Beckham's highly publicized Achilles rupture prevented him from playing in this summer's World Cup. Even Alex Wong, a contestant on this season's So You Think You Can Dance, had his rug-cutting dreams dashed by an Achilles laceration.
While these types of injuries occur among soccer players, dancers and everyone in between, runners are perhaps the likeliest candidates. Handling up to 12 times your body weight, that tendon has a big job. Achilles tendinopathies, which include acute tendinitis and the more chronic tendinosis, account for nearly 11 percent of running injuries. As many of these injuries result from training errors, experts agree that education about proper training and rehabilitation is the key to combating them.
Physiology of the Achilles
"The Achilles is the strongest and largest tendon in the body. It's a very important structure," says Claude Pierre-Jerome of Emory University, a leading researcheron the foot and lower leg. Joining at the Achilles is the gastrocnemius and the soleus muscles, which both come from the upper part of the lower leg. The Achilles tendon then attaches to the calcaneus on the back of the heel.
In addition to getting used a lot, the Achilles receives poor blood supply, which makes it particularly susceptible to injury and, once injured, is slow to heal. While tendon injuries can occur on the entire length of the Achilles, the blood supply is most lacking 2-6 centimeters above the insertion point, leading to the greatest percentage of injuries in that area.
The Achilles tendon carries a lot of load and, when you're running, the load increases. If the tendon isn't healthy and the load is increased, it causes injuries. All tendons, bones and muscles need cyclical loading to work properly, but sometimes the loading exceeds what the tissue has adapted to.
While the Achilles can tear or rupture completely, most of the overuse injuries associated with running are less acute. When it comes to Achilles pathology, most runners will suffer from either tendinitis or tendinosis. Tendinitis is when there is acute inflammation. The tendon itself is surrounded by a sheath and that becomes inflamed. Tendinosis is more chronic and runners tend to just run through it for months, if not years. That's where you get degeneration of the tendon itself. Regardless of the diagnosis, the culprit that causes these ailments is usually identical: training errors.
So Much Load, So Little Time
Most experts agree that overtraining or incorrect training, improper footwear and certain types of terrain lead to most Achilles tendinopathies. Unfortunately , Running is one of the main activities that leads to Achilles tendon injuries.
Typically these Achilles injuries are caused by building up mileage or intensity too quickly, or doing too many hills. When you do too much too soon, things start breaking down. Speedwork and hill training are commonly identified causes that spring from training. While these are necessary aspects of any good training plan, injuries come from jumping into them too soon or too fast.
Your own biomechanics (determined by genetics) can play a role, but causes can also be traced to shoes and terrain. Some people wear shoes that aren't appropriate for running and that puts an extra load on the tendon, which then causes injuries.
Dr. DiPretoro has seen many patients with Achilles injuries who wear shoes with too much cushioning and not enough support. He explains that a highly cushioned heel allows your feet to sink down too far, while your calf muscle is simultaneously contracting. Then you have the tendon being pulled in two directions. It's being yanked down at the same time the muscle is pulling it upwards and it over stretches.
Similarly, overly soft surfaces that cause the tendon to work harder, like sand, have been said to cause Achilles injuries. Also, the crowning affect of many roads that can lead to imbalances when runners are always on one side.
Road to Recovery
We hope runners will take care of these injuries early on when they first start having pain. In those cases, it can be treated with rest, ice and elevation to start with. Even a few weeks of gentle treatment and decreased mileage can get a runner over a mild case of tendinitis.
In all cases, the first line of defense is understanding the pathology. Your personal running history, the length of time you've had the injury and the other activities in which you are involved can all be important factors in determining a treatment plan.
First and foremost, we have to calm down the symptoms before we can be aggressive with any stretching and strengthening. Unless you are having significant pain with every walking step, we usually prefer not to cut out training, but to cut it down. This is the very reason for the 10 percent rule—avoiding mileage increases from week to week that exceed 10 percent is one way to curb Achilles injuries. Experts agree that cutting back on mileage, avoiding hills and staying away from speedwork for a few weeks can sometimes be enough.
As the rehabilitation progresses, there are a number of different exercises that have been shown to be beneficial. For chronic Achilles tendinosis, in particular, eccentric training is often prescribed once the runner is asymptomatic. To do this, stand on a ledge or platform with your heels off the back and do a toe raise with both feet; come back down using only the affected side. While this may not work for many patients, research suggests that it is helpful to some runners. Do not allow your heel to go down too far off the platform, thereby overstretching the Achilles. It is meant to be a light strengthening exercise.
Keeping the calf muscles healthy will also help to rehab an ailing Achilles and prevent further issues. Besides the heart, the calf muscle is the hardest working muscle in the body. It's taking stress and applying stress with every single footstep. Most doctors and PTs will recommend fairly gentle stretching. Runners should stretch the calves by placing hands against a wall with one leg extended straight back with the knee straight and the other leg forward with the knee bent. The straight leg will stretch the gastrocnemius and the bent knee leg will stretch the soleus. Since these are the muscles that eventually connect with the Achilles, their flexibility leads to less stress on the tendon.
Upon following your Podiatrists' orders regarding icing, training modifications and stretching and strengthening routines, you will also want to check your footwear. Put simply, choose a shoe that is right for your foot type. Adding in heel raises and orthotics may also help calm the symptoms. We usually suggests a ¼-inch heel lift in a runner's shoes, saying that such lifts can decrease the stress on the tendon by 10–15 percent. Additionally, lifts can be built into orthotics, which also help cut down on three-dimensional torque.
If you react quickly, it could take as little as three weeks to heal. However, if you react slowly, it could take three months, six months or longer. In the interim, substitute some of those running miles for biking and swimming. Through crosstraining, you will continue to bank cardiovascular fitness without further irritating the tendon. In the end, smart and methodical training will help you avoid making your Achilles heel, your Achilles heel.
While these types of injuries occur among soccer players, dancers and everyone in between, runners are perhaps the likeliest candidates. Handling up to 12 times your body weight, that tendon has a big job. Achilles tendinopathies, which include acute tendinitis and the more chronic tendinosis, account for nearly 11 percent of running injuries. As many of these injuries result from training errors, experts agree that education about proper training and rehabilitation is the key to combating them.
Physiology of the Achilles
"The Achilles is the strongest and largest tendon in the body. It's a very important structure," says Claude Pierre-Jerome of Emory University, a leading researcheron the foot and lower leg. Joining at the Achilles is the gastrocnemius and the soleus muscles, which both come from the upper part of the lower leg. The Achilles tendon then attaches to the calcaneus on the back of the heel.
In addition to getting used a lot, the Achilles receives poor blood supply, which makes it particularly susceptible to injury and, once injured, is slow to heal. While tendon injuries can occur on the entire length of the Achilles, the blood supply is most lacking 2-6 centimeters above the insertion point, leading to the greatest percentage of injuries in that area.
The Achilles tendon carries a lot of load and, when you're running, the load increases. If the tendon isn't healthy and the load is increased, it causes injuries. All tendons, bones and muscles need cyclical loading to work properly, but sometimes the loading exceeds what the tissue has adapted to.
While the Achilles can tear or rupture completely, most of the overuse injuries associated with running are less acute. When it comes to Achilles pathology, most runners will suffer from either tendinitis or tendinosis. Tendinitis is when there is acute inflammation. The tendon itself is surrounded by a sheath and that becomes inflamed. Tendinosis is more chronic and runners tend to just run through it for months, if not years. That's where you get degeneration of the tendon itself. Regardless of the diagnosis, the culprit that causes these ailments is usually identical: training errors.
So Much Load, So Little Time
Most experts agree that overtraining or incorrect training, improper footwear and certain types of terrain lead to most Achilles tendinopathies. Unfortunately , Running is one of the main activities that leads to Achilles tendon injuries.
Typically these Achilles injuries are caused by building up mileage or intensity too quickly, or doing too many hills. When you do too much too soon, things start breaking down. Speedwork and hill training are commonly identified causes that spring from training. While these are necessary aspects of any good training plan, injuries come from jumping into them too soon or too fast.
Your own biomechanics (determined by genetics) can play a role, but causes can also be traced to shoes and terrain. Some people wear shoes that aren't appropriate for running and that puts an extra load on the tendon, which then causes injuries.
Dr. DiPretoro has seen many patients with Achilles injuries who wear shoes with too much cushioning and not enough support. He explains that a highly cushioned heel allows your feet to sink down too far, while your calf muscle is simultaneously contracting. Then you have the tendon being pulled in two directions. It's being yanked down at the same time the muscle is pulling it upwards and it over stretches.
Similarly, overly soft surfaces that cause the tendon to work harder, like sand, have been said to cause Achilles injuries. Also, the crowning affect of many roads that can lead to imbalances when runners are always on one side.
Road to Recovery
We hope runners will take care of these injuries early on when they first start having pain. In those cases, it can be treated with rest, ice and elevation to start with. Even a few weeks of gentle treatment and decreased mileage can get a runner over a mild case of tendinitis.
In all cases, the first line of defense is understanding the pathology. Your personal running history, the length of time you've had the injury and the other activities in which you are involved can all be important factors in determining a treatment plan.
First and foremost, we have to calm down the symptoms before we can be aggressive with any stretching and strengthening. Unless you are having significant pain with every walking step, we usually prefer not to cut out training, but to cut it down. This is the very reason for the 10 percent rule—avoiding mileage increases from week to week that exceed 10 percent is one way to curb Achilles injuries. Experts agree that cutting back on mileage, avoiding hills and staying away from speedwork for a few weeks can sometimes be enough.
As the rehabilitation progresses, there are a number of different exercises that have been shown to be beneficial. For chronic Achilles tendinosis, in particular, eccentric training is often prescribed once the runner is asymptomatic. To do this, stand on a ledge or platform with your heels off the back and do a toe raise with both feet; come back down using only the affected side. While this may not work for many patients, research suggests that it is helpful to some runners. Do not allow your heel to go down too far off the platform, thereby overstretching the Achilles. It is meant to be a light strengthening exercise.
Keeping the calf muscles healthy will also help to rehab an ailing Achilles and prevent further issues. Besides the heart, the calf muscle is the hardest working muscle in the body. It's taking stress and applying stress with every single footstep. Most doctors and PTs will recommend fairly gentle stretching. Runners should stretch the calves by placing hands against a wall with one leg extended straight back with the knee straight and the other leg forward with the knee bent. The straight leg will stretch the gastrocnemius and the bent knee leg will stretch the soleus. Since these are the muscles that eventually connect with the Achilles, their flexibility leads to less stress on the tendon.
Upon following your Podiatrists' orders regarding icing, training modifications and stretching and strengthening routines, you will also want to check your footwear. Put simply, choose a shoe that is right for your foot type. Adding in heel raises and orthotics may also help calm the symptoms. We usually suggests a ¼-inch heel lift in a runner's shoes, saying that such lifts can decrease the stress on the tendon by 10–15 percent. Additionally, lifts can be built into orthotics, which also help cut down on three-dimensional torque.
If you react quickly, it could take as little as three weeks to heal. However, if you react slowly, it could take three months, six months or longer. In the interim, substitute some of those running miles for biking and swimming. Through crosstraining, you will continue to bank cardiovascular fitness without further irritating the tendon. In the end, smart and methodical training will help you avoid making your Achilles heel, your Achilles heel.
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