Achilles Tendon help !

A friend of mine has been having trouble with her achilles tendon and not really got anywhere from her GP. I asked her to give me a script of what the problem is so that I could post it on here and see if anyone can help or point her in the direction of an expert in the Wigan area who is a runner themselves or who understands running injuries. This is what she sent me....

"Right here we go- hard lump on ankle tendon, which is aching and hot in the morning. If I am still for long periods it goes stiff and can be quite painful 😖.
I have iced it most nights, most days take ibruprofen and ibulieve gel alternately.
Went docs again on Tuesday after not running on it for about a month and I've got stronger anti inflammatory tablets, he's gonna send me for physio and ultrasound. He said its tendonitis and so far he doesn't think the lump has ruptured! Looking on tinernet and non impactive exercises are best -swimming n cycling. Also very flat shoes can be bad and it recommends gel heel inserts for running which I used to have up to the double marathon training so looking to use these again once I'm running again"

Any help or advice would be appreciated. She wants to get back running as soon as possible but doesn't want to start too soon to avoid serious injury to her Achilles.

Old recurring problem for me. Can be three forward then all of a sudden two back, if you over-do it. Physio didn't approve of breast-stroke because of 'flicking your feet'. Takes time, so you need handle the mental depression somehow. Physio said 3 weeks then confessed to more 'you wouldn't have behaved if I had said more than 3'. Informed me after 6 weeks that I could walk long distances in boots if I started slowly. Drove to Glen Etive: it worked. Depression cured. Best of luck.

The following is based entirely on my personal experience; I have no qualifications in physiotherapy etc.

If there is a hard lump, it sounds more like tendinopathy than tendonitis. The unwanted lump needs to be broken down, and it's a slow process, with most of the work being done by the runner herself, not the physio. It's a regime of "eccentric stretching" (heel drop) exercises; a Google search of terms like "eccentric stretching for Achilles tendon" will lead you to websites explaining this. My physio's prognosis was that it would take 6 to 9 months to get back to normal running mileage, which turned out right, although I was able to start the very gradual build-up within about 2 months of the diagnosis; but I am 58 years old, so it may be quicker for someone younger, depending on the severity of the problem. Last Saturday I ran my first race since the tendinopathy became apparent (Wardle Skyline): no problems with the Achilles, but the race did something horrible to my big toe!

Regarding alternative exercise while recovering: I don't swim, but I do enjoy cycling. My physio's advice was that cycling is OK as long as you maintain your feet in a "neutral" position, i.e. flat on the pedals.

I didn't take any anti-inflammatories, apart from a few applications of Ibulieve in the first days after the pain started (and it didn't seem to have much effect). The physio didn't use ultrasound, but he did some manual work on the tendons to help break up the lumps.

In conclusion, do see a physio, who will have the specialist knowledge that your GP may not have. And do be prepared for a rather long, slow recovery process.

This link http://www.runningwritings.com/2013/...n-runners.html is by far the most comprehensive and well researched piece I have found on Achilles problems.

In summary, it's all about the eccentric heel drops, don't bother with anti-inflammatories as it is not inflammation, its a degeneration.

Thanks all for your posts so far. I'll pass them on to her.

Hammer the calf raises. worked for me.

With these injuries it is very important to be careful with whatever kind of rehab you are doing. The Achilles rupturing can stop any kind of physical activity you if you are unlucky, and in some cases tendinitis in the Achilles can even lead to bursitis. Here is a good article that gives some advice on dealing with Achilles tendinitis https://runnersconnect.net/achilles-...hy-in-runners/

Just a slight continuation of this -
Generally speaking, yes, hammer the calf raises... but make them heavy rather than doing loads of them.... if you can physically do 10 calf raises then you're doing them too light. Load up.

Eccentric contractions have shown to be no more effective than concentric, so don't worry about doing it off a step, just calf raise from the floor.

Note that there are a couple of different types of tendonopathy - reactive and degenerative, and it will depend on which type you have, and what stage of tendonopathy you are in as to what might make it worse or better... so even though there are general guidelines, its probably best to see someone that can give you specific advice according to your circumstances.

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Originally Posted by zephr

Just a slight continuation of this -
Generally speaking, yes, hammer the calf raises... but make them heavy rather than doing loads of them.... if you can physically do 10 calf raises then you're doing them too light. Load up.

Eccentric contractions have shown to be no more effective than concentric, so don't worry about doing it off a step, just calf raise from the floor.

Note that there are a couple of different types of tendonopathy - reactive and degenerative, and it will depend on which type you have, and what stage of tendonopathy you are in as to what might make it worse or better... so even though there are general guidelines, its probably best to see someone that can give you specific advice according to your circumstances.

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Do you have a reference for that middle paragraph re eccentric vs concentric? - and you can of course do concentric on a step and eccentric on a floor.

I have had some low level Achilles pain (I wouldn't go as far as calling it a real problem yet), and since I stopped doing calf raises it's actually disappeared for now.

I do a lot of strength work, squats, leg press, etc, and was really hammering the calf raises.

Maybe I was just doing too much with all the running as well... in fact it was probably just coincidence, as I've recently changed my day-to-day trainers, and most of all I also started icing it quite regularly... but thought I'd share...

I would however recommend skipping with a rope as a fantastic way to build your calves up. If you can work up to 5 x 3 minute rounds then your calves will certainly be in very good shape (and your shoulders!)

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Originally Posted by Travs

I have had some low level Achilles pain (I wouldn't go as far as calling it a real problem yet), and since I stopped doing calf raises it's actually disappeared for now.

I do a lot of strength work, squats, leg press, etc, and was really hammering the calf raises.

Maybe I was just doing too much with all the running as well... in fact it was probably just coincidence, as I've recently changed my day-to-day trainers, and most of all I also started icing it quite regularly... but thought I'd share...

I would however recommend skipping with a rope as a fantastic way to build your calves up. If you can work up to 5 x 3 minute rounds then your calves will certainly be in very good shape (and your shoulders!)

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.... or jumping just a few inches off the ground with the same timing as if you were skipping with a rope - I find the rope is just a distraction/time waster. Then you can do it as hops - 2 steps each side, 4, 8 ... all good plyometric stuff and great for the calfs/Achilles tendons.

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Originally Posted by Mike T

Do you have a reference for that middle paragraph re eccentric vs concentric? - and you can of course do concentric on a step and eccentric on a floor.

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I dont actually have one on me (as it were), but Im sure I can dig one out for you...
Just in case youre wondering, it'll almost certainly come from Seth o'neill or Jill Cooke. I think it's Jills work...

MikeT - Sorry about the wait...

It's actually from a recent(ish) systematic review of tendon loading protocols by Malliaras et al.
Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.

publicly available pdf is here....
http://physiovelo.com/wp-content/upl...mes.pdf?x12367

The clinic is based in Pride Park, Derby offers specific treatment options that are discussed with you and are tailored for your individual needs. Highly trained with over 20 years of experience, the physiotherapists use physical treatments to restore and maintain physical, psychological and social well being. Services are available for Physiotherapy and Sports Massage for sports Injuries. We provide assessment, treatment and advice to individuals, sports teams and local businesses in Derbyshire

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Originally Posted by Yaks

This link http://www.runningwritings.com/2013/...n-runners.html is by far the most comprehensive and well researched piece I have found on Achilles problems.

In summary, it's all about the eccentric heel drops, don't bother with anti-inflammatories as it is not inflammation, its a degeneration.

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This is excellent - thanks for posting :)

I have just started with this too, it is very mild, no pain after the initial onset yesterday evening while walking home up hill; just very slight discomfort today with no impact on walking or doing anything really, but slight swelling is definitely there.

I am not too upset, something going wrong somewhere, no matter how careful I am being, was kinda to be expected after such a long break from running, but yeah, I better get stuck into some heel drop exercises.

While I was searching on this topic, I found a physiotherapy service specifically targeted at achilles tendinopathy conducted over video call, they certainly seem to know what they are on about and focus on active recovery so you don't lose your fitness while healing your tendon.

https://www.treatmyachilles.com

Disclaimer: I haven't used their service so have no first hand experience. I will be monitoring my tendon closely and if I don't see an improvement this week with the heel drops, I will probably give them a call.

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Originally Posted by zephr

MikeT - Sorry about the wait...

It's actually from a recent(ish) systematic review of tendon loading protocols by Malliaras et al.
Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.

publicly available pdf is here....
http://physiovelo.com/wp-content/upl...mes.pdf?x12367

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Thanks for that. It is my understanding that in general they feel that the outcome with eccentric exercise is no better than the outcome with combined exercises. In the summary they do say that loaded eccentrics are probably better in athletes with strong muscles/high loads, whereas the combined exercises are probably better in those with weak muscles.
When I do calf drops (for prevention, despite the lack of evidence) I do them on the floor, not a step, so as not to stress the Achilles tendon insertion into the heel, and I go up on both feet and come down on one, so there is a concentric component in the exercise, albeit not a heavily loaded component.
Of course the exercise that you don't do will not work - eccentrics are simple, but, compared to some other programs, do have the disadvantage of (supposedly) being done twice every day.

Just listening to this interview with Professor Håkan Alfredson, it's quite interesting and discusses the difference between midpoint and insertional tendinopathy:

https://soundcloud.com/bmjpodcasts/t...dinopathy-with

An important point to note is that if the tendinopathy is insertional that the heel drops should only be performed to the point where the foot is level and doesn't extend beyond the pinch point.

I've been doing these exercises on the leg that is showing symptoms but you have me thinking that I should probably do them on my other leg too.

For what it's worth I don't find the 2 x 90 repetitions each day to be a problem, it takes a little time and I am getting muscle soreness towards the end of the sets, which I take to be a good thing. I don't think it will be long before I start loading.

I think you are probably very wise to do these as a preventative measure Mike T :)

I found these videos that should help eliminate the possibility of any misunderstanding on how to perform these exercises:

https://youtu.be/M6EKuuZ7C2E

https://youtu.be/XYl8pOkw-aE

Update: 4 days of doing these exercises and the difference is significant. The tenderness has diminished considerably and I have no pain in the tendon while running. I have been able to continue my training no problem, just making sure I take it a bit easier and don't push it. Which is probably sensible anyway.

My calf muscles hurt from doing these exercises though, this is muscle pain, nothing else, and there seems to be bits of muscle at the bottom of my calf that are developing at an alarming rate, I mean I guess the muscle was always there, but I can see it and feel it whereas before they were kind of lost.

I am also taking Vitamin C in the morning and MSM in the evening to help the production of collagen. This is info I know from elsewhere, not mentioned in any of the rehabilitation guides for achilles tendinopathy, but it can't hurt, it's just vit c and sulphur - both foods rather than medicines.

I am also being careful not to over stress the tendon insertion point by not dropping too far below the step. One time I did it too far and it just felt a little bit wrong. Having heard that the way to strengthen the insertion point is to not descend below the step level, it seems sensible to build that up really slowly.

I'll keep reporting back on my progress and hope my experience helps others :)

I am still doing these exercises, all pain and discomfort has all but gone. Some very slight tenderness, but almost nothing, certainly nothing to be worried about at this point.

No interruption to my training at all.

These exercises seem to be working :)