Achilles Tendonitis, part 2: Treating your Achilles tendonitis

Achilles tendinitis can be an annoying and chronic problem if it isn’t addressed early and properly. Most cases are mild, but its important not to ignore the warning signs and assume it will go away on its own.

Being able to identify which stage of healing you’re in is critical in knowing how to approach managing the problem. Acute tendonitis can be defined as the first 4 days after injury. Let’s say you ran sprints on the track without a proper warm up on Monday. That evening you notice that there’s swelling and discomfort in your Achilles. Tuesday morning rolls around and your Achilles is a lot more uncomfortable and swollen. Monday is day 0, Tuesday is day 1. That following Friday is day 4. Subacute tendinitis is 5-14 days after injury. Post acute tendinitis is more than 14 days after injury.

Simple, right? No… not really. Because Achilles tendonitis is actually considered a chronic overuse injury. This means there has been microtraumas from repetitively using and loading the Achilles tendon. This process can occur over days, weeks, months, even years. But doing too much, too soon, can cause a case of acute inflammation and pain as well. So can training errors and even new shoes!

As soon as you realize you irritated your Achilles tendon that Monday from sprint training, the best thing you could do is ice that tendon and rest it, to allow the symptoms to calm down. The worst thing you can do is wake early Tuesday morning with the intention of running up and down hills for 45 minutes. Research is a little wish-washy on how many days is recommended to ice an overuse injury. I typically tell my clients that for 72 hours after injury they ice the Achilles multiple times daily for 15-20 minute increments, and don’t do anything overly strenuous. That means no running, jumping, walking a lot, strength training of the calves…. Nothing. But if all goes well, the irritation will calm down considerably, allowing you to gradually return to prior activity.

ACTIVITY MODIFICATION

Swelling typically reduces around 7-14 days after a flare up, though may not be entirely gone. When the initial symptoms have calmed down, you’re ready to begin actively working on the problem to prevent it from happening again. If you’re that runner that injured the Achilles doing sprints, that means you can try a slow, light jog. No hills. No speed work. Easy, short, slow, flat jog. For the non-runner, this could mean getting back to some of your usual daily activities that were too bothersome to do while it was flared up. Most importantly, continue activity as tolerated.

My general rule of thumb is that if the Achilles hurts while running or doing any specific activity, that’s a clear warning sign that perhaps you aren’t ready to do that activity and to hold off a little longer. If there is no pain while doing the activity but there’s more pain the day after, then perhaps you did too much and should ease up a bit. If there’s mild pulling or easily ignored, mild awareness type discomfort then proceed with caution.

Avoid activities and movements that outright hurt. Especially avoid it if they are repetitious or place a lot of strain/stress on the Achilles. While still in the acute or sub-acute phases it will be important to ice the Achilles tendon immediately after you run or do any activity that may cause potential irritation. Think of it as your insurance policy against the Achilles flaring up again.

SHOES

You will find so much conflicting information on different shoes. Many brands will claim they are the best for Achilles tendonitis.

But there’s weak and contradictory evidence to show that heel lifts or shoes with a higher drop are actually beneficial. That said, it’s been my personal experience that I break out my Brooks Glycerin, with a 10mm drop, for running if I find my Achilles starting to get irritated. The higher drop can help decrease the load placed on the Achilles while running and allow me to run with less discomfort. That, combined with sticking with some of the activity modification rules laid out above gets my Achilles under control in no time.

That said, shoes can absolutely have a profound impact on how your Achilles feels. My personal recommendation is that you see your local physical therapist who can look at your walking/running gait pattern and take a look at your foot and leg alignment. Then head over to your nearest specialty shoe store (sorry, big box stores like Dicks Sporting Goods don’t count) to be properly fitted and set up with a good shoe. Stability shoes, rocker bottom shoes, and orthotics can potentially be helpful. But keep in mind you might need to try a few different pairs of shoes to find the right one. And please… put the flip flops, crocs, high heels, and flats in the closet for a while.

That said, shoes can absolutely have a profound impact on how your Achilles feels. My personal recommendation is that you see your local physical therapist who can look at your walking/running gait pattern and take a look at your foot and leg alignment. Then head over to your nearest specialty shoe store (sorry, big box stores like Dicks Sporting Goods don’t count) to be properly fitted and set up with a good shoe. Stability shoes, rocker bottom shoes, and orthotics can potentially be helpful. But keep in mind you might need to try a few different pairs of shoes to find the right one. And please… put the flip flops, crocs, high heels, and flats in the closet for a while.

STRETCHING

Sometimes we are more prone to issues like Achilles Tendonitis because our calf muscles are too tight. Too tight calf muscles can place a lot of extra strain on the Achilles. Think about it this way… Gently pull a finger backwards using your other hand. If you’re doing it gently it really shouldn’t hurt, right? Now pull that finger back a little harder. Is it a little more noticeable? Probably. Now pull just a little harder and stay like that for an hour. OUCH! That’s going to hurt! Our soft tissues under stress over a long period of time can end up hurting. It’s important to stretch those tissues regularly so they aren’t under constant stress.

Here’s another analogy… Our muscles and soft tissues are like rubber bands. Take a rubber band and stretch it out, then let go. That rubber band snaps back into place. Now do it again. Same thing happens, right? But if you stretch that rubber band again, and again, and again, eventually it stays stretched out. In other words, consistency and time is needed to make improvements in how flexible a person is. It will not do you any good to stretch today but not tomorrow and then just sporadically. Stretch every day while recovering from Achilles tendonitis. But be gentle and avoid pain. A mild discomforting stretch is okay. But not pain.

Here are the two most important stretches for Achilles tendonitis.

Gastrocnemius Stretch: Take a step back with your affected leg. Keep toes pointed forward toward the wall. Keep the knee straight and heel down. Bend the front knee to lean forward into the wall until a slightly discomforting stretch is felt in the calf of the leg in back. Hold for 30 seconds, repeat 3 times.

Soleus Stretch: Take a step back with your affected leg. Keep toes pointed forward toward the wall. Bend the knee and keep the heel down. Bend the front knee to lean forward into the wall until a slightly discomforting stretch is felt in the calf of the leg in back. Hold for 30 seconds, repeat 3 times.

STRENGTHENING

Strengthening exercises are absolutely critical to include in your routine while recovering from Achilles tendonitis. Strengthening exercises, when done properly, can help to rebuild the strength of the Achilles tendon, not just the calf muscles attached to it. And this is super important, because with age and repetitive use that tendon can become weak and wear down. There are degenerative changes in the tendon, much like when we get changes in our joints from general wear and tear. The biggest problem with these degenerative changes is that it can cause weakening of the tendon and make it more prone to actually tearing or rupturing entirely.

Do the strengthening exercise described below every day, within tolerance. No pain is allowed, but a mild ache or discomfort that quickly goes away after you’re done is okay. How do you know the difference between a mild ache and a pain? If you’re gritting your teeth or grimacing/wincing while doing this exercise, it’s too much and you could be just irritating the tendon further.

Eccentric Calf Raises: Stand on a flat surface. With both legs, push up on to your toes. Shift your body weight to the affected leg until you are standing only on that affected leg. Slowly lower down, over 3-5 seconds. Repeat. Begin with 10 repetitions, 2 times daily. Progress to 3 sets of 10 repetitions as tolerated.

Now you’ve got the basics down. Let’s recap:

-activity modification

-ice initially, then after activities that will irritate the tendon

-change up your shoes if necessary

-stretch and strengthen

There’s more to it, of course, but this should help you get started while you’re waiting the four weeks to see your local physical therapist and help you avoid the panicked midnight Google searches.