How to Diagnose and Treat Achilles Tendonitis
It starts off as stiffness – an aggravating tightness and pain that can lead you to believe walking will never feel normal again. For the first few steps in the morning, it feels as if someone has just struck you with an arrow. You limp as if you suddenly gained 30 years of age overnight and it takes you twice as long to get downstairs just for a cup of coffee. By the time you’ve finished the cup of coffee, eaten a bowl of cereal, and hobbled around the house to get ready for work your pain is almost nonexistent – or at least significantly improved. Whoever speared you with their arrow this morning has now become miraculously bored. Phew! You move on with your day by rushing to work, settling into your perfectly ergonomic desk chair (yeah right), cross your legs, and begin the slow slump into bad posture and eye strain.
It’s been two and a half hours of working, and your body – like a coffee pot – has filtered all of your morning coffee from your kidneys to your bladder. The pot is full, and nature calls. You uncross your legs, push the chair away from your desk and begin the adventure to the bathroom. AH! Another arrow has been shot into your ankle – maybe as a way to say “Hey, would you mind NOT crossing your legs for that long? Have you HEARD of a foot stool?” Hi-Ho, Hi-Ho, it’s hobbling to the loo I go….”
Fast forward 5 hours to the end of your word day – when you finally arrive at the track for a tempo workout with your team. And yes – I know you are still going to workouts and running on a sore ankle. The ankle feels a little stiff, but warm up drills do not cause sharp pain and in fact it might be feeling better. You start the first mile at an easy pace and pain is minimal – nonexistent even. Conversation with friends distracts you from any symptoms lingering in the background and pace picks up at mile two to a marathon pace. Still – no pain. Amazing! You’ve defeated the injury!
Hahahahha – ahhhhhhh. Wouldn’t that be nice.
Speed continues to increase, and by mile four you play with a 5K pace. You can feel the presence of another arrow being aimed at you as your achilles begins to slowly sting. Shoot. You bring down the pace to enter an early cool down and that seems to diminish the pain. The workout ends, you say your goodbyes (which last for at least 10 minutes – or more if you are from the midwest), and as you begin to walk to the car the sharp pain returns. Then, it isn’t until you get home and step out of your car that the final arrow strikes your achilles as you try to walk to your front door. Now, your ankle is angry, and concern fills your thoughts. Why won’t this go away? What am I doing wrong? Will it ever get better?
Yes – it will get better, it will go away, and the powers above will stop aiming their arrows at you someday. But when? How?
How Does Achilles Tendonitis Happen?
Injury to the Achilles tendon can happen for a variety of reasons; however, in runners it is likely due to overuse, over training, poor/old shoes, and weaknesses in the muscles surrounding the tendon (as well as above the chain).
*****Side bar – the “chain” refers to your lower extremity. So, up the chain means closer to your waist, down the chain means closer to your ankles. End side bar.*****
AND – let’s be honest – it is typically a combination of the reasons listed above. Am I right?? We overtrain in old shoes and are too tired to do our “band exercises” in addition to high mileage weeks. I get it.
First of all, I want you all to know that this injury is extremely common especially for runners. According to the latest research, achilles tendonitis occurs in 1 of every 20 runners. Although Achilles tendinopathy affects both active and inactive individuals, 24% of athletes develop the condition, and an estimated 50% of runners will experience Achilles tendon pain in their running careers (1).
WHHAATT???? That’s quite a bit. So, if you’re running group has twenty people in it, you better start rolling your calves and doing heel raises – because it is coming for one of you…….
What Are the Symptoms of Achilles Tendonitis?
If I did not already scare you, then hopefully you are still reading this blog. It is important to obtain a correct diagnosis prior to starting treatment for achilles tendonitis as it can mimic other common musculoskeletal injuries - AND - where your symptoms are located dictates which treatment approach will be most helpful for you. Common symptoms of achilles tendonitis include:
Pain and stiffness in the back of the heel or just above it.
Swelling and tenderness in the affected area. Your tendon may even have more redness.
Pain that worsens with physical activity, especially running or jumping.
Morning stiffness and pain with the first few steps.
What is the Difference Between Insertional and Mid-Tendon Achilles Tendonitis?
The main difference between insertional and mid-tendon injuries to the achilles is simply where along the tendon you are experiencing the injury. Some individuals develop tendonitis near where the achilles tendon inserts on the heel bone. Others will experience their injury higher up along the tendon. The crucial aspect of identifying the location of the injury is how you treat it, and there are critical differences in how you choose the appropriate exercises, manual techniques, and return to running strategies.
Insertional Achilles Tendonitis:
Location: This type of Achilles tendonitis occurs at the lower end of the tendon, right where it attaches to the heel bone (calcaneus).
Characteristics: typically involves inflammation, pain, and sometimes bone spurs at the back of the heel. The pain is commonly experienced directly at the heel and can be more localized to this area.
Causes: often associated with chronic stress on the Achilles tendon, such as repeated high-impact activities, poor footwear, or tight calf muscles. In some cases, it may also result from biomechanical issues or degeneration at the insertion point.
Mid-Tendon Achilles Tendonitis:
Location: affects the central portion of the Achilles tendon, away from both the heel and the calf muscle attachments. It can occur anywhere along the length of the tendon between these two points.
Characteristics: marked by pain, swelling, and inflammation in the middle of the tendon. The pain is often described as aching and may be more diffuse along the length of the tendon. There can even be a palpable nodule in the area that is painful
Causes: typically associated with overuse or repetitive stress on the tendon, often due to sudden increases in physical activity, improper footwear, or biomechanical issues. It may also result from a lack of flexibility or muscle imbalances in the calf, lower leg, and hips.
How Do You Treat Achilles Tendonitis?
Injury is not something to fear, but something to be prepared for and address with your healthcare team. Once you’ve recognized that you are struggling with achilles tendonitis, it is important to figure out your rehabilitation plan so you can return to running and activity pain free as soon as possible. Here are some effective strategies for prevention and rehabilitation of achilles tendon pain.
Rest and Activity Modification:
Give your Achilles tendon time to heal by reducing or eliminating activities that worsen the pain, like running or high-impact sports.
Consider switching to low-impact activities such as swimming or cycling to maintain your fitness.
Stretching and Strengthening:
Incorporate regular stretching and strengthening exercises into your routine to maintain flexibility and strengthen the Achilles tendon, calf muscles, and other lower extremity musculature.
HOWEVER, over-stretching an insertional achilles tendon injury may exacerbate symptoms or cause tendon tearing. make sure to consult your physical therapist for the correct exercises for YOUR achilles injury.
Alternative Therapies:
Consider alternative treatments such as shockwave therapy, dry needling, or soft tissue manipulation (i.e. massage, Graston, etc.) to speed recovery.
Ice Therapy:
Apply ice to the affected area for 15-20 minutes several times a day to alleviate pain. This is purely a strategy to help reduce discomfort especially if you have to be on your feet throughout the day.
Anti-Inflammatory Medications:
Non-steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen, may help manage pain and inflammation. Consult your doctor before using them.
Taping and Bracing:
Your healthcare provider may recommend taping (i.e. KT tape, Leukotape) or bracing techniques to support and stabilize the affected area during physical activity.
Temporary Orthotics and Supportive Footwear:
Using custom or over-the-counter orthotic insoles temporarily may help provide better arch support and reduce stress on the Achilles tendon as it is healing. Specifically, research shows using heel lifts of 8-12mm can be helpful for reducing strain to an achilles tendon during walking and running.
HOWEVER, orthotics and heel lifts should be used only during the initial healing stages and should be weaned out as you become stronger and less symptomatic. This is where working with a physical therapist can be super helpful for navigating this strategy safely.
Gradual Return to Running:
After your Achilles tendon has healed sufficiently, gradually reintroduce running into your routine.
Start with walk/run intervals within shorter distances and a slower pace inorder to safely test the integrity of your Achilles. This could be 10 repetitions of 1 min run/2 min walk and gradually progress to 20-30 min continuous running.
How Does Running Form Affect Your Achilles Tendon?
Ensuring proper running form can help reduce excessive strain on your Achilles tendon especially as you start to increase your volume and intensity. The calf/Achilles is active in very specific “phases” of the gait/running cycle. One moment occurs when your foot hits the ground, another when your foot is underneath you during single leg stance, and another during the final “push off” phase. However, don’t forget to focus on the other muscles that are active during these same moments of your running cycle. For example, your glutes and hamstrings help generate force for propulsion as well as decelerate the leg upon landing. It is very important to ensure your body can activate ALL muscles in the right pattern in order to absorb force from the ground, transmit it properly, and rapidly produce a force that results in fast efficient forward progression. WITHOUT causing too much harm to tendons, ligaments, etc. Therefore, it is important to instill a proper foot strike pattern (less heel strike), reduce excessive pronation in mid-stance, and maintain appropriate cadence (average 180 bpm) in order to achieve proper running form and reduce excessive strain on your Achilles.
How Long Does Achilles Tendonitis Take to Heal?
Well, that all depends of course – on age, activity level, lifestyle, diet, if it is chronic or acute, stress, hydration, etc. It seems somewhat irrelevant to put a specific time frame on the healing process because we are ultimately trying to rehabilitate this tendon towards better performance and resilience for the rest of your life - not just for the current level of inflammation. Often, we are preparing it to be better than it was before you were injured, so it is likely you obtain some of these habits (i.e. strength, stretching, training parameters) and practice them even after your pain is gone.
For my people who like numbers and time schedules – and believe you me I am very much that person - here's a rough timeline for the healing of Achilles tendonitis:
Mild Tendonitis: In cases of mild Achilles tendonitis, with prompt and appropriate treatment, you may start to experience relief within a few weeks. Rest, ice, and exercises can help speed up the healing process, which complete recovery taking 4-8 weeks.
Moderate Tendonitis: If the tendonitis is more moderate in severity - usually meaning more swollen/red or more irritated by activity - then it may take a bit longer to heal, potentially 3-6 months. Rest or activity modification along with corrective exercises and manual therapy interventiosn are key to effective treatment.
Severe Tendonitis: Severe or chronic Achilles tendonitis may require several months to heal, and in some cases, it may take up to a year or more. Severe cases often involve significant damage to the tendon (either insertional or mid-tendon), and treatment may include a combination of conservative methods such as physical therapy, or, in rare cases, surgery.
Remember, most injuries (especially repetitive, overuse injuries) happened from several months of improper training, weakness, bad shoes, etc. This is part of the reason why the rehabilitative process seems long. We all want a quick fix, but a quick fix most often leads to re-injury. Trust the process, and remember any time spent away from being active or tolerating normal movement is time you are spending getting stronger, increasing mobility, improving your health, etc. It is one of the few moments where we can enjoy a slower-pace, both in life and in training.