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ACHILLES TENDONITIS: WHAT CAN YOU DO?

by Mick Larrabee, PT, MS, SCS, EMT, CSCS

Even 4,000 years ago the Greeks knew a fair bit about the vulnerability of the structure that connects your foot to your leg. Today runners all over the world still feel the pain and vulnerability of Achilles. In fact, Achilles tendonitis is one of the most common running injuries accounting for about 1 in 10 of all running injuries. If left untreated (or improperly treated) this injury can become debilitating to the point where even walking is painful. Worse yet, you may end up on a table in the O.R.

This article will present a leading study that has tried to enhance our understanding of the condition as well as provide us with a few strategies to help prevent and/or rehabilitate the injury so that you can continue to train and have fun with running.

A team of researchers at Wake Forest University (2000) designed an experimental study to examine the causes of Achilles tendonitis (this was unique in that it was one of the first studies to investigate the causes by analyzing two different groups of runners). The purpose was to examine all possible biomechanical factors and activity patterns in runners with persistent Achilles problems and compare the results with similar runners with no injury problems. What did they find?

1. Number of years of running, training pace, and weekly mileage was all greater for the injured running group. This seems pretty logical, but doesn’t help us much if we want to keep running.
2. The first major finding was that the control group (C) showed much greater strength in the ankle dorsiflexors and plantarflexors when compared with the group suffering from chronic Achilles tendinitis (AT).
3. The second big finding had to do with the amount of foot motion between groups. At foot-strike the AT group rear foot is supinated more than the C group. As the body comes up and over the foot the maximum degree of pronation (and the velocity of that motion) is greater for the AT group. This means the AT group not only goes through a greater range of motion but it does so at a much faster rate (which is much harder to control). The consequence of this greater range and speed of pronation is that the Achilles tendon itself incurs a greater force as the foot hits the ground. As the rearfoot everts and the midfoot pronates the Achilles will “bow” or twist. The greater the “bowing” force the greater the strain on the tendon. This significantly increases the risk of exceeding tissue tolerance and injuries are more likely to occur.

DISCUSSION

What does all of this mean? First, you must be careful when trying to interpret the data for application to your particular circumstances. Every person is unique with different anatomical structures and biomechanical properties. In fact a case can be made that trouble at the Achilles can be directly related to poor eccentric control of the gluteus maximus and adductor muscle groups (a topic for another article). That is why general advice and programs must be taken with a grain of salt and one should proceed with caution. However, we do know that stronger muscles of the low leg can lead to a decreased incidence in Achilles tendinitis. Also we have found that those who pronate too much or too rapidly are at a greater risk. So where do we go from here? A great place to start would be to strengthen the surrounding musculature and make sure you are wearing shoes that provide enough stability for your foot type (may require orthotic intervention).

SIMPLE STRATEGY

The focus should be on eccentric strengthening of the gastrocnemius, soleus, and anterior tibialis. The following exercises target these muscle groups in a manner that is functionally related to running:

• Ankle to toe walks – Walk with straight knees, using the ankle only. Start by pulling the toes up as far as you can. Softly place the heel on the floor and then actively control the foot as it rolls onto the floor. As your weight rolls forward, actively push up onto your toes and lift your foot. Repeat on the other side and continue walking for 20 steps on each foot for a total of 3 sets.

• Heel walks – Walk with straight knees on your heels only. Pull toes up and keep them pulled up for 3 sets of 20 steps on each foot.

• Heel drop and calf raise – Stand on two legs, bend your knees slightly, and stand up on your toes. Start by allowing your weight to drop down, letting your heel fall quickly to the floor. Then, just before your heels touch down, control the movement and immediately push back up on to your toes. Perform rapidly and under control for 3 sets of 20. May progress to single leg as tolerable (focus is on pain free control of movement).

• One-leg knee bends – Stand on one leg with pelvis level and core muscles tightened. Allow the knee to bend, rolling it forwards over the foot (in line with, but not in front of, the 2nd toe). Then repeat the movement but this time allow the knee to rotate inward slightly as it bends (foot will pronate). Ensure that this movement is controlled. Both movements count together as 1 rep. Perform 3 sets of 10 on each leg.

• Dynamic one-leg knee bends – Exactly the same as above exercise, but this time perform the exercise as quickly as you can (with control). The faster movement further challenges your balance and the stability of the hip musculature. Perform 3 sets of 10 on each leg.

• Dynamic ankle jogging – Jog with straight knees using the ankles only. This means you must actively and vigorously pull the toes up when the foot is off the ground and rapidly extend the ankle, pushing into the ground during contact. Aim for a ball-of-the-foot contact with this exercise. Perform 3 sets of 20 on each foot. This exercise is not to be performed until your Achilles injury is “healed” and pain-free!

As with any condition, it is always critical to get an individual examination and a biomechanical assessment. With something as complex as Achilles tendonitis, there are no quick fixes or cookbook recipes for success – but, hopefully, the info provided in this article can provide a decent first line of defense.

MICK LARRABEE, PT, MS, SCS, EMT, CSCS IS A BOARD CERTIFIED CLINICAL SPECIALIST IN SPORTS PHYSICAL THERAPY AND A USA TRIATHLON LEVEL 1 COACH. HE CAN BE REACHED AT (865) 806-8911 OR VIA E-MAIL AT mike@optimalperformanceinc.com

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