Achilles Tendonitis Doesn’t Exist (But Here’s How to Treat it Anyway)

by Jason Fitzgerald

Confused? Don’t be – the injury is real but the term Achilles tendonitis is incorrect.

This was news to me until last week when I spoke to Jay Dicharry about how to treat Achilles injuries. Jay is the founder of the gait and biomechanics lab at Rebound Oregon. As a physical therapist, his expertise in biomechanical analysis has helped him effectively treat overuse injuries in endurance athletes.Anatomy for Runners

He’s also the author of Anatomy for Runners: Unlocking Your Athletic Potential for Health, Speed, and Injury Prevention, a definitive guide for runners with injury problems.

So instead of Achilles tendonitis, the proper term is Achilles tendinopathy. Jay told me:

There is no such thing as Achilles tendonitis. The definition of “-itis” implicates that a part of the body is swollen and inflamed, but the Achilles tendon is incapable of swelling (the bursae – a tiny fluid filled sac between the Achilles and the heel can swell, but that’s different). Instead of Achilles tendonitis, we should call it Achilles tendinopathy. Basically, the tendon is weak and dysfunctional, and thus compromised.

But let’s back up before we dive into the treatment plan for Achilles tendinopathy.

Don’t Make This Injury Mistake…

If you have tendinopathy in your Achilles tendon, you’ll recognize the initial period of stiffness followed by a more intense pain if you continue running. It may feel like a sharp pin is stabbing your Achilles during every foot strike.

I succumbed to this injury twice in the last 14 years of running. Before I knew how to treat the injury, the first incident was more severe. Lasting several months, it was a constant battle and I saw little progress.

Instead of  using a proven treatment system, I fell into the trap of dabbling: I iced inconsistently, tried stretching, lifted weights a few times, rested for a week, got one massage – yet still couldn’t get healthy. It was a classic case of the Try Everything, Try Nothing approach.

It seemed like my Achilles was doomed to being permanently painful. When the tendon was at its worst, it felt like it was separating from the heel. I asked a lot of depressing questions, like:

  • Do I need surgery?
  • How is the scar tissue going to be removed?
  • Will I run the same every again?

The worst part of Achilles tendinopathy is that I could run a little bit, so it was a constant tease. But I was always violently shoved back to square one when I tried to resume my normal training schedule.

When I got serious about treatment and recovery, I used a more systematic approach and was healthy within a week.

The next time I started feeling the warning signs, I went into Injury Red Alert Mode and was 100% recovered in 5 days. I still ran every day and only needed to cut out faster workouts.

This is how you can do the same.

Manage the Damage: the Acute Phase of Injury

Before we get to the specific treatment strategies and exercises for Achilles tendinopathy, you need to manage the acute symptoms of the injury.

Achilles tendon

This is where my advice will sound similar to other treatment plans: stop running, ice the painful area, and wear shoes with a more elevated heel for support. The goal is to take pressure off the Achilles tendon and reduce any swelling around the tendon.

This approach works for about a day and it probably won’t heal your Achilles. Where other Achilles tendinopathy articles may stop, I want to dive deep and explore what you really need to cure Achilles tendinopathy.

You’ll need a much more targeted treatment plan after this acute injury phase.

“Length Under Load” (so, length DOES matter…)

According to Dicharry, Achilles tendinopathy is a straightforward injury: it’s a length under load problem. Like all other tendons, the Achilles works best if it’s the right length. If it’s too short – or too long – things start to break down.

Jay told me that there are two reasons that Achilles tendinopathy occurs:

  1. Structural tightness of the Achilles itself. If the tissue is shortened, strain can increase when it is maximally lengthened during push off.
  2. Poor stability of the foot that places the foot in a dynamically lengthened position. In running, about 80-85% of your stability comes from the big toe. If your big toe can’t stabilize appropriately, all hope of a stable forefoot, rearfoot, and Achilles is lost. The Achilles becomes twisted like a wet rag. Since its in a lengthened position, its much more susceptible to strain and overload.

So the next question is, which person are you?

If you’re the first runner with Achilles tightness, you’ll need a combination of stretching and soft tissue mobilization to successfully open up the tissue so it can slide and glide in its normal window. I highly recommend a foam roller.

If you have poor stability and need to provide the Achilles tendon a solid foundation from which to work, you’ll need to develop more forefoot strength. Jay so eloquently said, “Fix the foundation (forefoot strength!) and fix the problem.

Achilles Tendinopathy Treatment

I’m going to let Jay dominate this section. Take it away!

If you fall into the “my Achilles is too short” category, stretching can help. Shortened tissues need to become longer and this can be accomplished two different ways. You can follow what’s been successful in lengthening soft tissues: hold stretches for three minutes, 4-6 days per week for 10 weeks.

Or you can adopt some aggressive soft tissue mobilization. Next time you go to the gym, put a dumbbell on the floor. Place your calf over the handle and raise your body up on your hands so that the weight is concentrated on the handle. You want to roll up and down the barbell handle looking for spots that feel sore. When you find them, stay put and flex your toes up and down to mobilize the area.

This is a quick way to open up soft tissue mobility – it typically takes a few weeks of doing this daily for 2-3 minutes to restore tissue length.

If you fall into the unstable category, it’s time to stabilize your foot. The best way to strengthen your foot is directly strengthen your foot! Overly cushioned shoes have made the muscles in our feet lazy. [Jason’s note: see my list of running shoe reviews for many minimalist and neutral shoes I like.]

Learning to isolate your big toe is critical to build a better foundation from your foot. Check out this article on how to see if you’re ready to go minimalist.

From here, progress up to lots of single leg balance exercises barefoot on the floor, and barefoot on rocker-boards for a great foot strength challenge.

Lastly – since Achilles tendons don’t swell, we can do some exercises called “Eccentrics.” These exercises aren’t designed to make you work on the way up – they’re designed to work you on the way down (like negatives at the gym). You lift up onto your toes with both legs and then raise the healthy leg up off the ground, and slowly lower down on the hurt leg.

Since swelling isn’t an issue, you aren’t going to hurt the tendon. Pain is actually OK on these too.

Dosage: 45 reps daily for 6 weeks.

And now, a few disclaimers!

I never allow someone to do eccentrics unless they are ready – meaning they understand how to isolate their forefoot strength and can keep their rearfoot stable on their forefoot as they raise up and down. If the foot is twisting excessively its just creating more problems.

If you are swollen, its not your Achilles, its from friction across the bursae that lies under the Achilles. These folks shouldn’t add in eccentrics until the acute swelling is gone and they can stabilize the foot.

For a more step-by-step rehabilitation program – including high quality videos and the top Achilles Tendinopathy Myths – check out the Injury Prevention for Runners program.

Just like race day, don’t try anything new if you’re battling an injury. Now is not the time to try a pair of minimalist running shoes or a set of barefoot strides. Let your Achilles recover, build more strength, and then think about adding new stresses to your running.

Jay finally has a few recommendations for finding running shoes:

Find a shoe that’s comfortable, offers a firm feeling underfoot, and flexes evenly with your foot. After all, shoes don’t stabilize the foot – muscles do. Following these guidelines will ensure that your foot functions as intended and that the shoe doesn’t get in the way.

And when you are healthy, remember that a little bit of barefoot running goes a long way. Barefoot running is like Elmer’s – a dab will do ya’! (Click to tweet!)

I want to extend a big thanks to Jay Dicharry for his insights into Achilles tendinopathy treatment. If you want to learn more or support his work, his book Anatomy for Runners is available on Amazon.

To get more information about injury prevention, sign up here and I’ll show you the top misconceptions runners have about injuries (and how to avoid them yourself).
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Kris

Jason, great article. I’ve been dealing with achilles pain for a few months. Nothing too bad, doesn’t hut when I run, actually hurts most when I wake up or when I’ve been sitting for a long time. My right achilles is noticeably tighter and that’s the one that hurts most. I’ve tried the eccentric exercises, but I did not do enough reps, and didn’t stick with it for 6 weeks. Can’t wait to try again and get rid of the nagging pain!

Chuck Swanson

How does a person figure out what their problem is? Want 2 address the issue appropriately but not sure how to tell of I’m short or twisted.

Jason Fitzgerald

I’d suggest doing both – you can perform the self-massage techniques and the stability/strength work.

Jeff McCloud

My question isn’t about Achilles pain. Rather, after I do a longish (6 or more miles) run, my left Achilles clicks a little in the morning. After I’m up and about for an hour or so, it stops. This started when I was training for my first half marathon last fall. It has not gotten worse or painful, but I worry that it’s symptomatic of something to come. Any thoughts?

Jason Fitzgerald

If it doesn’t hurt it might just be “one of those things.” I wouldn’t worry about it.

Jess

I’m so glad to hear the “3 minutes of stretching”! I have a friend who’s a professional acrobat (seriously) and when I once asked her how I might go about learning to do a split, her suggested stretches were all to be held for a minute minimum, and her real suggestions were for much longer. But my favorite PT always suggests just 30 seconds, which always feels to be to be way too short.

Those ‘eccentrics’ (I’ve also seen them called ‘reverse calf raises’ and I tend to just think of them as ‘drops’) are a really enlightening exercise. I have just the tiniest twinge on occasion in my left Achilles and came upon that particular exercise in a quest to figure out how to prevent more Achilles problems. The difference in strength in my forefeet is marked. I have been much more interested in foot strength ever since :)

ChrisC

I might just add here that there are two kinds of achilles tendinopathy, “midpoint” where pain is felt on the achilles itself, and the rarer “insertional” type, where pain is felt on the back of the heel, right where the achilles attaches. Insertional tendinopathy can sometimes be accompanies by bursitis, where the little fluid sac under your achilles gets angry and inflamed.

The reason I point this out is that the treatment is slightly different for each kind. For “midpoint” tendinopathy, eccentrics are generally done with your heels hanging over a step so at the end of a drop, your toes point up. For “insertional” tendinopathy, it’s best to perform the exercise on flat ground.

I struggled with the insertional variety for a while, and made the mistake of doing the midpoint exercises. Changing to the flat ground version cleared up my problems and I was back running again in no time.

This website has a bunch of info and photos detailing the exercise: http://runningwritings.blogspot.com.au/2011/08/injury-series-eccentric-exercise-and.html

Kellin

http://www.strassburgsock.org/achilles-tendonitis.html This sock can help! I use it and I love the whole design.

Abi

I am having a nagging pain in my heel. Could share on how to overcome this

Jason Fitzgerald

More likely plantar fasciitis. Try this: http://strengthrunning.com/2011/10/cure-plantar-fascitiis/

Jeremy

Great article. This really dove into the cause and how to treat achilles pain. I have been an avid runner for about 5 years now and developed tendinitis like symptoms and utilized the Achillease stocking for pain relief. It pulls from the ball of your foot rather than your toes in maintaining a comfortable stretch. Thanks for writing this article, and sharing the portion about elevating your heel, that is very important in recovery!

Jaqui

I started to jog on the treadmill a year ago and then began to road run when the treadmill broke. I loved it until I got tendonitis I’d origonally used shape ups I know don’t laugh I didn’t know any better and then brought a pair of sketchers go runs when someone told me of the dangers of using the shape ups, so I went from one extreme to anouther.having learnt by my previous mistakes could you please advise me. Where to go from.here,My doctors advise is painkillers and not to run but I love it ……..

Jason

Great wright up!! One question is after you rest and ice for a few days then start apply both PT’s when do you know when you can start easing back into running? 1-2 weeks of PT?

Shelley

My Achilles’ area is swollen like a golf ball and very painful. If it is not the tendon but rather the bursa sack, then what would be the cure for that? I am going to have to back out of my half marathon which is eight weeks from Saturday if I cannot get this healed. Please help!

Brandon

Hi, I’m a soccer player and I’ve been dealing with achilles tendinopathy for about a few weeks now. I have all the usual symptoms but they’re very mild since I stopped activity once i started feeling the pain. The odd thing is that the pain becomes much more severe once i put my cleats on and start walking. I recently put new arch supports in my cleats (i have extremely flat feet) so could that be the cause of the problem? I was under the impression that using arch supports could help prevent this injury so I’m a bit confused.
Also, i spoke to my school’s trainer today and she told me that she could wrap it with tape and I could play. Is that true and if so, is it enough to get me through the season? Keep in mind, I dont mind playing with a little discomfort but i dont want to be careless and end my season before it’s even started.

Mark Butler

Interesting article, I found some of the tips here quite useful when I was recovering from an Achilles injury when training for the Paris marathon this year. In fact it almost prevented me from running completely.

David Kelly

Eccentrics according to Alfredson’s protocol actually call for 180 reps per leg per day x 12 weeks!

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