Achilles Pain. Time to Take Action!

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I’ve had periodic issues with my left Achilles tendon. I’ve never had trouble with my right Achilles until just lately. I felt a bit of soreness one morning and found some swelling. I knew it probably wouldn’t “work itself out” (I sort of hate when someone says that about something. Nothing “works itself out.” Someone has to put in work in order to see progress.) The upside to having had this problem before is that I know how to address it now.

I believe my trouble may have started because of the long trail run/hike I did a couple of weekends ago in Telluride. It was about 12 miles which was a sizable jump from my prior long run of 7 miles. (Sometimes I’m not smart.)

I have attacked the injury with a fairly conventional strategy of slow and controlled heel raises. Here’s what it looks like:

I’m doing these exercises frequently throughout the day. If I can hit 15 reps then I add weight. Fifteen reps isn’t a magic number by the way. Most importantly I work to a high level of exertion, pretty much to failure.

I’ve run several times since feeling pain and doing the calf raises and I feel fine. That’s a good sign. I probably don’t need to take time off from running.

This exercise is boring and I hate doing it. (Sounds like what a lot of people say about going to the gym.) I have shown a propensity for weakness in my Achilles tendons in the past though. This is exactly the type of thing I need to do and I should be doing continually. It’s easy to skip this stuff because I don’t enjoy it. My body doesn’t  though even though there are potential negative consequences to this course of non-action.

There are lots of things in life like that.

Got Dorsiflexion?

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The toes, feet and ankles get no respect. I’m not sure a lot of people walk into the gym and say, “Okay, today is foot and ankle day! Gonna work those parts hard and make ’em strong!”  We throw shoes on them and ignore them. Think about this though: It’s only every single step that we need those obscure parts to work correctly.

If we look at the body as a kinetic chain then we start to see that the feet and ankles don’t live in isolation. Movement or lack there of at the feet and ankles may create problems all the way up through the legs, hips, spine and shoulders. If an athlete doesn’t have sufficient motion at the ankles then he or she may not perform at his or her best.

Similarly, limited foot and ankle motion may be a contributor to pain. I’m not just talking about foot pain either. Again, if we consider the interconnectedness of all the joints and limbs of the body then it may not surprise us that faulty foot/ankle movement could contribute to back knee pain, hip pain, back pain — even shoulder or neck pain!

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Dorsiflexion: There’s no substitution for it!

In my observing both my clients and myself, I see a lot of us don’t quite have optimal  dorsiflexion. It’s easy to overlook but as I’ve argued, it’s very important. I know in my case, my various plantar fasciitis/Achilles tendon issues have improved as I’ve worked on my dorsiflexion. (Strictly speaking, I don’t know if limited dorsiflexion was a cause or effect of my foot and Achilles pain. That said, working on improving dorsiflexion
has coincided with those problems fading out.)

Dorsiflexion is more than just forward and back motion. There is always a 3D aspect to movement and we want to consider that. Also, We have a couple of different muscles (well… more than a couple but we’re considering mainly just two) that cross at the ankle. The following drills emphasize both the gastrocnemius muscle (the straight-leg drills) and the soleus muscle (the bent knee drills.)

Achilles Tendonitis Progress

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My Achilles pain was getting better and then it flared up again recently and it has stayed flared for a while. This has been an ugly aggravation as it was a serious regression. Now, I’m very happy to report that my Achilles tendon irritation seems to be fading away. I’ve done three short-distance run/walks with no pain. (Will it stay gone is the real question.) What has helped?

Time off

Initially I thought that simply changing the way I ran would allow me to side-step whatever healing process that needed to take place. I revisited several technique changes that helped me overcome a past bout of Achilles pain. I discovered that there was no magic fix. Minding my technique is a good idea but it seems my tissues still needed time to heal.

Heel lift

I put a 1/4 inch heel lift in my shoe. The idea is to give a little bit of slack to the sore tendon.

To this point, I made sure not to do much in the way of stretching the tendon. It’s often a mistake to think that if it’s sore, it must need stretching. In fact, the damage to the Achilles may have been brought on by it’s being stretched too much and/or too fast.

Eccentric strength work

I’m continuing the work I wrote about in the last blog post. Runner’sConnect.net has a comprehensive guide to both Achilles pain rehab and prevention strategies. I won’t rehash it here.

Extensor hallucis brevis work

I think this has been a BIG ONE. I believe that part of my problem stems from my inability to adequately anchor to the ground the distal end of my first metatarsal, aka the ball of my big toe. How might that affect my Achilles tendon?

Too much of this may over-stress the Achilles and cause pain.

Too much of this may over-stress the Achilles and cause pain.

If I can’t secure that first met head to the ground then I have a weak foot tripod as the Gait Guys have described it.That means that my foot might pronate in an uncontrolled way which can result in something like the image to the right. Too much of that done too often and/or too fast could over-stress the Achilles causing damage and pain. To form a solid foot tripod, I need to be able to secure the center of my calcaneus (heel bone), first metatarsal head (ball of the big toe) and the fifth metatarsal head (ball of the little toe.)

(To be clear, I can’t say this is The Cause for anyone else’s Achilles problems. Someone else may be able to run with lots of pronation and feel fine.)

How did I know I had difficulty getting that met head to the ground? I’ve been videoed running and I could see this extended pronation occurring. I could feel it as I tried doing the exercise in the following video. This gets into what seems like some real minutiae. For me, it seems pretty important. Also, I don’t believe this movement is trained in the eccentric strength protocol I mentioned above.

Metronome running

I’ve read several discussions (here, herehere) on running cadence and loading rate as it pertains to injury risk. Essentially, by using a quicker cadence we should load the tissues of the foot for less time per foot fall thus resulting in less stress to those tissues. That’s exactly something I need.

I went back to using a metronome when I run so that I can make sure to keep a quick pace. I set the metronome from 170 to 180 bpm and matched my cadence to the beat. It’s definitely a quicker cadence than what I’m used to. Seems I’ve backslid some on minding my cadence. Going forward, I think it will be a good idea to periodically run with a metronome to ensure that I’m staying quick on my feet.

 

More Achilles Tendon-itis/-osis/-opathy (or Whatever It Is)

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About three weeks ago I went for a run in the snow. Part way through I felt some irritation in my left Achilles tendon. Like anyone who loves/needs to exercise, I kept running and I tried to convince myself that it wasn’t too bad, that it would probably go away soon or maybe if I changed my stride slightly it would resolve during the run.

I was wrong! I really irritated the thing and had to walk about a mile. This was the latest flare-up of a years-long lingering issue. (I’ve discussed the Achilles here and here, as well as left heel pain/plantar fasciitis hereherehere, here, here and probably in some other places… You’d think for someone who’s considered this issue so much that I wouldn’t have it anymore.)

Prior to this Achilles flare-up, I’d had some of some old familiar heel pain. It wasn’t debilitating but it was a signal that something wasn’t as it should be. Again, I ignored it to a large degree and figured it would resolve. I should’ve paid closer attention to it. Essentially, it wasn’t a problem until it was a problem. Time to get back to work on this thing.

Tendon injury: A complex issue

Why do we get injured? How do our tissues (like tendons) become damaged? If we administer the right amount of stress and then recover we get a positive adaptation–we get stronger. In contrast, if we administer too much stress and we don’t recover then we get some type of injury. Thus too much stress delivered too often and/or too fast has been my problem. I need to increase my tissue tolerance to the forces of running.

A recent article from Alex Hutchinson is titled Pro Tips on Treating Tendon Injuries. This article covers a debate among members of the Canadian Association of Sports and Exercise Medicine in Ottawa. Several top sports physicians and therapists were asked: Which therapy should the squash player try next? (I’m not a squash player but I have the injury they discussed.) If you’re dealing with this issue it’s definitely worth a read. It discusses several methods: eccentric strengthening, nitroglycerin patch, dry needling, cortisone, and platelet-rich plasma.

There wasn’t 100% agreement on anything much, but Hutchinson’s concluding statement was this (emphasis is mine):

“So what should the poor squash player do? In the question period following the debate, most participants conceded that strengthening exercises are the path to long-term health. Depending on the specifics of your tendon injury, other techniques may provide relief to allow you to exercise, but they’re not permanent cures.”

Cures I like. I have no interest in simply treating symptoms. Thus I decided it was time to implement something with which I’d been familiar but which I knew wouldn’t be very exciting at all: the eccentric strength protocol.

Eccentric strengthening

First, what does “eccentric” mean?An eccentric contraction is one in which the muscle is contracted but it’s also lengthening. Think of doing a bicep curl. You know the part where you yield to gravity and lower the weight? That’s the eccentric portion of the movement. (In contrast, the concentric portion is where you overcome gravity and bring up the weight.) For this particular protocol, we want to fight against the lowering action and lower very slowly.

I found a very thorough resource for this project from Jeff Gaudette at RunnersConnect.net. It’s titled The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy. (The title of this thing just screams ACTION!! doesn’t it?) You can download both the Injury Treatment PDF and the Injury Prevention PDF. As the title suggests, this is a thoroughly researched guide to dealing with tendon injuries. I appreciate very much that there is both a treatment and prevention strategy. I won’t go into the whole thing but here are the basics:

The strength protocol consists of two exercises: a straight-kneed and a bent-kneed
eccentric heel drop. The protocol calls for three sets of fifteen heel drops, both bent- kneed and straight-kneed, twice a day for twelve weeks.

Standing on a step with your ankles plantarflexed (at the top of a “calf raise”), shift all of
your weight onto the injured leg. Slowly use your calf muscles to lower your body down,
dropping your heel beneath your forefoot. Use your uninjured leg to return to the “up”
position. Do not use the injured side to get back to the “up” position! The exercise is
designed to cause some pain, and you are encouraged to continue doing it even with
moderate discomfort. You should stop if the pain is excruciating, however.

Once you are able to do the heel drops without any pain, progressively add weight using a backpack. If you are unlucky enough to have Achilles tendon problems on both sides,
use a step to help you get back to the “up” position, using your quads instead of your
calves to return up.

The eccentric exercises are thought to selectively damage the Achilles tendon, stripping
away the misaligned tendon fibers and allowing the body to lay down new fibers that
are closer in alignment to the healthy collagen in the tendon. This is why moderate pain
during the exercises is a good thing, and why adding weight over time is necessary to
progressively strengthen the tendon.

You do these exercises for 3 sets of 15 reps, twice daily. There are photos showing these exercises including a modification if you have what’s known as insertional Achilles tendonitis. Again, read the whole thing if you want the full rundown of this protocol.

More thoughts

Part of why I haven’t done this in the past is that it is slow and tedious! Three sets of 15 slow reps makes time crawl like some sort of crippled tortoise. It ain’t fun! Plus I’ve never cared much for doing calf work. That said, I need to fix this problem. This process seems to be the best way to go about it, so I’m on board.

Something else I realize is that if I’m prone to this injury and I want to avoid it then I need to do the preventive work. That means setting aside time throughout the week and during my workouts to do some of this stuff.

I’ve been doing this work for about the past three weeks and I am getting better. I’ve done a couple of short run/walks and I’m not in the clear just yet. The only option I see is to continue doing what I’m doing.

Update

I just went on a run of a little over two miles and the Achilles feels fantastic. No pain! Felt like I could’ve run all day–which would’ve been stupid of me. This protocol is working for me right now.

Techniques to Help You Run Pain Free

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I’ve used a few simple techniques to help a few of my clients with their running technique.  These ideas have also helped me overcome a long-term bout of heel and Achilles trouble.

My clients often hurt when they ran so if nothing else, I figured they needed to run differently somehow. There was no guarantee that what I would show them would solve their problems but clearly the way they were running wasn’t quite working.

The following are drills and cues that I’ve used.  Effective cueing can be challenging.  I have in my mind a movement a feeling and an experience that I’d like you to have.  I have to translate what I feel into English and transmit that message to you.  My words may hit the mark or you may have absolutely no idea what I’m talking about!

Hop up and down.

Hop up and down.  How do you land?  On your heels?  Most people land on their toes and to some degree their heels settle to the ground.  It happens naturally.  Your probably don’t need to think about it too much.  In this way, we effectively dissipate the impact forces and avoid too much jarring and banging into the ground.

Run in place.

Now run in place–quickly!  Again, how do you land?  I think most people land similar to the way described above.  It’s a light landing on the toes, not heels first.  This is pretty much one-footed hopping.

Where do your feet land?  Directly under your hips.  That’s about where we want the feet to land.  In contrast, what we don’t want is for your feet to fling out in front and slam into the ground.  To that point…

Quick Pace

Overstriding is a frequent issue in injured runners. By overstriding the foot lands out in front of the runner and he or she slams hard into the ground with every foot fall. This can cause lots of stress to various tissues and joints and it’s likely a cause of pain.

This is a good contrast in foot placement.  The guy in back is overstriding.

This is a good contrast in foot placement. The guy in back is overstriding.

By running at a quick(er) pace we facilitate the feet landing under us, not out in front.  We create shorter loading times of the bones and joints and thus reduce the stress that may be causing our pain.  It’s difficult to overstride with a quick cadence.

For a most runners this means consciously picking up the pace. This can feel awkward at first and may feel inefficient.  One way to start to adjust your cadence is by using a metronome when you run.  Start at your normal pace and sync the metronome to your pace.  From there you can up the beat and match your pace to the metronome.  This takes time and practice.  If it’s important then you’ll do it.

Again, this all may feel very strange–and it should.  After all, if our current chosen running technique is causing pain, then it stands to reason that a new and better running technique should feel weird.  As with any new skill, it won’t feel strange forever.

Lean forward from the ankles.

chi_postureLearning to lean from the ankles–not the hips!–is important.  By leaning from the ankles we sort of fall forward.  We keep the hips under us, not poked out behind.  When leaning from the ankles it’s difficult to overstride and slam the foot into the ground. Here’s a drill to learn how to lean from the ankles.

Run tall.  Keep eyes on the horizon.

The simple cue to “run tall” seems to work well for a lot of runners.  I’ll keep it simple and leave that phrase as is.

Keep your eyes on the horizon.  This works well to help keep you tall.  Your body tends to go where your eyes go.  If you stare at the ground then you’re likely to slump forward.  You won’t be running tall.  Learn to use your peripheral vision to see the ground. The guys below are running tall and gazing out.

These guys are RUNNING REALLY TALL!!  You should do it too!

These guys are RUNNING REALLY TALL!! You should try it!

Run lightly.  Quick pace.  Lean from the ankles.  Run tall. Eyes on the horizon.

Here’s a good graphic.

I’m not going to say a lot more other than I like the information presented here:

better-running

Skipping

Finally, here’s a skipping drill that may help you get a feel for running tall, running lightly and not pounding your heel into the ground. My hope is that this drill will transfer to your actual running. Skipping involves an exaggerated running gait and you don’t actually want to bound and prance to an extreme degree.

Achilles Tendon Injury Resource

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I just found this site The Running World According to Dean and it’s got some very interesting information, particularly some good information on Achilles tendonitis and/or tendonosis.  I’m going through this issue right now and it’s tremendously frustrating and mysterious.

achilles tendon

Click image for source.

It’s not a cut-and-dried sort of thing.  It seems everyone’s Achilles issue is particular to them.  It may arise from simple overuse like running too much, too fast, up too many hills and/or running too fast up too many hills.  It could also arise from various biomechanical issues that aren’t always easy to identify.  The wrong shoes seem to also play a role.  Even certain types of medication can contribute to the matter.

Beyond the many causes, there are almost as many treatment recommendations: ice, heat, stretch, don’t stretch, run a little, don’t run at all, orthotics, shoes…  Anyhow, if you’re going through any of this then this site might be of help to you.