Are you a runner with Achilles tendonitis? - These mistakes might be stopping you from getting better
The Achilles tendon is the largest (and strongest) tendon in the body and accounts for 20% of all tendon injuries (Tarantino et al 2023). It's a common injury that presents to me as an Osteopath who works with middle and long distance runners.
What does Achilles tendinitis /tendinopathy look and feel like?
The achilles (pictured) will often present as painful, swollen and typically its function will be impaired. Achilles tendon pain tends to either be at the insertion site where the tendon meets the bone of the heel, or mid-portion which is right in the middle of that thick tendon. Patients typically come to see me either with an acute pain that has developed for the first time or with a grumbly achilles that has been bothering them on and off for some time (usually they're embarrassed to admit how long they've been putting off coming to see someone about it!) Full recovery can take a year or longer and re-injury is very common, especially if a return to sport has been rushed (Silbernagel et al 2020).
Mistakes I find runners often make when dealing with achilles tendonitis:
Stretching the calves - calf stretching introduces one of the things a tendon hates and that is compression. Stretching the calf compresses the Achilles tendon and typically makes it more sore. I will often remove any calf stretching that my patient's with Achilles pain have been doing in their own time.
Start / stop loading - this is a common mistake people make with most running injuries, not just Achilles tendinopathy, but when runners experience pain they often stop running completely for a week or so, and then try running back at their normal training load - or 75% perhaps, then experience worsening pain over a few weeks and have stop again, but this time for longer. This start stop approach doesn't allow for an inflamed tendon to heal or respond well to any well intended rehab, and makes for a frustrated runner. I give my patients parameters that typically allow them to continue running at a reduced load as we work on their pain, and then guide them along a graded return to their full training load. Its a marathon, not a sprint!
Inappropriate cross training - patients who like to run will often opt for replacing their runs with lots of walking, and get frustrated that their Achilles pain isn't improving despite resting. Walking can be equally irritating for an inflamed Achilles, so I guide patients towards activities like swimming, cycling and rowing to maintain their cardiovascular fitness in a way that doesn't tax the Achilles tendon excessively.
Poor rehab - some patients find their way to us after seeing a few other professionals first and still struggling with their same pain. The answer for why their pain hasn't improved can be attributed most often to not seeing an osteopath or physio that works with runners, or at very least with active people. They may have been given some bodyweight double leg calf raises to do, done them diligently and don't understand why they're not better. Sound familiar? Answer: you don't have extremely stubborn Achilles pain, or a problem that someone can't fix, you've just not been doing appropriate rehab. This sort of rehab might be appropriate in the first week or so, but if you want to get back to running then this just isn't hard or challenging enough. We want to start to introduce single leg work, targeting the gastrocnemius and the soleus (soleus works very hard during running and is so often missed in rehab protocols!), weighted raises, plyometric work to get more sports specific and proprioception work to help the foot and ankle get strong again.
Not addressing other biomechanical imbalances - weakness of the hip stabilising muscles, core, poor spinal rotation or hip extension, reduced glute or hamstring strength, foot or ankle restricted movement or poor strength. These all have an influence on how much load we place through our calves when running, or contribute to asymmetry in our running gait that can perpetuate these injuries. We have to look at how the rest of the body is functioning, and typically I'll look at patient's running gait and footwear as part of that picture.
Achilles tendonitis can be a frustrating and debilitating injury for many runners, but with the right assessment, treatment, advice, rehab, it doesn't have to be an end to your running pursuits.
Rebecca van Dooren is the founder and clinical director at Balanced Osteopathy. She has spent the last decade working with runners spanning from spinters and marathon distance to ultra runners, at varying levels.
Rebecca is available at Balanced Osteopathy London on Tuesdays, Wednesdays and Fridays
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