Sore Achilles? Reset first
by Greg Dea
*This is part one of a two-part article set, which is wrapped up by Greg’s book, Return to Field Sports Running Manual. The book is available on Apple and Amazon: iBooks, kindle ebook and paperback.
Your assignment is to try to push on with running, even though you have an Achilles tendon problem. Read on.
First up – your Achilles tendon problem is like many others, but it’s unique to you, so your circumstance is specific. It’s not desirable to speak generally about a problem within a particular person, but there are standard solutions.
There are different causes, contributors, complicators and locations for Achilles pain:
- You might have a painful nodule in the middle of the tendon,
- You might have creaky, mushy tissue around the tendon that feels yuck when they move your ankle up and down,
- You might have one of the Achilles tendon injuries that hurts where the tendon attaches to your heel.
Since each one is different, they each have different approaches. I’ll target this story about what I’ve seen most in field athletes and road and track runners – the sore nodule in the mid-tendon.
If this sounds like you, you might be able to keep going but take the verbal medicine I’m giving you – you may need to stop running right now – at least for a short period, and quite possibly for many weeks. Coaches hate to hear you’re out of running, but they are grown-ups, and you’re a grown-up, so treat it right and do what’s required.
Many times, the pain settles spontaneously, only to come back later.
At other times, the tendon pain occurs after a temporary increase in tendon loading. For example:
- An increase in speed,
- An increase in running distance in one session or several sessions combined,
- An increase in frequency of running, or
- Even something as seemingly insignificant as running on a cambered surface. An example would be when you run where the road slopes a little to drain water, then when you run back home, you cross the road only to end up having the same camber.
Be careful also of the “usual run” that has no change in any of those parameters but follows on from a period of stress in other ways. For example, if you’ve had a fatiguing event but haven’t recovered properly, then went for a run, this can interfere with general or specific mobility or control of mobility. Also, such fatiguing or stressful moments can increase the hormones that stimulate inflammation.
Here’s the responsible advice: Don’t be the person whose Achilles tendon pain comes from a medical problem. If you try to apply a fitness solution to a medical problem, you won’t solve your problem. A quick check with your responsible health practitioner is the first step.
There is some good news:
BREAKING NEWS: TENDONS DON’T LIKE TO BE RESTED
Mid-substance tendon problems don’t respond to complete rest, so you are not going to be expected to stop training completely.
They do not get better with rest; they get better with modified load.
They get better with better movement in other parts of the body.
They get better with improved load tolerance in other parts of the body.
They will often benefit from direct treatment, so get ready to step up and help your little buddy.
In the Functional Movement Systems, one of the principles that guide clinicians and coaches through injury and movement problems is the three-step paradigm of Reset, Reinforce and Reload. This applies to Achilles pain too.
The Reset means when someone does something to you that removes pain or restores movement you couldn’t do yourself. With advances in self-help, we can use many tools and strategies to reset ourselves.
When it comes to pain in the tendon, it matters whether you have just had a new episode of pain in the last 1-2 days, or whether it’s been hurting beyond 2 days.
If you have a new Achilles pain, within a day or two at most, you may have benefit from a drug that is often disregarded as useful for Achilles tendon injuries. The medicine Ibuprofen has been shown to inhibit activity in the tendon cells. These cells normally secrete a protein called Decorin to fill up the space in between the collagen strands in your tendon. After a stimulus to your tendon, the cells may change their activity to secrete a water-attracting-protein called Aggrecans. This type of protein is usually found in other tissues like cartilage and is the main reason for the swelling in a tendon. You want to block these cells right away – if you miss the opportunity to minimize the tendon swelling in the short term, the thickened tendon can weaken the tolerance to load. Ibuprofen is one option in the first 2 days. There are some recommendations to extend the use of ibuprofen to 4 to 8 weeks after initial injury [1, 2].
If you do not have a fresh Achilles tendon pain, there are some big-bang-for-buck therapies that can reduce tendon pain within one session.
You should have an experienced, skilled clinician check on the tissue quality above and below the painful part of the tendon. In simple terms, that means poke and push around the calf muscles, shin muscles and soft tissues on the sole of the foot. It’s no joke to hear that painful spots in any of these places can actually send pain to the Achilles tendon. There’s a small proportion of athletes who do some self-myofascial resets, via a massage stick, a foam roller, or another self-treatment device on a sore spot nearby only to find that the movement that hurt their Achilles reduces or abolishes. For the stubborn painful spots, some western-style dry needle therapy, with acupuncture needles, can enhance the treatment to these sore areas.
Alongside tissue quality, ankle joint, big toe joint, knee and hip joint mobility drills, with belts/straps/bands are not to be underestimated when it comes to altering both Achilles tendon pain and the sticky movement that is associated with it. Dr Lee Burton, CEO of Functional Movement Systems, demonstrates an effective midfoot self-mobility reset that often increases ankle movement and reduces tendon pain.
It is also conceivable that changes to lymphatic flow above and below the painful tendon can affect the tendon pain in a single session – I’ve seen it happen. There are clusters of lymphatic nodes in the sole of the foot and behind the knee, with lymphatic vessels throughout the tissue between these areas. The lymphatic flow continues to the hip, abdomen, thorax and neck, so any changes to blood flow, lymphatic flow, respiration and movement in these areas may affect blood flow downstream.
In addition to the strategies mentioned above for single session relief, you can build on the short-term reset with medium-term resets.
Extracorporeal shock wave therapy is one that my colleagues tell me is effective and that has been shown in scientific studies to have comparable results to eccentric exercise [3], but I’ve not used it. The shock waves are toxic to peripheral nerves and this might explain why pain is reduced [4].
One of the biggest bang-for-buck things you can do in the medium-term is to consider the use of GTN patches. This must be done with your local doctor who is experienced in sports injuries. GTN, or Glycerol Tri-Nitrate, is usually used to treat angina (heart pain), as it releases nitric oxide which opens blood vessels. It is not clear why opening blood vessels helps Achilles tendon pain since it has been shown that there is an increased capillary flow already at the site of tendon pain, but it certainly does. It is conceivable that changes to blood flow above and below the painful tendon can affect the tendon pain – the GTN has an effect throughout the whole circulatory system, not just at the tendon. Just as described above, it is also conceivable that changes to lymphatic flow above and below the painful tendon can affect the tendon pain. There are clusters of lymphatic nodes in the sole of the foot and behind the knee, with lymphatic vessels throughout the tissue between these areas. The lymphatic flow continues to the hip, abdomen, thorax and neck, so any changes to blood flow, lymphatic flow, respiration and movement in these areas may affect blood flow downstream.
So many of my field and road/track running athletes with Achilles tendon pain have had their pain abolished within a couple of weeks using GTN patches. If you think that’s a long time, it is not – these tendons can be painful for weeks to months. To use GTN, you will need a prescription from your doctor, who should be familiar with its use in Achilles tendon injuries. If your doctor doesn’t know about it, go to one who does, or provide them with this article to study, followed by this article about long-term results. Further, many of my athletes have had significant reductions in Achilles tendon pain after treatment to lymphatic nodes and the pathways between them.
The resets mentioned above are clearing the pain and resetting tissue mobility. After these passive resets, there are countless specific and general movement strategies available to clean up the limp you developed when you started with Achilles pain. That’s for part two.
*This was part one of a two-part article set, which is wrapped up by Greg’s book, Return to Field Sports Running Manual. The book is available on Apple and Amazon: iBooks, kindle ebook and paperback.
1. Fallon, K., et al., A “polypill” for acute tendon pain in athletes with tendinopathy? J Sci Med Sport, 2008. 11(3): p. 235-8.
2. Knobloch, K., Tendinopathy and drugs–potential implications for beneficial and detrimental effects on painful tendons. J Sci Med Sport, 2009. 12(3): p. 423.
3. Rompe, J.D., et al., Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med, 2007. 35(3): p. 374-83.
4. Maffulli, N., U.G. Longo, and V. Denaro, Novel approaches for the management of tendinopathy. J Bone Joint Surg Am, 2010. 92(15): p. 2604-13.