Achilles tendon injuries are some of the most feared injuries in sports. Whether the issue is a tear, inflammation, or a tendinosis of the Achilles, any of these conditions can place an athlete on the disabled list or out of competition and training for an extended period.
I recently completed an extended rehab process with a top American distance runner. He'd been suffering with the symptoms of a tendinopathy for nearly ten months, and it took a very involved approach with a lot of problem solving to sort it out. Often with Achilles problems people think that it's simple, you just have to treat the Achilles, do some basic loading and so on. However, behind many injuries to the Achilles tendon there are other factors. With this athlete, for example, it turned out that he'd suffered a severe ankle sprain and some tearing of his peroneal tendon before developing the damage to the Achilles. All prior efforts to rehab the Achilles had failed because he hadn’t dealt with the underlying problem of the sprained ankle and also had a nice set of compensation patterns to work around that which needed to be dealt with.
So any discussion of root causes of injury begs the question: Are Achilles injuries preventable?
I believe the answer is yes, if you have the right prehab protocols in place and you have good therapy that's able to catch and spot things before they unravel. It's going to be very important with an Achilles problem that you can either prevent it ahead of time or get on top of it quickly, before running into this chronic phase or risking a serious tear. Today I want to explore a few causes of things that you can watch for in your own running to avoid suffering damage to an Achilles or head it off if you've already got some.
One thing that we see a lot in looking at Achilles problems is an ankle sprain in the past. Having sprained your ankle previously destabilizes the foot and the ankle joint, usually causing some of the bones in the midfoot, especially the navicular, to become jammed and fixed. Once you lose that mobility in the midfoot and the ankle, there's reduced normal function of the foot and damage to the ankle ligaments and tendons causes proprioception qualities to go down (the ability of the body to know where it is in space). As the midfoot and the ankle lose proprioception and also become more rigid, the foot often resorts to excessive motion in the wrong directions. This is something that you could readily observe in yourself, a running partner, or another athlete. The foot will tend to either pronate or supinate excessively, and/or there can be excessive abduction of the toes, which is toeing out. This is a good compensation for the body while it's dealing with the sprain, it helps to stabilize the foot, but it's not a good long term solution as it causes other problems up the chain, and also tends over time to create a subtle yet noticeable shearing force on the achilles tendon.
The tendon of the Achilles is engineered such that it normally works as a spring in contracting and relaxing in plantar flexion and dorsiflexion. It's a tremendous performer and is very efficient at storing and preserving elastic energy.The tendon does very poorly, however, once you introduce rotational movements or shearing pressures that create torsion on it. This constant, repetitive, low, but steady stress on the tendon from torque and shear will slowly aggravate the collagen fibers of the tendon and cause first inflammation and then eventually damage. The ankle sprain problem is a good example of a root cause, but it's not the only reason this happens.
Foot Contact Mechanics
Many people simply get jamming and altered foot and ankle mechanics due to poor contact, so if they run with their foot in the wrong position as it hits the ground and the joints aren't aligned properly, then you also run into this typical injury chain or mechanism of compensation.
Hip Mobility Issues
Another common background issue to Achilles problems is that they tend to correlate with a reduction in hip mobility. Many athletes, especially those of us who sit for extended periods, have poor hip mobility. If the hip doesn't extend and internally rotate properly and doesn't allow the athlete to push off powerfully behind him/herself, we can see the problem where the whole chain of the posterior side isn't working together well and the calf must push hard to get the job done. This is a typical scenario that you see time and time again linked to an Achilles injury. Remember, the way the whole chain works together to put force into the ground is the key to running fast and preventing injury. If the hip is tight or weak then as the leg recovers to approach the ground the athlete is risking a diminished extension reflex and reduction in force application to the ground.
Thoughts on Treatment
Naturally, everyone always wants to know the timeline for recovery from an Achilles injury and, of course, it's usually varied. There are some athletes that can bounce back extraordinarily fast, which in itself is a particular form of talent, an ability to recover quickly. And for some people recovery is painstakingly slow. To read an example of how treatment progressed with the professional athlete referenced earlier in this article, click here.
When treating tendon issues, we want to keep in mind that loading is important, and we need to do work where the injury site is being strengthened and stretched, yet not overly so. I always tell my patients to keep their symptoms at less than a four out of ten level, no matter what. They should do some sprint drills to work on mechanics and re-learning proper motor patterns as long as this is pain-free. They should be doing eccentric and isometric strengthening exercises for the calf and the tendon that will help to lay down new collagen fibers in the proper orientation and will strengthen the area. Finally, assessing the afore-mentioned other areas like the tarsal joints and hip strength and range of motion is a must.
All these things can be done prior to complete healing as long as you simply monitor pain symptoms. It helps to have the supervision and guidance of a professional, someone who has experience rehabilitating this kind of injury, but a good standard mode that seems to work from my past experience is keeping people in that area of discomfort that's a two or maybe a three out of ten, but always avoiding or shutting down activity when they get to that level four.
While the Achilles is a serious injury and we've known about it since the ancient Greek mythology, it doesn't have to be something that ruins an athlete's career. I'm really motivated and inspired to see people recover from this injury. I'm confident that with good professional oversight where needed, and best of all, good preventative analysis and pre-treatment, athletes can overcome this issue to continue training and performing to their best.