Risk Factors for Achilles Tendonitis

Achilles Tendonitis is a very common injury among runners of all abilities. A University of Wisconsin Study of track injuries reported that during a 17 year period, tendonitis accounted for nearly 9% of reported injuries. It is an inflammation of the band of tissue that connects calf muscles at the back of the lower leg to your heel bone.

 

I suffered through this injury for over a year until I was properly diagnosed and treated. It really slowed my training, so my goal with this article is to share the symptoms, risk factors, treatment options and best prevention strategies so you can prevent achilles tendonitis from slowing your training.


I don’t recommend self diagnosis of any sporting injury because every injury is different in some way and each requires specific assessment and treatment. If you suspect you may have achilles tendonitis, I urge you to get it properly diagnosed by a trained and certified medical expert.  It would be irresponsible of me as a certified coach to attempt to manage your injury in an article.

Use the following information for guidance only. Although I provide much researched details along with a logical and effective rehab program recommendations, I am not a qualified medical professional, so I encourage athletes to seek professional medical opinion for diagnosis and to confirm treatment protocol for any injuries.  


Symptoms & Warning Signs

 

Achilles Tendonitis is often characterized as an overuse injury. The tendon may be painful to touch or move. The area may be swollen and warm. You may have trouble standing up on one toe. You may also have trouble finding shoes that fit comfortably.

Risk Factors & Treatment for Achilles Tendonitis

Photo by Jenny Hill on Unsplash

For most athletes, the injury starts as mild discomfort or ache in the back of the leg or above the heel, typically experienced at the beginning of a run. Tenderness, stiffness or the ache may just be in the morning, but often improves with mild activity. However, as the injury persists untreated or more typically untreated properly, the pain becomes more severe and continues after prolonged running (especially on hills), stair climbing or sprinting.

As the pain persists and if left untreated, where the athlete continues to train, the tendon gets weaker, making it more vulnerable to a tear (rupture). This a painful injury that usually requires surgical repair. This is why if you experience persistent pain around the Achilles tendon and it’s affecting your running gait, you need to seek professional medical attention. Do this before the pain becomes too severe or the achilles tendon becomes torn (ruptured).

 

Risk Factors

Achilles tendonitis typically has two causes. One is muscular and the other structural. It’s more common as you age, because the structure of the Achilles tendon weakens with age, which can make it more susceptible to the injury.


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The structural cause of achilles tendonitis is weakness in ankles and feet. Excessive pronation (rolling inward on the foot when walking or running) turned out to be the primary factor for my injury. A naturally flat arch in your foot can put more strain on the Achilles tendon. Other structural causes include chronic ankle instability or a recurrent “giving way” or rolling of the ankle.


 

Also runners with a slight leg-length discrepancy, can cause the body to compensate and put soft-tissue structures like the Achilles tendon more vulnerable to a tear.

The muscular cause is short, inflexible (tight) calf muscles which can develop over time with runners who don’t perform regular stretching & strengthening exercises. There are two large muscles in the calf. When they are strong and stretched out, they create the power needed to push off with the foot or go up on the toes. However, if the calves are short and inflexible, the achilles tendon will then attempt to compensate for the limited range of the calf muscle, so any strain from footstrike to takeoff will be absorbed by the tendon.

In my experience, it’s common for runners to have tight calf muscles, so as you can see below, calf stretches is one of the primary focuses for rehab and prevention.

Other risk factors for achilles tendonitis include:

-Athletes new to running or just starting on a training program.
-Sudden drastic (more than 15% per week) increases in weekly mileage.
-Sudden increases in speed work or hill training
-Wearing high heels regularly can shorten the Achilles tendon, making it more prone to injury
-Prior history of achilles injuries
-Old (worn-out) or improper running shoes (shoes that don’t offer sufficient heal support or stability)
Achilles Tendonitis Risk Factors

Photo by Daniel von Appen on Unsplash

-Weakness in the hips & glutes
-Poor biomechanics (form or gait), which is often the result of structural or muscular issues discussed above.
-Overweight runners

The bottomline is that there’s many risk factors that contribute to achilles tendonitis. Typically it’s a combination of these factors that result in the onset of the injury.

Diagnosis

A physician should diagnose the cause of the pain. This is very important. Although this is a comprehensive article, it should only be used as a reference. Do not use the contents of this article to self diagnose your injury.

A doctor’s diagnosis will come from a combination of a physical exam, the patient’s history (filling out a questionnaire) and if necessary, diagnostic tests. The tendon will be very tender when palpating (feeling) or squeezing it from the sides. There may be a nodule or lump felt in the middle of the tendon.

Another test is the “calf-squeeze” where they test the integrity of the Achilles tendon. The doctor may also ask the patient to do a series of exercises such as hops, jumps or leg lifts. They want to understand the level of activity-related pain, as well as exactly where the pain occurs.

Besides the clinical exam, the doctor will ask questions of the patient to ensure all details of the injury are understood.

For example, patients may describe pain as sharp versus dull, intermittent versus constant, and mild or severe. What makes the patient better or worse, such as whether the pain increases with activity. There will also be questions about his or her recent sports involvement, including any changes to the training schedule, surface or type of sport being played. Patients should expect to report past injuries and/or inflammations of the Achilles tendon, including when and how they occurred, if they recurred, and what treatments were used or have been recently used.


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Lastly, the patient will be asked to describe any changes in the Achilles tendon area, such as increasing pain at the bony prominence at the back of the heel, swelling, tenderness, redness, or loss of strength or range of motion.

X-rays aren’t typically used in diagnosis of tendonitis, instead they can be used to help diagnose if there’s any bone problems. However, an MRI or Ultrasound scan can determine the extent of the injury and indicate a precise diagnosis

 

Treatment

 

The main treatments for Achilles tendinitis DO NOT involve surgery. However, it is important to remember that it may take at least 2 to 3 months for injury to properly heal.  Although most athlete’s don’t want to hear it, they will need to temporarily decrease or stop any activity that causes pain. If they can do so without pain and if their physican gives the “go-ahead” the athlete may be able to continue run or walk on smooth, soft & flat surfaces. I would definitely recommend avoiding hills & speed activity.

Different therapy options can get you back to the trails and running healthy. Typically a doctor or physical therapist will recommend any number of the following nonsurgical activities:

To fight the pain, oral nonsteroidal anti-inflammatory medications may be prescribed to reduce pain and ease swelling. People with asthma, kidney disease, or liver disease should first check with a doctor. Steroid injections, like Cortisone, can reduce tendon swelling, but they don’t cure the problem. In my research, I found a number of sources indicate concerns that taking these kind of shots were associated with a greater risk of tendon rupture. Remember, managing the pain is only the initial part of the treatment.  The ultimate goal should be to address the root cause and prevent recurrence.

Other pain management strategies involve elevating the foot and keeping it raised above the level of the heart to help reduce swelling. An icing program involves applying ice to the Achilles tendon area for 15 to 20 minutes, 2 to 3 times per day. Remove the ice if the injured area gets numb.

 

Alternatively, runners can switch to low impact activities such as biking, eliptical, swimming, rowing machines or other activities that put less stress on the Achilles tendon.

Once the pain is managed, physical therapy and shoewear modification the most typical treatments for patients with tendon inflammation and early degeneration. For overweight runners or runners who pronate or have bio mechanical risk factors, high stability running shoes will help to prevent the injury from recurring. If you’re not sure what shoes are high stability, ask the experts at your local specialty running store. I while back, I wrote a detailed article about how to pick the right running shoes.

One of the treatments that my physical therapist tried in order to allow me to run a race, was heel lifts. These moved my foot away from the back of the shoe. Unfortunately, it only helped for about half the race, before the pain returned and became unbearable.

One unproven treatment option is with platelet-rich plasma (PRP) injections. I don’t have any experience with this treatment, but during my research for this post, it was identified as an option. However, a recent study couldn’t conclude that this was a viable protocal to treat the injury.

 

How Middle Age Runners Stay Injury Free

 

If the above treatments DO NOT improve symptoms, you may need surgery to remove inflamed tissue and abnormal areas of the tendon. If there is a bone spur irritating the tendon, surgery can be used to remove the spur. These options are rare, but I wanted to point them out.

In most cases, lifestyle changes help improve symptoms. However, it’s important to remember that symptoms may return if you DO NOT limit activities (risk factors) that cause pain or if you correct bio mechanical risk factors, including stabilizing the foot, strengthening weak supporting muscles and correcting short calf muscles.

This is exactly what happened to me years ago. I would rest, ice, change to a more stable shoe and attempt to strengthen my calf muscles, but the root cause for me was a combination of pronation, weak glutes and hips and my footstrike was mostly on my heal (as opposed to fore or mid foot).

It’s really important that you ultimately understand which risk factors are causing your Achilles tendinitis. Left unproperly treated, the injury may make you more likely to have an Achilles rupture. This condition will cause a sharp pain that feels as if you have been hit in the back of the heel with a stick and surgical repair will be necessary.

 

Prevention

Prevention is by far the best way to avoid potentially major problems with Achilles tendon pain. It is far better to complete a program of 10 – 15 minutes of stretches & exercises a few times per week than have 2-3 months out of training or risk an Achilles rupture.

Below are stretching exercises that would be perscribed by your health care provider or physical therapist. they should be done under the supervision of a physical therapist, at least initially, because they could damage the Achilles tendon if they’re not done correctly:

Gentle calf stretching exercises can help stretch the muscles and aid recovery

 

Stretching Exercises

There are a number of exercises you can do to stretch your Achilles tendon. Here are some of the most popular:

Calf Stretch: Place your hands on a wall with one leg straight and the heel to the ground. Place the other leg, with the knee bent, in front of the straight leg and push your hips toward the wall. Stretch your calf to the point where you feel a strong pull but no pain. Do not let your heels come off the ground. Hold the position for 10 seconds, then relax. Repeat 20 times on each foot in a slow controlled manner.
Achilles Tendon & Calf Streching Exercise

 

Sitting Heel Raises

Sit on a chair and raise your toes up as high as you can without pain. Slowly lower your heels. Do this 20 times a day. You can make it harder by pressing down on your thighs or holding a weight on your thighs.

Bilateral Heel Drop

Stand at the edge of a stair or a raised platform that is stable. Put the front part of each foot on the stair. This position allows your heel to move up and down without hitting the stair. Hold on to a railing or support to help your balance.

Slowly lift your heels off the ground and slowly lower your heels to the lowest point possible. Be sure to do this in a controlled manner 20 times. You can also do this starting on the floor rather than the stair.

Achilles tendon & calf strengthening exercise

Exercises to keep your calf muscles strong and flexible will help reduce the risk for tendinitis. Overusing a weak or tight Achilles tendon makes you more likely to develop tendinitis. As long as the leading risk factors (as diagnosed by a medical professional) are addressed, performing eccentric strengthening exercises is one of the best ways to ensure that a full recovery can be achieved.

 

Strengthening Exercises
Farmer’s Walk on Toes – watch video or follow instructions below

Grab a pair of heavy dumbbells and hold them at your sides at arm’s length. Raise your heels and walk forward (or in a circle) for 60 seconds. Be sure to stand as tall as you can and stick your chest out. Choose the heaviest pair of dumbbells that allows you to perform the exercise without breaking form for 60 seconds.

Single-Leg Standing Dumbbell
Achilles Tendon Strength Exercise

Grab a dumbbell in your right hand and stand on a step, block or 25-pound weight plate. Cross your left foot behind your right ankle and balance yourself on the ball of your right foot, with your right heel on the floor or hanging off a step. Put your left hand on something stable—a wall or weight rack, for instance. Lift your right heel as high as you can. Pause, then lower and repeat. Complete the prescribed number of reps with your right leg, then do the same number with your left (holding the dumbbell in your left hand).

Straight-Leg Calf Stretch

Stand about 2 feet in front of a wall in a staggered stance, right foot in front of your left. Place your hands on the wall and lean against it. Shift your weight to your back foot until you feel a stretch in your calf. Hold this stretch for 30 seconds on each side, then repeat twice for a total of three sets. Perform this routine daily, and up to three times a day.

Foam Roller – Calf Roll
Foam Roller for achilles tendonitis

Place a foam roller under your right ankle, with your right leg straight. Cross your left leg over your right ankle. Put your hands flat on the floor for support and keep your back naturally arched. Roll your body forward until the roller reaches the back of your right knee. Then roll back and forth. Repeat with the roller under your left calf. (If this is too hard, perform the movement with both legs on the roller.)

Foam rolling can be a great tool for recovery, but I would caution that it doesn’t always work immediately, especially with really tight calf muscles. It’s not unusual for tight muscles to take a few weeks to release as long as you’re consistently rolling.

 

Regular Prevention Program

1. Intelligently increase your distance and intensity – Many runners get impatient and make sudden increases in distance or time, especially if they’re falling behind with their scheduled training. Schedule your program then be disciplined enough to execute it. Very often tendonitis is caused by a sudden increase in load or force. If you do have a hard session(hills, intensity), no problem- but it’s very important that you choose to rest the next day or perform a low impact session the following day.

2. Introduce changes gradually. Be careful with hill sessions, change of running shoes or change of terrain.

If you go from road running to off road- or vis versa- the altered terrain can cause tweaks in the Achilles tendon.

If you feel tweak or a strain, revise your training immediately and do not try to push through. It is better to have one week off then to attempt to push thru, make the injury worse and require 2-3 months off of training due to injury. Also, if you get new running shoes, I recommend walking in them first and slowly increasing the distance and intensity for 7-10 days to allow your body to adjust & to break in the shoes.

3. Always complete a proper warm up and cool down. This includes after run/training stretches. Even though you may be pressed for time. It’s essential to stretch after your run. Just take 3-5 minutes to slowly stretch out your calf muscles, achilles, hamstrings, IT band and lower back. If you’re in the habit of performing these stretches, you’ll likely prevent recurring injuries.

4. Regularly perform foam rolling. Calf, quad and lower back muscles tend to get very tight.  Sometimes stretching is not enough. I highly recommend foam rolling at least 2-3 times per week to prevent tight and knotted muscles. Rolling out the calf muscles will help prevent your Achilles tendons from getting get injured.

5. Regularly complete strength training. Especially the exercises listed above.

6. Get a sports massage – These can really help preventing injuries. Massages enhance flexibility, help to improve blood flow in muscles and tendons and a can help heal little tweaks in muscles and tendons quickly before they become problems. During marathon training, if you can afford one and have the time, it’s ideal to get a sports massage monthly.

7. Gait analysis – How you run is VERY important in the prevention and treatment of Achilles tendon pain. In most cases, runners with Achilles tendon pain have poor running mechanics. They over pronate, they have weak hip muscles and have very tight hamstrings and calf muscles.

Top Prevention Tip:

Get your gait analyzed – this is VERY important. I suffered for over a year with this injury before a sports therapist video taped me on a treadmill.  He reviewed my gait in slow motion & confirmed that I was pronating.  He also identified some issues with my stride. I had been running for 30 years and didn’t think I was a pronator, but it turned out that I had developed this condition which was ultimately affecting my achilles.

There’s a lot you can find out from a video analysis, I highly recommend this solution. You will be amazed at all the ways you can improve. For me, this was the best way to prevent injury and also dramatically improve your running speed.


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