Achilles tendonitis: Early self-treatment and when it's gone too far, Part 2
/In part 1 you learned the basics of treating a recent onset of Achilles tendonitis. Much of that should emphasize the soft tissue mobility of the lower leg (which is more than just stretching). For those of you that don't have a grasp on how to be working on the soft tissue of your lower leg with foam rolling, self-massage and other techniques, check out my post and video here.
If reduction of mileage, over-the-counter anti-inflammatories and ice don't help knock out the pain then it is very likely that you are no longer dealing with an inflammatory condition. The tendon area could feel increasingly stiff and tight after you have sat for a while and then place weight on the leg or when you first put weight on the leg in the morning after sleeping. When that initial inflammatory stage has started to pass in 2-4 weeks and you still haven’t gotten anywhere because you continue to have pain, then consider professional guidance. This is especially true if the injury keeps occurring or you notice the Achilles tendon itself remains swollen or is thickening in size or is forming hard nodules. Another issue to note here is that pain where the Achilles tendon attaches to your heel will often be harder to treat and slower to resolve. Indications for seeking professional help immediately would be:
any indication of bruising in the heel or Achilles area
inability to bear enough weight to walk normally with that leg
you felt a "popping" sensation at a single moment of injury
you can't make your calf contract firmly to point your toes downward or can't perform a calf raise
If you feel any of these situations apply to you then you need more immediate attention with a medical professional.
There are several things to consider with advanced examination and treatment. First being the findings of neurological and musculoskeletal exam. Second being running gait evaluation results. Third being training errors, footwear, terrain and so on.
If you recently changed your running technique so that you land forefoot first and push off heavily from your forefoot then you might want to reconsider jumping into that abrupt change. If you are an aging runner this could be especially risky. There are often balance and stability deficits that result in poor control of the entire leg, which we will discuss in a future blog post. I would also suggest strengthening your hips. It is very common for me to see knee and ankle injuries on the same side as an athlete's weaker hip muscles. This feeds back into the stability control problem. Your movement needs to be precise.
Any care needs to consider the phase of healing that the tendon is in. The illustration below summarizes this nicely. Ultimately, we are interested in the Achilles having an appropriate level of collagen (scar) deposits and remodeling those deposits to support the injured area. That sounds simple but if you look at the time frame along the bottom axis of the graph you will notice that collagen is being placed as early as 3 days but needs to continue for weeks to months afterwards. Tendon healing, unfortunately, tends to lean toward weeks and months, which is why you shouldn't delay proper care and ignore the pain. This doesn't mean you won't be able to exercise during that time.
PHases of injury healing, From Daly TJ: The repair phase of wound Healing, re-epitheliazation and contraction. In Kloth CL, McCulloch JM, Feedar JA (eds.): Wound healing: alternatives in management. philadelphia, FA davis, 1990, p 15.
Tendonitis and a tendinosis are both treatable with some of these techniques in common and some techniques being very different. Tendinosis, the more degenerative condition, requires heavy commitment to a home exercise program to perform strengthening exercises as well as manual therapy in the clinic to decrease scar adhesions, increase ankle motion and maybe even provoke an inflammatory response in the tendon area again. The strengthening must be performed frequently enough and with enough difficulty to force your tendon to adapt, similar to your normal exercise routine. The trick is knowing how much pain to push through. Both injuries can be treated successfully.
Mid-stance of running gait
The good thing is the human body is adaptable. The bad thing is it takes time and effort. Depending on where you area in the injury process, you might be able to run again sooner with some simple running gait changes to decrease the Achilles tendon load, proper strengthening, balance training, decreased training stress and properly addressing calf muscle tissue integrity.
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