(You Probably Do Not Have Achilles Tendinitis)

The Achilles tendon is quite vulnerable to injury, especially if stressed the wrong way. It actually accounts for 10 percent of all running injuries. But, more on this later…First, let me explain.

The Achilles tendon is like no other tendon in the body. It’s the largest and strongest tendon in the body and connects the gastrocnemius and soleus muscles to the heel bone. Its round shape combined with the rotational movement of the ankle causes the tendon to get “wringed out.” This is why we need all of the right conditions to make sure this wringing is no more than the body can take.

Achilles Tendinitis or Achilles Tendinopathy?

“-itis” is a Latin derivative meaning “inflammation.” Therefore, this title only applies in the presence of localized swelling that a clinician can feel. This occurs, but is far less common than what is called Achilles Tendinopathy. “-pathy” simply means “something’s not right” but does not indicate it’s an acute problem.

This differentiation is a big deal. Why? Because effective treatments are extremely different in an “-itis” vs a non”-itis.”

But your issue has to be Achilles tendonitis because it hurts so much, right?

No. It’s true that inflammatory cells do stimulate pain, but we can also get significant pain from adhesions inside tissues that were once inflamed and are no longer. So when you first injured the tendon, it possibly was tendinitis back then but once your body processes the inflammatory cells it becomes tendinopathy and can still hurt quite a bit.

So let’s focus this article on how we address Achilles tendinopathy.

The pain associated with Achilles tendinopathy is generally due to one of two conditions: lack of mobility or strength.

This tendon, which has a hard enough job in ideal circumstances, does not tolerate well when it does not have the mobility or strength it needs to complete a run.

Here’s how you ended up with an Achilles tendon that does not have enough mobility and/or strength:

One day the Achilles was irritated. This could have even been an Achilles tendinitis temporarily depending on whether there was palpable swelling. It could’ve happened from a plethora of causes including, but not limited to, suddenly increasing hill work or speed work, suddenly moving into a minimalist shoe, or attempting to rapidly change running form.

Underlying this much too rapid change, were less than ideal conditions for the Achilles including, but not limited to, not enough glute or hamstring strength, a stiff ankle joint, or not enough great toe mobility.

So you were already primed to over-challenge the Achilles and then a perfect storm occurred.

As we naturally heal from this episode, we develop scar tissue inside the tendon. This scar tissue makes the tendon functionally weak over time. The scar tissue serves an immediate necessary purpose, but if it is not reabsorbed by the body entirely, the tendon is left tighter and weaker then it should be.

Therefore, resolution of Achilles tendinopathy involves eliminating tendon scar tissue.

This is done three ways:

  1. Expert soft tissue work.
    We are big advocates of self soft tissue mobilization, but when it comes to helping the Achilles tendon remodel/reduce scar adhesions, it is advised to get an expert clinician to help. Popular and effective clinical strategies include Active Release treatment, instrumented soft tissue mobilization, and ASTYM. All of these techniques break up adhesions encouraging the body to remodel the tendon. When followed by proper strengthening, the tendon remodels much stronger and more mobile.
  2. Eccentric strengthening.
    Eccentric strengthening is when you strengthen a tendon while it is lengthening. An example for the Achilles would be rising up on the balls of the feet and then slowly lowering back down to the ground. Eccentric strengthening has been proven to be critical for tendon remodeling after scar tissue has been broken up. A 2010 study in the American Journal of Sports Medicine shows a majority of Achilles tendinopathy can be resolved with eccentric strengthening. (1)
  3. Work on your own mobility.
    This is not just about your Achilles. In fact, your Achilles is usually the victim here. What underlying circumstances do you have going on in your whole leg that precluded this condition to occur? Most people cannot answer that question themselves without a running medicine expert’s assistance. When you discover where you are tight or weak, working on those areas will create an environment where your body can process the scar tissue in the Achilles. For example, if your ankle joint is the issue, and you work on it to reduce the stiffness, you allow the Achilles to stretch which helps process scar tissue.

Be careful to not allow your Achilles tendinopathy to be treated as a tendinitis as the healing can be inhibited by this approach. For example, NSAIDS have been shown to slow tendon healing. So, without active inflammation, why would you take them? (Note: even with active inflammation, it’s not a slam dunk to take them considering the delayed healing potential). Other tendinitis strategies such as ice and rest are similarly ineffective.

Next time on “Your Achilles and You: A happy marriage” we will discuss how running form can be behind a reoccurring Achilles problem. Till then..!

1. Silbernagel KG, Brorsson A, Lundberg M.
 The Majority of Patients With Achilles Tendinopathy Recover Fully When Treated With Exercise Alone: A 5-Year Follow-Up
 Am J Sports Med. 2011: 39; 607-613

Dr. Eric Schweitzer, DPT

Founder at IdealRun
Doctor of Physical Therapy, author, professor, runner and triathlete – has practiced physical therapy for more than 15 years.He runs a successful physical therapy practice, Premier Physical Therapy, located in Clearwater, Florida and is the founder of IdealRun a personalized online running gait analysis.
Dr. Eric Schweitzer, DPT

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