“Grief of The People” – Achilles Tendon Pain

Stay the CourseTwo columns back, I wrote about plantar-based foot pain. Its brother in the running-injury world is Achilles tendon pain. In Greek, its literal translation is “Grief of the People” (this must’ve come about, after the original marathon, right?) While perhaps less crushing than PF, Achilles tendon pain can be a season- and career-wrecker. Similar to PF, this is because of the myriad of factors conspiring to keep you in pain.

Achilles tendonitis, like plantar fasciitis, can be a misnomer. True inflammatory injuries can occur – namely with abnormal (excessive) forces put on the issues. However, most chronic Achilles pain falls into the “-osis” category – lacking inflammation, but painful just the same.

The causes and treatment of Achilles tendon pain is similar to PF, but with some important mechanical – and psychological – considerations.

Achilles Tendonitis, Differential Diagnosis

Like PF, Achilles pain can develop as a result of dysfunctions from following tissue types:

Soft tissue strains. Like plantar fascial strains, the Achilles tendon can be overworked by high-intensity running or excessive uphill running, where the dorsiflexed ankle places stretch-strain on the calf and tendon.

A perhaps lesser known, but notable, role in Achilles and calf loading is the role of forefoot striking. A forefoot strike loads muscle tissues to a greater extent (versus joint- and bone-loading) than a midfoot or heel strike. This is neither advantageous or disadvantageous – as excesses in either tissue type can be problematic. But recognizing the effect of foot strike – and overall stride mechanics – on tissue loading is imperative at treatment and recovery of posterior heel pain.

Joint pain. Like PF, the joints of the posterior foot, when dysfunctional, can create pain, in two ways.

First, asymmetrical loading or positioning of the joints, namely the calcaneus, can create straining forces on the tendon.

Achilles - Neutral

Neutral joint alignment, rear view, of the foot. Note the close proximity of the talocrural and subtalar joints to where the Achilles tendon runs (red line).

 

Achilles - supination

Possible Achilles stress with a persistent supinated foot strike.

When the heel bone is persistently angled, it creates increased – and asymmetrical – strain on the Achilles.

Secondly, irritated joints of the rearfoot can flat-out create referred pain into the posterior heel and Achilles area, mimicking tissue pain without actual Achilles pathology.

Nerve pain. Nerve involvement in posterior heel pain is seriously overlooked, but can play a significant role in pain generation and persistence.

The nerves of the lumbar spine create two major nerves – the femoral nerve, with supplies the anterior thigh, and the sciatic nerve, which supplies the posterior thigh and entire lower leg. At the level of the knee, the nerve splits again into the tibial and fibular branches. And at the ankle, the nerve branches once more – into the medial and lateral plantar nerves.

Irritation and tension of the sciatic nerve – anywhere along its course, from the low back to the toes – can cause posterior heel pain in two ways. First, by flat-out mimicking Achilles pain – the hallmark sign being pain in the heel at rest, usually when sitting. Secondly, tension and irritation of the nerve can cause increased muscle tone in the calf: if the nerve is in tension, the body will try to keep strain off the nerve by keeping the ankle flexed. This constant “revving” of the calf can keep the muscle-tendon in a state of tightness and irritation, preventing healing.

Refer to the PF article about the differences between soft tissue and referred joint (or nerve) pain.

Treatment Approaches

Please discuss any of the following treatment approaches with your doctor, physical therapist, or chiropractor before performing.

Soft tissue

The standard treatment approach for soft tissue – Rest, ice, soft tissue mobilization, stretch, strengthen – applies to Achilles tendon pain with a few notable adjustments:

  • Soft tissue mobilization – because the Achilles is such a thick, strong, heavily-used tissue, it can be helpful to have one to two thorough soft tissue mobilizations performed by a physical therapist or licensed massage therapist. But avoid doing any more.

Repetitive mobilization only creates more irritation; once the tissue becomes mobile, allow it to rest. If pain persists, there are likely other issues at play (joints, nerves, loading forces) that must be addressed.

  • Stretching. A truly strained Achilles is that – strained, over-stretched. Be very careful stretching an irritated Achilles. The ankle stretch pointed out in the PF article is a great option, but aim to stretch tissues “around” the painful area – namely the middle to upper calf and (if possible) the very bottom portion of the Achilles. Play with the knee flexion angle – with gentle force – to focus the stretch.

Overall, less is more with Achilles stretching. Perform stretching only twice daily, and at times of known stiffness – first thing in the morning or after prolonged sitting or resting.

  • Strengthening. Most soft tissue issues of the calf and Achilles are not because of weakness of the tissue, but overload. That said, the idea that an injured Achilles – especially in an acute (<2 weeks) or subacute (<1-2 months) state – is “weak” is a misnomer.

Repetitive strengthening with calf raises (concentric or eccentric) is seldom needed and can perpetuate the tissue overload.

Joint Pain

Interestingly, the treatment approach for joint-related posterior heel pain is similar to those recommended for PF: mobilize the mid- and-rearfoot. Ankle dorsiflexion mobility is important to ensure that the talus – the bone sitting atop the heel – stays happy. Irritation of the talar joints – above, at the tibia/fibula, and below with the calcaneus – can refer pain posteriorly at the level of the mid-substance Achilles.

Folks with referred joint pain in the Achilles will commonly experience pain upon impact at the tendon-level during running, yet frequently not be able to palpate (“touch”) any soreness. Moreover, those with referred joint pain frequently experience their Achilles pain at rest due to achiness of the irritated, dysfunctional joint.

The most important mobility exercise for Achilles tendon pain treatment is the “heel bone wiggle.” Be sure that your heel bone can move, and that it is not “stuck” bent inward (inverted). A persistently inverted calcaneus can either be a sign of a stuck, painful joint and/or cause an angled, asymmetrical strain on the straight Achilles tendon coming down from the calf. Get it moving, or hire a skilled PT or chiropractor to do it for you.

Nerve Pain

Because of the repetitive stress placed upon our legs, namely with trail ultrarunning and its extreme distances, grades, and terrain, it is all too easy to develop troublesome nerve irritation in the legs. Nerves need to be able to slide and glide freely through tissue, from the brain to the toe. When “caught up” in stiff tissue, pain can develop anywhere along the length of the nerve.

To treat nerve tension, namely in the lower legs:

Obtain a thorough soft tissue mobilization of the lower legs, not just the Achilles, but also the medial shin. This is where the tibial nerve lives. Often, a good mobilization of the medial shin (namely the posterior tibialis, under which the tibial nerve lies) while do wonders to “free-up” the nerve.

Then, gently self-mobilize. Perform this stretch. Most folks with nerve tension in the lower legs will experience “tightness” sensations in the lower legs, ankles and feet during this stretch. As with PF, perform ten to twenty slow, gentle (but slightly irritating) reps, three to four times, daily.

Motor Control and Brain Factors

Run mechanics and psychological factors play an enormously important role in the recovery from Achilles tendon pain.

“Be forward!” Previous columns have talked about the importance of trunk alignment and foot strike, as related to the rest of your body. Runners with chronic Achilles pain tend to land with their foot in front of their center of mass (nearly always with a forefoot strike). Moreover, runners returning to running while in pain tend to run “scared,” with a cautious, backward-leaning “Hope I don’t hurt it!” posture.

Be forward! Keep your trunk momentum forward. This will help keep your foot strike beneath you, preventing braking forces going into the Achilles.

“Run Wholefoot!” An important factor in the development and persistence of Achilles pain is a forefoot strike pattern. The Achilles, by definition, is a force transferring tissue between the foot and the rest of the body. Forces enter via the foot and transfer through the tendon up the leg, then return – over and over, on the course of a run.

Foot strike plays a role in the degree – and intensity – of Achilles stress. The more anteriorly the foot strike, the higher proportion of stress is absorbed by the Achilles. Conversely, a mid-or heel strike tends to transfer forces through other muscles (the tibialis brothers) or bones (heel, ankle, shin). Tremendous debate rages on about which type of foot strike is optimal. As yet, there is no set answer.

However, if you have Achilles pain – and you are a noted forefoot striker, simply relaxing into what I call a “whole-foot strike” will take significant stress out of the Achilles. Allowing the joints and bones to do some joint loading – even if temporary – will allow you to run without excessive Achilles strain.

Here’s a mental and physical exercise to try, as you return to running with Achilles pain. Imagine you are running through thick sand (or mud or snow): what would happen if you ran on a stiff, forefoot? Instead of sinking, imagine landing on a soft, wholefoot, wherein you stay on the surface.

“Let it go!” A vital element of run mechanics is relaxation. But as part of the injury process, there is a tendency to tense and protect. Instead of allow relaxed, normal motion, runners with Achilles pain will typically tense and protect the ankle; the idea being that by tensing, they will prevent painful dorsiflexion.

Normal tissue mechanics involve gentle flexing and extending. Instead of preventing “stretch strain,” a tensed ankle causes unremitting tightness in the Achilles and calf. It keeps the tissue tense and the pain persistent.

To return to healthy, pain-free running, you have to “let it go!” Run with a relaxed, “floppy” ankle – allowing the ankle and foot to freely move. This can be enormously difficult, especially for runners with chronic Achilles pain. Shaking out of the hands while running can reinforce the “floppy foot” mechanics. Positive self-talk – “relax!”, “let it go!”, “You’re fine!” – even aloud, can also be extremely helpful to ensure relaxed, normal joint and tissue movement.

Don’t “Pool Run”…Run in the Pool! A terrific way to work on several of these elements at once is to run in a pool. I don’t mean pool running – or faux-pawing in deep water, pretending to run. I mean, practicing your Rucky Chucky Crossing by literally running in shallow water. Find a pool with a three- to four-foot deep end and…run! Focus on quick, relaxed strides.

Shallow water running has the following benefits:

  • 50% less weight-bearing (at waist deep water) – in other words, 50% less tendon loading.
  • Water resistance that promotes a forward trunk engagement and less braking forces.
  • A relaxing environment; the water providing sensory input that relaxes muscles and joints.
  • Peace of mind, knowing that you’re “safe” from over-stressing the tissue.

Avoid hill running. Stay away from the hills until you’re able to perform all of the above elements, pain-free, and can run at least 30 minutes with minimal soreness. Hills invariable strain the Achilles (or joint and nerve-factors) in both directions. Stick to the flats until the “grief” subsides.

* * * * *

Achilles pain is so grief-inducing because of the conspiracy of factors. But by systematically defusing all the factors, you may more effectively return to happy running. Good luck!

Call for Comments (from Bryon)

  • Have you been plagued by Achilles pain?
  • If you’ve overcome Achilles pain, what did you do to aid your recovery?

[The contents of this column as well as the author’s comments are provided for general informational purposes only and are not intended as a substitute for professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition.]

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 57 comments

  1. Charlie M.

    Similar to the comments left by Karl Meltzer and Geoff Roes re: Dakota Jones' plantar fasciitis ( or rather, fasciosis), the thing to realize is that if you've got full blown achilles tendinosis, is it will take a super long time for blood flow to heal that sucker. I had PF for 4+ years until it went away, and I've had AT for 2+ years now, and I'm just trying to keep patient. The main thing is: don't stop running! It will suck, it will hurt, you have to slow down, you have to make adjustments, you've got to try different shoes/exercises/prayers, but the body will heal…eventually. In the meantime, drink alot of craft beer and artisan wine and cheese, and don't complain to your wife…she will want to kill you if she hears about the injury one more time. And as always, another injury will show up soon to replace this one! So try to appreciate the injury while you've got it. You may miss it when it's gone… :) Great article Joe.

    1. OOJ

      Thanks for the post, Charlie. (This isn't Charlie M from MN, is it?)

      Two important points made:

      1.) Patience with the healing process. Not only is the blood flow low, BUT where there's collagen fiber scarring, it takes a long time – hundreds of "reps" over weeks and months – to reorganize into functional tissue. Be patient, keep moving.

      2.) "drink a lot, don't complain" – the importance of a positive psyche in the healing process. CRUCIAL.

      1. Charlie M.

        Nope, Joe, this is not Charlie M. from MN, sorry. This is actually Charlie M. who used to be Trail Clown, but I'm not allowed to use that blog name anymore. Feels liberating to be a real person again :) Thanks again for the article, it always is great to return from a morning run (achilles didn't hurt that much!) and read about the injury you have. Validating and makes you feel like others feel your pain…

  2. Brandon

    When will the medical community grasp the idea of eccentric loading for tendonosis issues. Studies have repeatedly shown the benefits and decreased healing times. Also new studies are showing that downhill running is a major cause of Achilles' tendon issues. Do the research on eccentric exercises. It pains me to see people using traditional pt techniques and suffering from Achilles issues for longer than necessary.

    1. OOJ

      Brandon,

      Thanks for the response! I've yet to be called "traditional", so I'll take that as complimentary.

      My philosophy as a PT is this: in about 90% of all injury cases I see professionally, (and about 99% of all running injuries, except falls or car accidents), are due to motor control factors, or…

      "Slamming your thumb in the door".

      In other words, our pain comes voluntarily (though perhaps not consciously) by how we move our bodies. How we put one foot in front of the other plays THE most important role in run performance, training sustainability, and – when all else is equal – performance.

      That said…I find that "traditional" strength, ROM, or mobilization techniques for any injury treatment are secondary to "taking your thumb out of the door".

      You're 100% correct about the research on eccentric loading. But does that matter if you go out and run with a braking stride? Or running with a stiff, "protective" ankle? Or as a ball of nerves, anxiously wondering "when will it hurt?"

      My professional (and personal) experience with injuries such as this is that these mechanical and mental factors play the prominent role in injury generation and perpetuation. And it's this unique perspective that I try to bring to the iRF reader with each column.

      Thanks again. And if you have time, please do post some additional info on the importance of eccentric loading in strength and tissue re-organization.

      1. Brandon

        Thanks for the great article and quick response. My achilles issues stemmed from a sprained ankle that resulted in decreased ROM and then doing a long run with significant downhill. I couldn't run for 18 months but increased ROM and eccentric heel drops healed it.

        Thanks for taking the time to educate all of us on frustrating injuries.

  3. Marc

    Thanks again for another amazingly detailed article Joe! I just overcame some Achilles issues a few months ago and I attributed some of the cause to doing too many hills with minimal shoes. As I switched to less minimal shoes with more sole I felt a lot less stress on my Achilles and calves. I haven't really noticed a change in my foot strike, but as minimal shoes promote forefoot striking this seems to align with your article.

  4. Todd Gallagher

    I've just come off an AT injury. I feel like the thing that benefited me most was using a roller ball or a tennis ball. While sitting on the floor with my legs straight out I place the ball on the tendon itself and roll it up and down with pressure (as much as I can handle). I also place the ball on either side of the tendon and repeat the rolling with pressure. It is somewhat painful, but it has eliminated the problem. I'm not exactly sure why but I'm sure doing this has helped to break down some of the scar tissue and stimulate an inflammatory response. I'm happy to say that I'm back running with no pain whatsoever. I am continuing to roll a ball on the tendon daily. I know it's anecdotal at best, but it sure helped!

  5. Doug K

    had mild achilles problems for a decade or two, managed them with stretches; the eccentric calf drops worked very well, thought I'd fixed it with those. However two years ago I precipitated a crisis by racing in Newtons which promote a forefoot strike, since when nothing has worked. Xray and MRI don't show anything unusual so at least it's not a bone spur. Upon trying the heel bone mobility exercise from the PF article it appears there is none.. also it never occurred to me that sciatic pain might be referring. Thank you for something new to try..

    Charlie M, "drink a lot of craft beer and artisan wine and cheese, and don’t complain to your wife"

    that's been my practice too, for all these decades.. Once I complained about getting slower and older, she responded, 'either train more or complain less', quite right too.

  6. Martin

    This one is a really nasty one. Took me 5 months to heal. I am pretty sure, it could have been 2 if I stayed off my feet, and especially did not try to run on it after a few weeks.

  7. Patrick

    I've had mid-portional AT for 2 years – and I've finally have it receding…there are so many opposing views of how to treat it (heat, cold, run, don't run…I ran through mine as it didn't really hurt to run [it was mainly sore to the touch with a small bump])…the key treatment: eccentric heel drops: if it's mid-portion, do the full eccentric heel drop…if it's insertional do eccentric heel drops to a flat surface…you have to commit to the protocol!…though I found that once/day (3 sets of 15 with leg straight and 3 sets of 15 with leg bent) seemed to work as well as the original protocol (doing the sets both morning and night – I did morning and night the '1st time' I did the 12-week protocol – it helped, but the AT remained sore and I still had a bump…) the key to really making progress for me was adding weight to the single leg drops – the 1st time I stopped adding weight at 40lbs..the second time i built up to 80 extra lbs (40 around my waist, 40 in a backpack) — that made all the difference.

  8. KenZ

    I've had two different bouts, the second of which I am still working through.

    BOUT ONE: Achilles Pain / Especially in the AM / No significant swelling or bumps

    I got over this by one simple things: Yoga's down dog, done at least 2x/day, 5-10 reps each time, held at least a minute or more each time. Probably because, as Joe pointed out, I wasn't stretching the Achilles so much as all the other stuff that runs up the back of the legs.

    BOUT TWO: Achilles Pain / Large bump-like nodules mid-Achilles on each side

    Been fighting this since last January, when I got it from being overly excited by the new NB MT110s (which I later returned). I'd used minimal shoes extensively before, but I think these effected me much more than others, AND the lateral buildup did me no favors either. In two weeks I went from zero Achilles issues to bumps almost the size of small olives. I should have taken pictures.

    Not willing to give up an ultra season, I managed my way through it and was able to knock off 3x 50 milers and 2x 100 milers (both with 20k+ vert in each up and down). But that meant keeping my mileage low (for me) and being very cautious on how to work the Achilles before and after runs. I will note that I, like Brandon, have found that it's downhill running that really seems to damage me, NOT uphill running even though that allegedly stresses the Achilles more. Somewhere in that statement is likely a clue to my particular biomechanics issues…

    Now that winter is here, I'm taking two solid months completely off running to try to get a handle on it. One month in, I will say that not running at all has… done nothing to help the recovery. I'm hoping the second month will be the charm… if not, then I'm back to running anyway.

    Here's what I've found works, or seems to help:

    **Yoga's Down Dog is still the best stretch if you do one. Again, I think it's that it gets the entire hamstring/back of knee/calf area which makes it so effective, NOT the actual stretching of the Achilles.

    **Eccentric heel drops in accordance with the Alfredson protocol. Joe, I realize you don't recommend this, but it seems to really help not only with the pain (likely due to warming up the area) but with the actual swelling as well (that I don't really understand why; is it reorganizing the tissue? WTH is going on there?). Note that the Alfredson protocol actually calls for 3×15 drops 2x/day, and then slowly adding weight (which I do with a backpack filled with bricks, and now also adding barbells hanging from the front). Also note that I do these WITHOUT weight prior to any run, and that is super duper helpful with the run itself. If you must run, definitely recommend unweighted heel drops before the run.

    **Rolling the calf all the way down the Achilles, both directly on the back of the leg and on both sides… with one leg on top to get all my weight on the rolled leg… on a wooden rolling pin. For realz. This is likely the same effect that Todd Gallagher noted by rolling with a ball. This seriously reduces the swelling and seems to help the pain significantly, although the rolling itself is excruciating. I do stand somewhat mixed in feelings about this, as it certainly mobilizes the inflamed area quite a bit, but as Joe notes above, doing it too much may be retarding healing in trade for mobilization.

    **I manually mobilize the Achilles by squeezing it (gently at first, then harder) while flexing the ankle. A few times/week. I also have heard, and have tried flexing the ankle while working the other areas in and around the calf/lower leg area and shin bone. Basically, ART, but done by someone with no ART training!

    **I have tried and occasionally use Strassbourg socks for sleeping, and that definitely removes any pain in the morning. I do a slight modification of the socks, that I find pull the toes up too much. That may be fine for PF, but I don't have PF. I modified them so that the pull is directly under the ball of the foot, not out in front of the toes. I will note that while this makes me much more pain free in the morning, I have zero idea if it help, hurts, or is unrelated to any healing process.

    1. OOJ

      Great feedback, KenZ!

      >**Eccentric heel drops in accordance with the Alfredson protocol. Joe, I realize you don’t recommend this, but it seems to really help not only with the pain (likely due to warming up the area) but with the actual swelling as well (that I don’t really understand why; is it reorganizing the tissue? WTH is going on there?).

      I *do* recommend strengthening, and eccentric loading is the premier, research-based protocol for both strengthening and the tissue remodeling, as I discussed in a previous comment. Thanks to everyone for pointing out this omission.

      However, the point of emphasis in this post is to examine the other factors besides soft tissue that play a role in the development and persistence of Achilles pain.

      That said: the best way to stop "thumb-slamming" pain is to first remove the thumb from the door. :)

      Once the thumb is removed, the necessity of "herculean thumbs" (e.g. robust calf/achilles strengthening) is significantly decreased.

  9. Jeff

    Wow…you hit the nail on the head with the "Run Wholefoot" part of your article…wish I read this before figuring it out on my own a month ago…was a major forefoot striker, especially my left foot for some reason…was getting bad Achilles pain and thru trial and error found out that running "wholefoot" fixed it. Of course the reason I turned into a fore foot striker was because I used to be a heal striker and was getting horrible ITBS…tried minimal shoes and learned to run forefoot which fixed the ITBS issue but guess I over compensated…oh well, I am good now! Man, if you would have told me there was so much to running two years ago I would have said you are crazy! :)

  10. Ron

    This and the PF article are really great, Joe. Many thanks.

    Can I ask you if you think that bow-leggedness has any affect on getting achilles pain and plantar fasciitis? My one leg is more bowed than the other, and so I seem to supinate on it more than the other side because the lateral side is more under my hips, and then the arch seems to collapse so that I get PTTD or some soft tissue injury on the medial ankle and heel, strain in this achilles (I had AT, per se, bad two years ago and it cleared up for the most part with eccentric exercises though it still can get sensitive to touch), and what seems like PF in the front of heel/near arch (and my third and fourth toe get bruised from lifting up). Yet, the arch (and calf?) is always really, really tight when I try to stretch it. So, its a paradox–supination and pronation. Sometimes it feels like the fifth metatarsal sort of 'slips outward, laterally, when I start to run, too. Wearing an orthotic at home seems to help the PTTD, but I can't run in these things. Pronation control shoes just seem to cause medial knee pain and don't seem to address the problem, so I've gone with light, flexible shoes the past few years. If the shoes are too stiff it feels like there is a gap between the shoe and the medial part of my heel. Any thoughts? It has been a mystery to all my docs (support for supination? for pronation? for arch?). I can't imagine that I'm alone with this, though. My other leg is fine and dandy. And yeah, I'm old and a lot tighter than I used to be…

    Many thanks…

    1. stan

      Ron, did you make any progress with your injury. It seems like i have something very similar(bow leg, arch, heel, ankle achilles pain) for about a year now. Cant really run without pain afterwords.

      Thanks,

  11. Jeremy

    The Alfredson Protocol works. But…be careful adding weight too quickly. The soleus and AT will be able to handle over 100 lbs in no time. However, be sure to watch your plantar region. Mine quickly got angry from all this extra work.

  12. Stephen

    Nope – you're not alone, exactly the same thing here.

    Motion control shoe causes medial knee pain.

    "Minimalist" shoes cause AT.

    Thinking about trying the Hokas for a kick ;-)

    1. Charlie M.

      Yup, me too. I always have tight calves and arches, I get knee pain with beefed up shoes, I get achilles problems with minimalist shoes, PF is always a danger depending on the cushioning/arch support…it's always a delicate balancing act on each and every run, that's what makes it thrilling: not knowing if I'll come home injured or not! If I concentrate on each and every foot plant I'm usually ok, but I come home with a headache from all that concentration. The thought of just running free like a child, ha! Never again…

      1. Ron

        Same with me, Charlie…same with me. I had a good summer in the PI Streaks II, but now they seem to be giving me trouble. I tried Joe's "flat foot plant, slide under" approach today. It was ok, but sort of tiring, and I can't go very fast with it. But, I'll keep at it, though I seem to remember trying this some other time, too. (Going through those boxes of inserts in my closet recently, I realize that sometimes I bought the same orthotics twice, forgetting I had tried the same ones before in the past!) Who knew that running could be so complicated when we were young, eh? If that left foot was only like the right foot, and that left shoulder was only like the right shoulder, and…and…and…. As you write, "Never again…" like Humpty Dumpty, once the injury is had it never seems to fully heal anymore.

    2. Ron

      Thanks, Stephen; good to know I'm not alone. Oh, I've got the Hokas, too (got them when I herniated my c6 two years ago–"I can run through this" (ah, no, I couldn't; had to put me down with pain pills for a few weeks)–. The knee guy said medial meniscus…but my neighbor got the same thing, and had an operation done by that guy, only to get the same thing on the other knee three weeks later…so, I said no to the operation, got out of the wedged 'motion control' shoes', and for the most part the medial knee pain has gone away (found a real good doc who said it was 'prearthritis'–the medial support was sending the shock right up from my foot to the inner knee, bypassing the bowed leg). (Oh, I gave the neighbor the same advice to go to neutral shoes and his 'meniscus' pain went away, too.) (I sometimes wonder who is designing these shoes…a pack of monkeys? E.g., a wedge for your arch collapsing??) The Hokas are ok, but I find them a bit unstable, and, well, they are BIG. I'm waiting for them to go on a diet in the spring version before trying them again.

  13. OOJ

    Ron-

    Thanks for the post. Your "bow-leg" can play a huge role in foot/ankle/heel pain. That angling of the leg changes the mechanics of everything down low. Sometimes that's hereditary, sometimes, it's post-injury.

    But the bigger issue is this: are the muscles of the hip and trunk "strong enough" to stabilize that leg? This is a tough issue to address, which is likely why you (and your docs) have challenges correcting this.

    Unfortunately, I don't have specific advice for you without seeing "the big picture", but you might consider talking to your MD or PT about factors in your trunk/pelvis/hip that may be contributing.

    1. Ron

      Many thanks, Joe. Yes, I wish that there was more research or recognition of this. My PT had me working on core up the wazoo after I got my c6 hernia. I'm not strongly bow-legged, so I'm sure that there are a lot of others out there like me that both supinate and pronate due to the foot collapsing. The leg seems stable, but it can't seem to hold up when the foot isn't (and so I also get inner groin pain on the single track around here after long runs).

      In your postings you write a lot about posture. Many of us when we aren't running are sitting. May I ask you how does that affect our posture when we run? Is this why older guys (and women) seem a bit bent over when they run (i.e., with their buts sticking out and overstriding)? I remember being a kid and seeing my coach run like this and thought it so strange, and now I sort of look like him.

      Thank you very much, again, for taking the time to share your expertise and knowledge with us.

      1. OOJ

        Ron-

        I can't with certainty if/how prolonged sitting posture affects running posture. BUT I will generalize that poor posture + time = sustained (e.g. "stuck") forward/rounded spines. This is common among older folks, both runner and non-runner.

        What I will speculate is that the adoption of a flexed running posture also has a lot to do with the development of "bad habits" as a result of extreme fatigue. Older distance/ultra guys can begin to run this way, in theory, because that's where their brain "learns to go" with fatigue.

        I can relate. I've spent the better part of the past six months trying to erase several fatigue based bad-habits (http://www.wser.org/top-ten/ – 1:45). No one's immune.

        1. Ron

          Many thanks, Joe.

          Gee, in the video, you look pretty good to me!–especially after 100 miles!!! Congratulations on your finish there. Good to know that what you preach has been put to the test of hard practice.

          Thank you, again, for all your expertise and advice (and your own testing of it!)

          1. OOJ

            Obviously you're not professionally trained in gait analysis ;-) I kid. Thanks, but like I said, none of us are immune. Like everything else, mindfulness and consistent work equals ongoing improvement.

  14. Bnak

    Big tendon with poor circulation.

    Eccentric loading promotes restructuring and strengthening of damaged tissue,hot and cold treatments promote circulation and healing. This is the winning combination!

  15. joel anderson

    I had AT since the Twin Cities Marathon this October that was not healing until my wife got me some sessions with a run coach for my birthday. By adjusting my running form, she has enabled my AT to heal. Specifically, landing flat on a relaxed foot/calf and pushing off from the glutes and hips rather than the calf muscles, with a forward lean from the ankles. My AT was in my right side, which the coach said I was over-striding with. Eccentric exercises have also greatly helped. The money spent for three sessions with a form coach more than made up for money that could have been spent on new shoes/insoles etc. Plus running with better form has made me faster! In seeing this injury heal so quickly with form changes, I am convinced that developing AT has much to do with poor running form and technique.

      1. rod beckner

        Thanks for another great read. I'm not having any injuries since switching to Stinson Evos last August. The soft sole just works beautifully for me. 620 miles on this 1st pair so far. Used to ride my bike a lot, but have not since running is more fun now, mostly painless and can be done regularly.

        When you lapped me at autumn leaves 50 mile this year, I was surprised how much you were on your fore foot. It looked liked you could have cut the rear 1/2 off the soles of your shoes before the race, left them at home and not known the difference. Your landing placement & stride length appeared excellent(to my untrained eye). Most importantly, you were cruising. Nicer weather would have given you the 50k record.

  16. OOJ

    Rod-

    Thanks for the comment, and congrats on the 8-lapper (as I did only 5)!

    Good observation the foot strike; however, that forefoot landing – as stated above – does cause me grief for both calf and achilles issues. It also causes some over-stride issues, to boot. Indeed, a more compact stride with a wholefoot strike makes for more efficient, less straining and faster (for sure >8 seconds) running!

  17. Ron

    Thanks, Joel. Tried the hip/glute push off today, and at least my ankles and lower calf were looser (starting to think that this is where a lot of foot problems lie). Will keep at it. Thanks for your advice!

  18. astroyam

    Question for Joe:

    Relating to the 2nd photo above, would the following be a way to diagnose this condition: sitting in a chair, raise the [for example] right foot off the ground 12", keep the ankle loose, and pushing the heel bone inwards (towards the left in this case) causes pain in the joint?

    Thanks for any feedback!

    -Chris

    1. OOJ

      Very tough to say, nearly impossible to diagnosis remotely, unfortunately! Usually stiffness is a greater indicator of a joint issue than "pressure pain". Your soreness when pushing could be a soft tissue (tendon near heel) irritation.

  19. Jim B

    I am a long distance runner and have been a forefoot striker nearly my entire running life. I recently developed a pretty bad case of sesamoiditis and have been trying to change my running style. I haven't had achilles pain at all until now and I'm wondering if it has to do with the fact that I'm changing my running style to land more on my heel rather than ball of the foot. It seems to contradict your findings but I'm assuming that I am a bit of an odd case. Thanks for the write up.

    -Jim

    1. OOJ

      Jim-

      Thanks for the comment!

      Without looking at your stride, I cannot specifically determine WHY your heel hurts. However, "achilles" pain with a heel strike may not be true achilles tendon irritation. Rather, it could be a referred joint pain issue. Both your forefoot sesamoiditis and this new heel pain could be symptomatic of "braking" – landing with your foot too far in front of your body.

      I love this drill: http://runningwellct.wordpress.com/drills-videos/

      Try this, focusing on a compact "push down, pull up" stride mechanic. This will help prevent any "foot out front" braking forces and reduce stress through your entire foot. Good luck!

  20. michael

    Joe,

    I recently developed achilles pain, I am confident that it is soft tissue, as I can palpate and locate a distinct position of pain on the tendon. However, when I run and start to feel tightness and swelling in the achilles, my foot also starts to feel tight throughout. There is even swelling accompanying it such that if my shoes become tighter and splaying my toes feels difficult. So, this has me wondering what the connection is, and if it is possible that a problem from within the foot itself is resulting in the tightening of the achilles and thus pain. Any input would be super helpful. Thanks

    1. OOJ

      First place to look: stride mechanics. Where is your foot landing, with respect to your center of mass?

      A foot that lands in front (and, namely on the mid-to-forefoot) of the trunk will [over]load the achilles.

      Any intervention to the achilles – though important – is secondary to making sure you're not overloading the achilles with your foot strike.

      Get someone to videotape your stride from the side, and go from there.

  21. Frank.s

    Thank you Charly for your comment; it strenghtens me in the idea that this is the way to go forward. My hips have hurt for many many years i just kept running and now i never feel them; However now my achilles hurts like hell but like you i try to be patient. I just don.t want to stop so i don't , on average i still benefit from running.

  22. Doug

    I've had AT pain for years, the severity varies. I had been doing heel drops for years with great relief. I went to minimal shoes and tried a more flat footed strike as opposed to a heel strike and thought I was dong well. NOW ITS WORSE THAN EVER. So I went back to a shoe with a 12 mm toe drop and added about 2mm inserts and things seems to be better and on the mend. I note too I pronate a good bit.

    S

  23. Doug

    Sorry my comment was sent accidently before I finished(not my computer, sorry). The bottom line question is: for someone with long term AT pain, is there a shoe you would recommend? It seems a bigger toe drop is helpful, although I like the feel and idea of a minimal shoe. I think a big toe drop in a flexable, light weight with a straight last and motion control would be best but cant find a shoe with that combo of features.

  24. Justin

    I've been dealing with AT pain for about 3 months now. I've had graston and ART done to both my achilles with a little success. Initially we thought the cause was my extremely tight and knotted calves but we fixed that issue and that helped a little also.

    I had a running assessment done and during the assessment I was overstriding and heel striking. My average cadence was about 174 strides a minute. The PT had me switch to forefoot strike and that fixed my overstriding and now my cadence is 180 strides a minute. We also found that my original shoes that were stability shoes were causing my feet to not pronate at all and in fact supinate. So we tried a neutral shoe and that seem to fix all of my bio-mechanical issues.

    The pain in my right foot is about an inch above the lateral malleolus. when I squeeze the tendon. However the pain on my left foot above level with my lateral malleolus.

    Not quite sure what to do. The PT has me on an every other day running program of run 2 minutes / walk 2 minutes for 20 minutes total. I have no pain while running but my left achilles gets sore sometimes. Any suggestions? The eccentric exercises seem to make my achilles more sore. I am working on hip strength since my IT Band seems to flare up a little in neutral shoes.

    1. Justin

      I also forgot to mention in the neutral shoes I land pretty far on the outside/lateral side of my shoe compared to the stability shoes. The running assessment found that I don't overpronate though. Could this landing on the outside prevent my achilles from healing? In the stability shoes I land more towards the middle of my shoe but don't pronate at all and if anything I supinate a little bit.

      1. Anonymous

        Sorry to hear about your injury, Justin, I did get over my achilles pain by doing stair stretching exercises, but in a really controlled fashion, something like this video: http://www.youtube.com/watch?v=H1W_I3YDvzU
        You're right–you don't want to really stretch it very far–it just makes it worse. And I think that graston does the same–you don't want to further tear the tissue, so you're right, get away from the graston. Don't stretch it to the point that you can feel it in the heel. Just like the video, stretch the calf and rear foot etc. down a little bit and then with your other foot pushing up on the toes, raise that injured rear foot, as well. (It takes a bit of practice to get it). Then when it is feeling like it is healing, I used heavy weights on one of those gym toe/calf building machines at the local YMCA, just dropping the heal a little below the level. Once I started doing this and I stopped really stretching it far it took about a month to get better. I guess that I did the supported stair exercises two or three times a day. I haven't had trouble since, though the supination is causing PF now!–but that's been two years and I over did it. I think that supination causes all sorts of problems–the achilles is bent and at least my arch seems to collapse all over the place in order to 'supinate' in its own screwed up fashion. If you supinate, yes, get out of the shoes with the pronation support, though maybe get some help to loosen up those ankles and their tendons so that you don't get PF or posterior tendentious on the medial part of the arch/heel like I do. Good luck with it. I got over it and another guy in town did too with a similar approach.

        1. Justin

          Thanks for the advice. I was going pretty much dropping as fall as my range of motion allowed me to on the heel drops. According to the running assessment that was done, with the neutral shoes I have perfect amount of pronation/supination, knee bend and my knees don't go inward compared to the stability shoes. The only thing different is I now land further on the outside but the PT said it shouldn't be a problem because of the pronation and supination is pretty much ideal to what I want. Since we switched shoes it seemed to help while running but I fear that I might be landing too far forward but I am just so used to being a heel/midfoot striker that I just have to get the feeling down.

          I'm seeing a chiropractor that is doing some ART and adjustments that seem to help with my mobility in my heel.

          I'm trying to get this taken care of as quickly as I can because I'm running Boston again in the spring and the 3.5 months off of running has put a long ways behind where I wanted to be after completing Boston this year.

          Good luck with your injury!

          1. ron

            From my experience, I'd say don't stretch it all the way down–I think that really what you are trying to do is stretch the calf, which this type of supported stretch and lift will do, I found. Not the achilles. In fact, when I had my AT and posterior tendon problems, I ran in some 'normal' mizuno trainers, with I recall, an orthotic in them. In other words, anything to prevent that AT and posterior tendon from being overstretched. I'm finding the same thing with the PF–I have it taped up now–stretching just makes it worse. I'm just tearing a tear. And with the AT, that seems to be hard to heal.

            I found, as a supinator, that trying too hard to achieve a more 'ideal' running form led into trouble–namely, arch collapse and PT/posterior tendon problems. After several years of running in racing type of shoes, I've achieved a more midfoot landing than I used to have I used to land way back with the knee almost straight), but I think that trying to achieve an 'ideal' running form is more of an ideal than a reality, at least for me. In any case, a time of injury is not a time to experiment with lower shoes and running form, I found. From my experience, you need to get that achilles healed, and that means not to stretch it too much and then when it is feeling better, at least I and another guy from around here found that some heavy weights were useful, bearing in mind that one isn't stretching it too far while using these.

            the one thing, by the way, that you may miss as a supinator when you switch out of 'stability shoes' is the medial knee pain–i.e., developing arthritis–that the pronation control will give you. Another neighbor and I both avoided what a doc termed 'meniscus injury' and the surgery he recommended, by getting out of those things. Finally found a running podiatrist a few weeks ago that told me, what I always felt and knew, that those things will just lead to arthritis for a foot like mine (and according to him, few people need a lot of pronation support).

            Good luck with it!

  25. Amy

    I cannot believe you guys are running with these injuries. I couldn't walk for more than 15 min at a time. But I was misdiagnosed for over a year with "plantar fasciitis". First PT referral after new doc was for posterior tibial neuroplaxia. Now it's Achilles tendinosis. Max walking (on hard floors like the mall) is 45 minutes 2 years later. I'm 28.

  26. Stan

    Hi Joe,

    Thanks for the incredibly insightful articles! Keep them coming!
    I was wondering if you could give me any insight on what I’m dealing with.

    About 5 months ago I started experiencing what I thought was midpoint achilles pain in my right leg, I reduced my mileage for about a month and it didnt get better. After I stopped running altogether I started having insertional achilles tendinosis on my left. Those stayed with me for about 2 months – I was somewhat diligently doing the Alfredson protocol – incorrectly – off of a stair not on flat ground. And all of the sudden started having arch pain – not pf (i dont have classic morning pain – it gets worse as im sitting and later in the day) – that basically lasted next 2 months with zero running. The achilles pain dissipated but foot pain did not. I slowly and gradually started running again and over 3 or 4 weeks foot pain was gone. But all the symptoms both feet came back pretty much overnight as I thought I was recovered.

    I figured I should start doing the alfredson protocol – correctly this time and maybe run very short and see how it goes. But Im worried that the Alfredson protocol might be causing might be a contributing cause for my arch pain.

    Does anything jump at you? Any thoughts on how you would go about treating it?

    Much appreciated!

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