“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.