Updated: Sep 19, 2022
Ginny is an avid recreational runner. She says often it's as much for her mental health as well as her physical health. The rainy winters put a literal dampener on her training, but she still gets out there at least a couple times a week. Her running volume took a hit in 2020, but in 2021 she resolved to get right back to her 2019 volume. A few weeks in she started to feel a twinge of pain in her left Achilles tendon, but it would go away after a mile or so. Within a few more weeks it wasn't going away and pretty soon it was bothering her with walking too. She rested it for 5 days. It felt better but as soon as she got back to running the pain was back. She went through this cycle a few more times, getting more and more frustrated. Why was her body not healing? At this point she came to see me to get a little help solving the mystery. We worked as a team and got her back to the running that her mind and body need to feel fulfilled.
Step #1 - Forget About Rest
Complete rest will just cause further stiffness to develop in the tendon. In my experience Achilles injuries are almost always precipitated by a change in activity level. For Ginny the unplanned rest during 2020 may have helped set her up for injury because of her ambitious return to her former training volume. Complete rest, then returning to prior activity will just perpetuate the cycle. Your tendon needs movement, even if it's just light movement at first.
Do some calf raises while sitting in a chair or use some elastic band to do resisted plantar flexion (toe pointing).
Keep the resistance light enough to be comfortable but strong enough that your calf feels exhausted after 30-50 reps. These light numerous reps will pump your calf muscles full of blood and increase blood flow to the tendon as well.
Repeat for a total of 3 sets, with 2 minutes rest in between sets. Repeat this routine 3-4 times a day. Within a couple of days you'll be ready for the next step.
Step #2 - Start To Load, Keep It Short
Tendons respond to tension, just like muscles do. Well, almost like muscles. Tension stimulates the cells in tendons to make more intracellular matrix, the viscoelastic stuff that makes up most of the tendon. It's a good thing, it makes them strong! Unlike muscles, the cells only respond for about 10 minutes. You can keep exercising but your tendon won't 'wake up' any more than it has already.
"Tendons are like 13 year olds. They'll listen for about 10 minutes then they'll just stop paying attention." – Keith Baar, researcher at UC Davis
After that initial 10 minutes, the tendon cells will stay active for the next 6-8 hours making more healthy tendon matrix to replace the injured area. At the 6 hour mark do another 10 minutes of loading to stimulate the healing process all over again. If you're motivated and organized you can do 3 sessions per day and that will be 3 times that you've kick started the healing process.
Step #3 - Go Isometric at first
Load your Achilles tendon with isometric exercise, or stretches under tension. This is an exercise where the ankle joint doesn't move, but the muscle works against some tension.
A classic example is standing with toes on a step and letting your heels hang down, then resisting the stretch enough to feel the tension, but not enough to cause your heels to rise. It may be a little uncomfortable, but shouldn't be painful. If it is painful then decrease the tension by using a belt or strong elastic band. If too easy, try it with one foot.
Hold for 30 seconds then ease out of it. Wait 20-30 seconds then do it again. Repeat the whole process for a total of 10 minutes.
The 30 seconds is important, to see a prior post that explains in more detail click the button below:
Step #4 - Slow And Heavy
As your Achilles starts to feel better you can start to incorporate different ways to load it. Heavy, Slow Reps are a great next step. For example:
Stand on a step as in the above example. Take 3 full seconds to lower your heels down through their full range (or heel if you're strong enough to do one leg at a time)
Take 3 full seconds to push your way to the top of your range. That is one rep.
Pain should not go above 2-3/10. A little discomfort is fine, it should feel better when you're done.
Repeat until your calf muscles are too tired to get through a full rep. If it took 5-8 reps to hit that point then you are at a good intensity for this exercise.
Rest 2 minutes, do three sets in all
Step #5 - Start To Experiment
When your Achilles is feeling stronger and better, it's time to start varying the loading pattern a little:
Walk with an exaggerated toe/heel rise. I call this the rocker walk. Pull your forefoot up into dorsiflexion as high as you can before heel strike and smoothly roll to flat foot. Use your calf muscles to exaggerate the heel lift as you push off
Walk backwards uphill
Walk backwards downhill
Jump rope, or just do two footed hops in place
Be Patient And Listen To Your Body
Tendons typically take longer to heal than muscle, bone, or skin because of reduced blood supply and slow cell turnover. Focus on the journey and be sure to notice those increases in tension tolerance, because they are little victories. For a typical Achilles strain like Ginny, it's reasonable to expect to be better within 2-3 months if you follow the steps and adjust your training volume in response to how your leg is doing. And remember this is just a rough guide and should not be thought of as an individualized medical intervention. If your injury is not getting better, it might be time to get some help. At Neighborhood Physical Therapy I help runners like Ginny all the time break free from the injury cycle and get back to running, often stronger and smarter about training than they were before the injury. #running #achilles #injury #rehab #exercises #ankle #phyiscaltherapy