More On Achilles Tendons II

Traditional approaches of therapy for Achilles tendonitis include: joint and soft tissue mobilizations; concentric exercises; stretching exercises; ultrasound; ice; iontophoresis; laser; friction massage; splinting; orthotics; NSAIDs; corticosteroids; activity modification; rest; and surgery. What is interesting is that there is a gaping chasm between health practitioners on what works “best”. What I have found is the old “if the only tool you have is a hammer then everything looks like a nail” approach. Whatever your practitioner is trained in or certified in is what they will recommend AND tell you it works. Wrong! I’ve been through it all, podiatrists want orthotics & splints; physical therpaists want every exercise variation (depending on their backgrounds and certifications); orthopedists will give you drugs tell you to rest – might send you to PT and as a last resort do surgery; chiropractors think it’s linked to your posture and your back so of course you need adjustments; massage and trigger point therapists think it’s related to tight muscles and you have to have them worked on – and of course do stretching.

Of course I’m generalizing so get off my case if you know of an exception or two. I’m relating to my 30+ years of on-again off-again tendonitis/tendonosis as well as volumes of anecdotal information from runners, the research and comments from the health professionals themselves.

Achilles tendinitis is what historically has been the label for that condition affecting the Achilles tendon. However, more and more over the recent years the term Achilles tendonosis is being used. Why? Because doubt had been raised as to how much inflammation (“itis” means inflammation) is actually the culprit or involved. It is indeed a “condition of” (“osis”) the tendon. There are a number of studies of the ailment now that have found no inflammatory cells present. Chronic tendonosis is usually anything that lasts more than 3 months. I will use the terms interchangeably mostly because I’ve known it as an “itis” for so long and most people know that term best.

There was an interesting meta-study (a study of studies) done on Achilles tendon treatments. They found for the most part very poor research design for the most part. Few had valid control groups. Why is that important? It means that the selection of subjects or the use of treatments can more easily be swayed. An important error researchers can be prone to is one of bias. Researchers are prone to “getting what they are looking for”. In practice that might mean I’m a PT who does a unique combination of exercises and deep massage and so I do a “research study” to show the efficacy of my treatments. Lo and behold, my data shows that with my treatments the subjects report a 75% decrease in pain symptoms and they return to activities within 6 weeks – 2 weeks faster than conventional methods. Without controls, randomization or blinding a study (subjects don’t know whether they are the experiment group or control group) the results are simply interesting but inconclusive. There are too many other reasons someone improved under that therapy regimen. This does not mean that the study doesn’t support the claim, it might.. but the way it was conducted – it also might not. Therefore it cannot be completely relied upon.

This meta-analysis did come up with at least one interesting conclusion. Eccentric exercises (i.e. heel drops) were benficial to rehabilitating Achilles tendonosis. However, it was not effective with insertional Achilles tendonitis. This is if your tendonitis is at the insertion point on your calcaneous (heel bone).

Here is the protocol followed in most of those studies. It is called the Alfredson eccentric protocol.

Perform 3 sets of 15 reps eccentric heel drops; twice a day; seven days a week; for 12 weeks; progressively add weight and work through non-disabling pain.

What is interesting is that the authors of the meta-study could not recommend the “work through non-disabling pain” part because ethically they couldn’t do this to their patients.

I personally have not tried this treatment as outllined. I have done heel drops as part of rehabilitation along the way. A heel drop is performed like this:
Stand on a step (or anything that lets your heel drop below level). Then raise yourself up onto your forefoot (tippy toes). From here there are two variations. Two-leg or single-leg drops. You may start with the two-leg one, it’s easier. However, if you think about it, we only run on one leg at a time and so the most “running-specific” method is to do a single leg drop. Slowly, drop your heel below level until you feel a stretch. Start with body weight and then you can add dumbells or a barbell with weights for added resistance. Raise yourself up and repeat.

Now, my orthopedist advised me absolutely NOT to do these. My PT said I absolutely should do them. So again, you can see why it is so difficult for Achilles tendonosis sufferers to figure out what to do. Still nobody completely agrees. What works for one doesn’t for another.

I’m going to look into two new methods of treatment out. One is the Pro-Tec support. The other is a physical therapy treatment called ASTYM. If anyone has experience with these, I would love to hear from you.

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About Dean Hebert

I’m a mental game coach, author and speaker. I work with individual athletes, parents, coaches, and teams on sports performance enhancement. Beyond my academic post-graduate work in sports psychology - the psychology behind athlete performance – I am a certified Mental Games Coaching Professional (MGCP) and certified hypnotherapist. I’ve authored several books and hundreds of articles. “Coach, I didn’t run because…” (2008) is a seriously light-hearted look at making excuses not to workout and how to overcome them. “Focus for Fitness” (2009) and “Screw the Goals Give me the Donut” (2010) are two of my eBooks on mental game approaches for the everyday athlete. I wrote these because I believe that everyone can benefit from the powerful mental techniques that the world’s best athletes use. I have been cited in Runners World, Best Health magazine (CN), SWEAT Magazine, and the Washington Examiner amongst many other publications. I have been a featured mental games coach in Runner’s World and for the internationally acclaimed trail running resource - trailrunningclub.com. I also regularly appear on sports and fitness talk shows such as LTKFitness, Runnersroundtable and for more than three years I have co-hosted a weekly video series with Coach Joe English for Running-Advice.com. I specialize in mental toughness training. My clients include tennis, synchronized swimming, golf, race-kart, soccer, motocross, volleyball, MMA, cycling (road, off-road, time-trialist), running, duathlon and triathlon, basketball, football and baseball athletes. I have coached world-class athletes and athletes internationally. I have a passion for working with youth athletes and helping them apply mental game skills and techniques to all areas of life. Most importantly, my aim is to have people enjoy sports and life to their fullest through peak performances.
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24 Responses to More On Achilles Tendons II

  1. Darrell says:

    I am training for a marathon and I ‘m doing 2 sets 3 times a day single leg is working well i ran 22 miles today. After wasting 2 weeks of doing stretches the dr gave me . I started the Ecc.. lifts after going to PT. I am also wearing heal lifts when running. I have gotten up to adding 55 extra lbs on calf raise machine when doing this. I am definitely seeing progress even though i was feeling too well and ran in racing flats up a hill after it started good and setting me back a week or so. I recommend following the PT’s advice and doing the eccentric training. I do one set straight leg and the other with knee slightly bent. check the web there are photos out there on eccentric training and the bent leg method. hope this helps this injury sucks but I am still running the richmond marathon.

  2. Good for your. Yes the eccentric muscle workouts are good. They are the only ones to make a difference as far as I can tell.

  3. Doug says:

    Hi Dean,

    I found your blog when searching for runners’ experiences with ASTYM. My PT just started it on me today, and I’m still a little shaky on the idea. I just finished having Active Release Technique done, which also breaks up scar tissue, and failed to work for me.

    Did you end up having any experience with ASTYM? I’m continuing with the therapy regardless, just wondering what kind of luck other runners have had with it. The numbers on their website are amazing, but as you’ve said, who would expect otherwise?

  4. Doug,
    I now have three runners I coach who are currently getting or got ASTYM. One with plantar fasciitis… total cure. One with hamstring issues… total cure. One currently under treatment for shin splint related pain… TBD.
    There are several PTs in the area certified in ASTYM. All 3 of my runners have had the same PT.
    So, I have to admit that at least on certain ailments it seems to be helping.
    It isn’t covered by my insurance so I haven’t broken down to go do it yet… but I am more than interested.
    Thanks for reading.
    Coach Dean

  5. David Kelly says:

    I’ve struggled with this problem for over 5 years. I’m currently checking out Chi Running to try off-loading my Achilles and avoid heel-striking. Video analysis showed that I was a serious heel-striker and my cadence is too slow. It’s very insightful to watch yourself running in slow motion – I’m no longer confused as to why my Achilles hurt!
    We are not supposed to heel strike and can only do so because we wear cushioned running shoes. I’ve started running for 30min x 5 times per week in mid-chest depth swimming pool. This allows me to focus on technique without any pain. My plan is eventually to get going on soft grass barefoot. I know it will take a long time to change style but I’ve tried everything else and this makes most sense to me.
    Goog luck

  6. Wow,
    I sure hope for the best for you. Certainly every runner is different biomechanically – there are forefoot, midfoot and rearfoot (heel) strikers. However, heel-striking is most absolutely not a cause for Achilles issues. It is a strength and stability (of your foot plant) as well as flexibility (for some) issue. I have never in my 37 years of coaching and running nor in my association with numerous physical therapists ever heard of changing to a non-heel striking form to cure Achiiles issues. Conventionally, it is recommended to use a heel lift but that is to relieve stress due to the over stretching. A true forefoot runner does not run on tippy toes… they have to let their heel touch down. It is just that their footstrike is such that the forefoot strikes first, it rolls back (though briefly) to the heel then back up to the forefoot for push-off.

    I agree slow-mo of your footstrike is cool. Cadence itself is not related to Achilles problems of course. However, footstrike time might be.

    Your running in the pool is perfect rehab. It will most definitely make you stronger without the trauma of terra firma running. Of course it will actually slow your cadence down even more due to the resistance of the water.

    Achilles tendon related injuries have a number of causes and so there are also a number of interventions. Not all work for everyone. I sure hope Chi Running works for you. Thanks for your comments. Please keep me up to date on your progress.

    PS
    I am getting more and more positive comments and results regarding ASTYM treatments.

  7. Pingback: Achilles Tendon - Comeback Case Study - 6 Month Follow-Up « The Running World According to Dean

  8. Mart says:

    Hi,

    I found your blog when searching for how moving to landing on the forefoot would affect achilles pain.

    If you take a look at my site you will see that I’ve also been suffering with achilles tendon pain – couple with a stress fracture of my fibula. This all happened about 5 months ago – the stress fracture is ok now but the achilles are still giving me problems. I’m trying to move to a midfoot strike (currently heel) as I know this is the best for reducing overall injury risk.

    I have also found that eccentric achilles stretches have twinged my tendons where they join the heel… so I’m giving them a rest for now!

    Mart

  9. Hi Mart,
    Thanks for dropping in. It sure is a pesky condition. Here is what I know:

    From all I’ve researched forefoot stirkers put MORE not less stress on the Achilles tendon.

    Changing your “natural” footstrike more often leads to – not prevents – injuries. There is no such thing as a “preferred” footstrike regarding Achilles tendon injuries.

    There are just a different set of issues with forefoot strikers… even then, it’s highly individual.

    Sure hope it works for you.
    Coach Dean

  10. Hi Dean,

    Yeah.. think I was wrong in my first comment! I meant to say midfoot!

    My achilles may snap if I move to a forefoot footstrike!

    Regards,
    Mart

  11. Adam says:

    Hi Dean,

    I’m skeptical of the Pro-tec support (or any other method of bracing), at least for any extended period of time during training. In my case, after an aggravation of chronic tendinosis I wrapped both calves and feet with tape and ace bandages (I’m sure you’ve seen trainers do this or perhaps you’ve done it yourself). It provided excellent support, in fact it was probably too much. Feeling good (and exhibiting the lack of discipline you mention elsewhere as a big obstacle to recovery) I ran a fast tempo workout two weeks into recovery. The pain afterwards was pretty severe. Nothing had ruptured, however the taping scheme had subjected the soleus and compartment muscles to considerably more shock than normal — o.k. for easy paced runs, perhaps, but terrible while running fast. I’m back to mostly easy paces now, unwrapped, wearing heel lifts in regular shoes (but not in running shoes — they hurt my feet), and starting eccentric exercise routine. I’m still on course for a June marathon debut, but I wish I could do more quality work.

    Adam

  12. Thanks for the input. I agree with being wary of taping/wrapping. At least you can run easy. At least you should make it through the marathon.
    Without quality work you’ll probably suffer on pace and overall comfort but you can at least finish it. Stick with the eccentric exercises… they seem to hold decent promise… most of the time. Love to hear your progress along the way.
    Coach Dean

  13. Adam says:

    Did 10.2 miles at faster than MP (69 minutes), with no pain. I’m staying cautious, but hopeful, most certainly to finish, and to be at least in the ballpark of my 3-hr. goal time.

    Adam

  14. Blake says:

    If you have insertional achilles tendonitis, do not do your eccentric loading to dorsiflexion. Stop at ground level. Jan 2008 BSMJ issue had a pilot study on this–much better results this way–about 67%. If you have mid portion, use the full range of motion in eccentric exercises and your chances are almost 100%.

  15. Dean Hebert says:

    Blake,
    Interesting pilot study results. I do state that there is a difference with insertional tendonitis in my original article (paragraph 5) so it supports the study I mention.

    Again, as I caution everyone with this ailment, it’s an “experiment of one.” Try different things and see how you uniquely respond. The studies are full of these kinds of recommendations and absolutely none are the single cure… as evidenced of course by the 33% who were not helped with the pilot study you quote. I think all of the comments and research data support just that point. No medical professional has the definitive answer. There is no definitive treatment.

  16. Dean Hebert says:

    Here’s a response from a mom whose son had Achilles tendonitis:

    He has taken to heart your encouragement and advice…when we were at the shoe store last weekend we ran into another high school runner from our area. As she was talking to the salesperson, I couldn’t but overhear that she was coming back from an Achilles injury..of course, I talked to her and asked her about her symptoms and recovery etc…she told me that she had to sit out the entire XC session because of the injury. I asked how the injury started and she told me that it started with a mild discomfort in her heel and as she continued to run on it it worsened where she almost couldn’t walk. She added that she ran with the pain for over a month before it was too much for her..and by then she caused too much damage. I talked to her Mom and she said it was a devastating time for them because she was a very promising runner (I could obviously empathize). Billy heard the conversation and had one thing to say, if she would’ve just stopped running when the pain started and been patient, she may have not lost an entire XC season (your advice did not hit deaf hears) 🙂

    Well it looks like we are on our way with a slow and methodical approach. He is still swimming 3X a week and incorporating running every other day with core workouts built in (he takes Sunday off as a rest day). His coach is making sure he is taking it slow; 30 minutes at an 8 minute pace,,,with stretching before and after (we are still icing after the workouts…even though there is no pain..maybe too over cautious ??). If he is feeling good his coach will have him increase his workout 10% a week. Track practice begins March 2nd, so he is trying to build up for that. He has attempted no hills or speed.

    Thanks again for everything, as always, I will keep you posted on the progress..and of course any records he might break 🙂 The future looks bright !!!!

  17. Dan says:

    After almost ten years of battling achilles tendonitis/osis I have just started ASTYM. I’ve done it all and I am a bit skeptical but we shall see. First session was intense but felt promising. A lot of crunching everywhere.

    • Dean Hebert says:

      Please come back and update us on this. I have since had two other runners do ASTYM with great results… I personally haven’t had it done.

      • Dan says:

        So far so good on the ASTYM. Two sessions so far plus strength conditioning, acupuncture and Bill Peterson’s orthotics are bringing me back from the “dead”. I can’t remember the last time my achilles felt this good………a lot more scar tissue to go though. I ain’t out of the woods yet by any means.

      • Dean Hebert says:

        Thanks for the update… it sure has helped several of my runners. I’ll keep hopes high for you!

      • Dan says:

        The ASTYM is going much better then I expected! It can be down right sadistic but it is the first therapy that I have done that actually is trying to heal rather then just dull the pain. My therapist is the only Physical Therapist in Tucson that is certified to do this treatment and she is attacking it full force. The scar tissue is actually getting smaller and thinned out. I can’t say enough about it. Thank God I found this. If anyone is in Tucson and wants to try ASTYM feel free to contact me and I will gladly give you the information. And for the record I am a confirmed skeptic and I don’t throw around recommendations lightly.
        You will need a Doctor’s Rx.

  18. Dean Hebert says:

    Well, you join the group of runners I know who have tried it. Glad you’re getting better!

  19. Staci says:

    Glad to see this blog. I’ve been dealing with on-again-off-again tendinitis/ois for over a year now. I tried ASTYM last summer to get thru the Seattle Marathon. It worked a little but not great. After the marathon I took time off from running but kept up the eccentric exercises & stretching. When I started running again I felt great.

    Then a month into running I started came up with ITBS. I started focusing my exercises & stretching on this problem and now my Achilles Tendinitis is back again, of course 5 weeks before my next marathon.

    So, I’m back in to ASTYM and PT. I’ve stopped running as from last year I learned my lesson and I’m going to be patient and let things heal properly this time. I have no clue what to do as I keep thinking things are better and then “wham” I get hit with another injury.

    • Dean Hebert says:

      Ah yes.. welcome to my world. I did ASTYM also and it helped a lot but now I realize I have more issues – an extensor/flexor tendonitis it appears. It’s now been several months without running.

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