The first Tuesday in October I popped home at lunchtime between visiting clinics. As I walked in I noticed a red plasticised package on the side, and my eyes fell on the logo which was poking out at the side. It was the Virgin London Marathon logo.
Just then Diane my lovely cleaning lady (and fellow runner) came downstairs and said ‘I think that’s your London Marathon package... open it we’ll see if you got in on the ballot’.
I ripped open the package, thinking well I’m certain I haven’t got in! My eyes fell upon the word ‘Acceptance form’,
‘OH my God, I cried... I’m in!’ Then flooded in a multitude of emotions… disbelief, excitement and then the thought of those cold long runs popped back into my head, quickly followed by the thought of my old nemesis – my Achilles tendon injury. What to do? One thing’s certain, with the honour of getting in the ballot, I certainly wasn’t going to give up the place. But I needed to work on my Achilles too as they take a long time to fully rehabilitate, anything up to 6 months.
The Achilles is the tendon formed as the gastrocnemius and soleus – the calf muscles – join to insert on to the heel bone. The Achilles tendon has to tolerate the highest loads in the body
An Achilles tendinopathy rather than signs of inflammation, there are cellular changes to the tendon and to the arrangement of collagen fibres. This makes it difficult for it to tolerate loads. It is correcting this that is at the heart of treatment.
Features of Achilles tendinopathy are the gradual onset of morning stiffness which may resolve within 5-10 minutes, and stiffness when walking after sitting for long periods. The pain/stiffness will typically “warm-up” during the first 5-10 minutes of a run.
They are commonly associated with training errors such as rapidly increasing training intensity or duration. Also changes in training surface or footwear, and any asymmetry in the mechanics and control of the leg and pelvis.
Principles of conservative treatment:
- Improving the tendons tolerance to load is a key feature.
- Biomechanical correction
- Manual therapy can be helpful in reducing the pain and discomfort
- Strength training and correcting training errors
Whilst there may be a need to cut running initially, there is also general agreement that off-loading the tendon for too long is unhelpful. It is important to work out how much running can be done without affecting the symptoms. So morning stiffness can be a good indication of how the tendon is coping with load.
Evidence has shown that slow, heavy load-strength training can improve a tendon’s tolerance to load and this is one of the gold standards for treatment but it is important, though, to avoid overload through other aspects of training while strength training, otherwise it will fail.
Calm down reactive tendinopathy with isometrics bilateral heel raises, several times per day.
Then when the tendon is less reactive eccentric calf raises with use of weights both in standing and seated positions. Loading three times a week is optimal, but changes to the tendon do take time, so patience is needed.
There may also be specific biomechanical factors feeding into the tendinopathy. Gait should be analysed to identify what they need to work on or change. It may be a biomechanical foot problem, or to issues around the hip/pelvis. Equally trunk position and lack of flexibility in the spine and pelvis can cause problems as can control issues in the foot or knee.
All the evidence points towards load management as the best way to rehabilitate Achilles tendinopathy, along with looking at the global picture.
With all this in mind I best get cracking Virgin London Marathon here I come……...
You can read more about Jane Morris here.