Help!! Have been running for 7 years and recently approx 3.5 miles into the run right achilles started hurting. No known reason. Have been off & on icing, stretching & antiinflammatories. Is it best to wait until 100% resolved or is it OK to run on?? Not too sore to run on. Have taken a week off and is about 80%. Suggestions? Thanks!!
I think you need to make the cal regarding running or not. In general I'd be very cautious.
"Kick off your high heel sneakers, it's party time."
-- From the song FM by Steely Dan
You may be able to run on it now, maybe at reduced pace and/or distance. Only you can know for sure. Meanwhile, check out this article, which provides some rehab techniques/exercises. Calf tightness/weakness is often the source of achilles problems.
I agree with Jim and Len's points about calf tightness being a problem, since it over-stresses the Achilles tendon. Regarding the PT article, note that the strategy changes for "Severe Conditions" at the bottom of the article. This highlights one of the most important things to know about rehabbing injuries - especially self-rehabbing injuries: Different degrees of dysfunction require different strategies. The usual advice to ice, stretch, exercise, massage, or medicate injuries cannot be applied universally. If you are not sure, especially if you are worried about an injury, you are better off leaving it to professionals than taking the risk of making things worse. But read on, because my intent is to arm you to handle this properly.
Years of studying muscle pain and dysfunction have led me to the same conclusions others have reached after studying muscle pain and dysfunction for years, which is the same point made above. Different degrees of muscle dysfunction require different strategies, and these must be applied in stages as the injury worsens or improves. When I hear athletes recount how they continue to have nagging pains after icing, stretching, exercising, and medicating, it reminds me of the old definition of insanity, which is to do the same thing over and over again, expecting a different result each time.
Especially when it comes to medication, you want to defer to professionals only. A licensed professional's feet can be held to the fire if he/she overprescribes, but that won't happen at your local CVS every time you refill a self-prescription for OTC meds. Heeding all label claims, these chemicals really aren't safe to use without professional guidance, because they work by interfering with key components of the healing process, which tend to hurt due to the tearing down and rebuilding process of inflammation. We once thought them to be safe, in that it was once assumed they could not kill us or harm us irreparably, but we now know better. Nevertheless, we are left with the retail infrastructure created in innocent times. I don't know about you, but I have seen the pain-med section shrink in drug stores over the last several months. I hope this is a good sign, and not just temporary economics. Self-medication is rarely a good idea. Systemic (taken internally) medication can affect the entire body, not just the areas you are attempting to treat.
Apart from NSAIDS, I'll reduce my usual advice to one paragraph: Ice judiciously. Ice can do good things and bad things. Good is to reduce swelling by temporarily slowing immune response in a confined area, and to increase blood flow by chilling the tissue to provoke this reaction. Bad is to numb against perceived pain during activity, and to increase the risk of spasm by chilling muscles below their operating temperature. A stretch, especially of the eccentric kind mentioned in the article, must be proportional to the health of the tissue being stretched. A stretch is just a contraction in reverse, and can produce or increase the same damage as continued exercise. Exercise can be tonic during rehab, applying the same cautions as with stretching. Strengthening is most effective before an exercise regimen, to prevent injuries. After an injury, it serves to organize healing tissue, as long it it is done at a level that indeed allows damaged tissue to heal without unnecessary scarring. Massage, properly done, has the effect of relaxing tight tissue, reducing the load on tissue trying to heal, and the Achilles tendon it pulls upon in this case. It can be overdone, but is frequently underdone. The gentle circulatory benefits without the strain of exercise, the profound chemical/neurological changes that occur, and the important feedback to the central nervous system that retrain function, are routinely underestimated. Just make sure you do it right, in the right amounts. If you are not sure, don't waste your rehab time. Ask, or learn how.
The article correctly used the term "Tendinosis," rather than "Tendonitis," to describe an injury with similar symptoms to yours. It has been found that the "itis," which means inflammation, was assumed but not actually present in a majority of cases. Actual degradation of the tissue, "osis," tells you exactly what the problem is: a tearing apart of the tendon by overuse. Using this to inform your rehab strategy, you will see that the drugs are a waste of time, often counterproductive, or risk complications, and stretching and exercise must be used with great caution. You can also see that anything that speeds or enhances immune system activity to rebuild, while reducing strain on the injured area, carries the most benefits.
My strategy to deal with Achilles issues, which I have had myself, extend beyond recovery interventions. Any good PT will tell you that injuries, particularly those that pick on one side over the other, often reflect a biomechanical or structural imbalance. This can be anything from a difference in relative leg-length (which most of us have), to differences in foot structure, hip structure (or function), and/or bad technique.
While there are a few things you can do about structure and biomechanical imbalance, from corrective exercises to orthotic interventions like the heel wedges mentioned in the article, you want to keep in mind that some interventions are not meant to be permanent. Wedges and arch supports are examples of temporary interventions. Shortening the Achilles to reduce strain also shortens the calf muscles and can backfire by reducing function. Scientifically designed orthotics that improve foot and leg action without replacing, therefor weakening normal function, are an example of a more permanent approach. There is also the primitive approach of going barefoot and forcing your body to adapt to the equipment you've got. This can be painful and greatly limit your mileage, but in moderate doses over a sufficient amount of time, may retrain your muscles to perform in ways that popular footwear may have underutilized, over-protected and allowed to become dysfunctional.
Bad technique can be difficult to describe. In many cases, technique reflects individual structure, and cannot be changed too much without causing other problems. In most cases, though, bad technique in running evolves from too many junk miles performed while tired. I have found a good strategy is to do some strenuous repeats after a warm-up, before doing your regular mileage. This can allow you to get away with a lot less miles, while giving you the opportunity to experiment with maintaining form while running tired, the main goal of mileage. You work with fresher muscles, and less potential for accumulated damage. I've been able to run Boston qualifiers on an average of 20 miles per week this way.
In general, tightness of the calf muscles will strain the Achilles tendon.. but strain, Tendinosis, or Tendinitis are not the only sources of pain in this area. Your brain maps pain based on neural input into images that approximate tissues that might be in jeopardy. Notice I did not say that it maps them exactly or correctly. As a general rule, it gets close, but there are many exceptions to this rule. False Achilles Tendinitis is possible when muscles contributing to plantarflexion of the foot sustain damage, even in the form of microtrauma or mini-spasms. In these cases, the pain that is felt along the Achilles has nothing to do with the tendon itself. The brain interprets the muscular dysfunction as an injury in the target tendon, and can remain indefinitely regardless of how healthy the tendon is or becomes. An example of this is Tibialis Posterior dysfunction. The Tib P. is a weak plantarflexor that inserts into the arch of the foot via a long skinny tendon behind the Achilles. It is located deep in the center rear calf between the Tibia and Fibula, and helps tension the arch of the foot. It can't be massaged through tough Gastroc and Soleus muscles, so these have to be relaxed first to allow access to the Tib P.
Regarding the main plantarflexors Gastrocnemius (superficial, upper rear calf) and Soleus (2nd layer, upper 2/3 rear calf), Gastroc tends to produce pain, oddly, in the arch of the foot, while the upper portion of the Soleus produces pain locally, the lower portion in the Achilles/ankle area, and the lower/lateral portion in the lower back, around the Sacrum. As you can see, these are notable exceptions to the rule of accurate pain-imaging by the brain.
If you are going to foam-roll to relax your calves, as Jim mentioned, target the area below the mid-rear calf and above the Achilles tendon, which grows out of the merged ends of Gastroc and Soleus. I don't recommend foam-rolling the Tendon itself, but some manual mobilization of the tissue to either side of the tendon can mobilize lymphatic flow and facilitate healing via waste disposal, one of the jobs lymph performs. Back to the roller, it works best in the direction of venous and lymphatic flow, from bottom up, or toward the heart. Applying pressure in the reverse direction works against these mechanisms and the valves that control them.
A note here about so-called "medical massage," which is defined more by insurance companies than good medicine. Medical massage techniques confine operations to the immediate and adjacent areas of concern, rather than taking a holistic approach to structure, antagonistic muscles and groups as should always be done. An example is relaxing the dorsiflexor Tibialis Anterior to reduce strain on the plantarflexors Soleus, etc. on the other side of the joint, all of which might be necessary only because the hip flexors are tight. Restriction to a painful area billed in 15-minute increments may make good economic sense to accountants, but no medical sense whatsoever. Do it right, and they often will not pay. Do it yourself, and it no longer matters.
You can see from the above that there is a lot more to learn about controlling pain and injuries than the old RICE rule, which was formulated to address acute tissue trauma. Repetitive-motion injuries/dysfunctions are a lot more complicated. One last word about health professionals: They don't always have time or patience for athletes with self-inflicted injuries. In many cases, they think we are crazy, and will tell us not to run. Sometimes they are right. Listen to them carefully to tell the difference between helpful information and simple fear of your condition getting worse. Of course the doomsday scenarios are always possible, but it is much more likely that properly informed, you will learn how to get out of the way of your body's natural ability to heal itself.
We plan on eccentrically loading the muscle around 80% improvement before she starts to run again... here's some research on eccentrics http://www.p2sportscare.com/2011/07/11/eccentric-rehabilitation-exercise-for-achilles-tendinosis/
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