Achilles Tendon Pain in Runners. Tendinopathy Explained.

The achilles tendon has brought down mythical warriors and many weekend warriors alike.  Tendinopathy- by definition, implies that some degree of degeneration is occurring within your tendons. It sounds scary, or you might be rolling your eyes.  This is not a getting old thing. Most of you with achilles tendon issues will recover without surgery. Most tendon researchers consider that achilles tendinopathy is a training error.  That could mean that you tried to change or ramp up your activity too quickly. You need to understand that it might take many, many months for the achilles tendon to heal itself.  Tendinosis responds very well to physical therapy. Full rest is almost never necessary and might actually worsen your situation. Keeping in mind that it might take 3-4 months of the proper exercise to get you back on the road might help you avoid unnecessary surgery or aggressive treatments.

Achilles tendinopathy – that really painful lump on your achilles tendon seems like a rite of passage for most mature runners.  It hurts, it lingers — but nearly always subsides over time, with or without medical intervention.

Tom was a gifted runner.  At 50 he could cross the finish line after running 26.2 miles in under 2:40.  During the summer he was a laid back member of one of my running clubs.  His pace slowed, and we shared many great stories as we ran 10 miles through some of the most wonderful trails our county has to offer.  He didn’t mind slowing down to a far more achievable pace for his 50 something friend.

The fall marathon season was approaching Tom stepped up his training.  He quickened his pace on our Sunday runs.  Now they were more like training runs for me:-)  He had to do most of the talking — I grunted back a yes, no or hell yeah every now and then.  We were not running at a conversational pace — for me.

Distract the patient while nature heals them.

Late in September Tom started to complain.  His achilles was bothering him.  He couldn’t walk when he first got out of bed. But after he warmed up everything loosened up.  He ran, he trained, and rarely complained out on the trails.  After his runs he was never happy.  The pain returned.  The lump was larger on his peak days.  Like most, he wanted something done NOW.

Achilles tendinopathy (AT) is like that friend we all have.  It comes around at most inopportune times.  Achilles tendon pain due to tendinopathy will recur if your training ramps up too quickly and your acute training load (ATL) exceeds your chronic training load (CTL) or the amount of challenge your achilles is used to over a long time frame.  My own case of AT proves that theory year in and year out :-(.  For most runners with achilles  tendonitis, achilles pain or tendinopathy – most experts would agree that the onset of pain is usually due to a training error.

Tom first came to my office in a professional capacity months ago.  A good exam, gait evaluation, flexibility assessment all showed he had classic AT and many predisposing issues going on.  First came the education.  AT will flare up… but it will eventually go away… It will simply take much longer than you want to heal.  Here are the stretches and workouts to perform.  Keep up your running with a few adjustments to schedule and all should be well and good.  Rest is NOT a good treatment for a hot or painful achilles tendon.  Tendons evolved to handle load or stress.  If you unload them with complete rest you might make the issue worse.  The proper prescription for treating tendon pain involves changing the type of stress or load that the achilles sees.  For example… a very painful tendon might be treated with isometric exercises for the first few days/ weeks.  Then over time we progress to concentric exercises and eventually throw in agility work and eccentric exercises when the tendon is further along its path to recovery.

Just a few weeks later Tom asks me which “expert” would I go to.  Hmmm … ok, I’m too old to be hurt by this, and second opinions are commonplace so I threw out a few names.  It wasn’t long before he bought the hype and signed on the dotted line.

There are no orthopedic issues that surgery can not make worse

Since that fateful day when we last ran the trails together Tom has endured 6 months of physical therapy after a long surgery which was complicated by a “small” infection.  He has not been able to run more than 100 yards since.

In sham controlled studies, surgery for achilles tendinopathy has not been shown to be more effective than a fake operation or properly performed physical therapy.  Even an MRI doesn’t play much of a role in achilles pain.  The MRI is often misread as a “partial tear”. That is usually incorrect.  The partially torn region is actually degenerative tissue.

The only surgery without complications is a surgery on someone else.  Many of the painful tendon conditions we suffer from will eventually subside and resolve on their own… often with the help of our physical therapy colleagues.  Benign neglect is a very beneficial treatment protocol.  If we can distract you long enough, nature and your body will heal many issues which ail you.  Many of us consider tendinapathy to be a right of passage through middle age.  Tendonapathy will come, will annoy, and more often that not, with time and proper treatment will go away.  Surgical steel or injections rarely has a role in AT management.

I saw Tom at his house the other day…He’s a bit depressed… but he has his hopes set on running again in late 2017.