It has been estimated that pain in the area of the Achilles tendon is responsible for more than 10% of all running injuries and is a common reason for exercising clients to cancel personal training sessions or, worse still, drop out of exercise programs totally. Achilles tendon injury also accounts for more than 10% of all football training and playing injuries—and with more than 230,000 Achilles tendon injuries reported in the US each year – this is an injury area all fitness professionals need to understand.
Causes of pain and discomfort in the Achilles region can be a due to overuse conditions such as Achilles tendinopathy and retrocalcaneal Bursitis or the acute symptoms associated with a complete or partial Achilles tendon rupture.
In cases that involve a gradual onset of pain in the Achilles region, it is uncommon to tear the actual tendon. However, it is still important that a full examination is made to allow a complete and accurate diagnosis of each individual condition.
To fully understand the problems that fitness professionals face in dealing with pain and injury in the Achilles region, it is important to know the anatomy of the area involved.
The Achilles tendon is the thickest and strongest tendon in the body and acts as the combined tendon of the gastrocnemius, soleus and the often forgotten plantaris muscle. The tendon is covered by a paratendon, which is a continuation of the fascia of the abovementioned muscles and blends into the periosteum (a specialized connective tissue covering all bones) of the calcaneus.
There are two bursae in the region of the Achilles tendon that can also be involved in pain production in this area of the body. The retrocalcaneal bursa lies between the rear of the calcaneous and the insertion of the Achilles tendon, and the Achilles bursa which lies between the insertion of the Achilles tendon and the skin. These bursae act to facilitate the sliding of the Achilles tendon over the bony surface of the calcaneous - damage or inflammation of these structures can lead to a condition called Bursitis.
The patient who complains of a gradual buildup of symptoms and especially pain and stiffness upon rising in the morning is likely to have developed an overuse tendinopathy or retrocalcaneal bursitis—and this is the most likely diagnosis for the majority of exercising participants. Regardless, a full examination is recommended to rule out the more acute Achilles tendon rupture.
Up until the late 1990s the primary diagnosis for any athlete with pain in or around the Achilles tendon was Achilles tendinitis - however researchers then discovered that the majority of patients complaining of Achilles tendon pain (except those with definite ruptures of actual Achilles tendon) have Achilles tendinosis (or tendinopathy) rather than Achilles tendonitis. The term “itis” refers to an inflammatory process, while the current term “tendinosis” or “tendinopathy” is used where there is no inflammation present and the microscopic structure of the collagen fibers has become scarred and disorganized, implying that a degenerative process is at play as opposed to an inflammatory process.
The pain from overuse conditions such as Achilles tendinopathy and retrocalcaneal bursitis will generally ease with walking and may even disappear completely during a training session, only to return several hours after the session is over. This is a dangerous period for many fitness professionals, as the client (and trainer) often think the problem is getting better because the pain goes away during the exercise session, when, in fact, this is a possible sign that the condition is getting worse and heading towards a more chronic stage.
In their excellent text Clinical Sports Medicine by Australian Sports Physicians (an essential reference for all fitness professionals), authors Peter Brukner and Karim Khan outline a number of factors that may predispose athletes to Achilles injury – these being:
- Years of running — long term participation can lead to insufficient recovery and eventual damage to the tendon structure.
- Increase in activity — this can refer to increased distance, increased speed or an increase in the amount of hill work – both incline and decline.
- Decrease in recovery time — either by overtraining and completing too many sessions or by cross training in multiple disciplines – again reducing rest time between sessions.
- Change in surfaces — can link back to track versus road running and even training on heavy grounds for footballers during rainy periods.
- Change in footwear — including sprinters using low heel spikes shoes and increased training in football boots that may not be as well-designed for longer distance as the athlete’s usual running shoes.
- Excessive pronation — Brukner and Khan point out the increased load on the gastrocnemius-soleus complex required to re-supinate the foot for toe off – including a strong rotational force in the Achilles tendon with excessive pronation.
- Calf weakness — may be due to past injury to the calf musculature or inadequate strengthening of these muscles to cope with the increased load caused by running training.
- Reduced muscle flexibility — the compensation for a lack of ankle dorsiflexion is to increase pronation – increase training loads also typically lead to a reduction in muscle length unless steps are taken to increase flexibility training.
- Stiffness in or around the ankle joint — any past injury to the ankle complex (especially if the injury led to immobilization in a cast) regardless of how long ago the injury occurred can reduce the available range of ankle motion – this reduced range leads to compensations such as increased pronation.
- Poor choice of footwear — this is without doubt one of the major causative factors in the development of Achilles tendon issues – good running and football shoes need good lateral stability control and increased forefoot flexibility.
As with all overuse conditions, the management program must involve an attempt to correct the predisposing factors that contributed to the initial injury. This may involve a modification of the training program, new and well-researched footwear, calf stretching, and possibly an orthotic to correct excessive pronation. You may also need to modify your client’s running location and overview the full training program to ensure that adequate rest is scheduled and efforts made to increase calf strength and joint flexibility.
The keys to successful rehabilitation of Achilles tendinopathy are early diagnosis, adequate rest and frequent icing to prevent further collagen damage. Local physical therapy treatment involving tendon massage and ultrasound is also useful, as well as placing a small heel raise in the shoes to reduce the load on the tendon.
Even with early management, this condition can still take between three and six months to completely resolve, so it is important to be patient and not return to full activity to soon.
It is important that the personal trainer work in association with the treating physical therapist or sports physician to ensure correct rehabilitation guidelines are followed. The trainer is vitally important in the design and implementation of return to activity programs and graded exercise progressions to ensure that the injury does not re-activate due to an overly-aggressive activity program in the post injury rehabilitation stage.
It is also essential from a legal perspective that fitness professional exhibit due caution when discussing injury issues with clients – and always recommend a full medical evaluation of any problem or injury that is mentioned in sessions or suspected from the client's training program and history.
Key factors to reduce and manage Achilles injuries
- Pain that goes away during a run can indicate that the problem is getting worse, not better.
- Poor and worn out footwear is the most common cause of Achilles tendon problems.
- Be careful not to choose your shoes on looks, but select on feel and get professional advice.
- If you are deciding between two different shoe models, put one model on the right foot and the other on the left foot and see if one model feel more supportive and comfortable when walking and jogging in the shop.
- Your shoes may need to be replaces every 3-6 months depending on how often you run and despite the fact that the shoe still looks fine on the outside.
- Calves get tighter with training, so ensure that every running session is followed by at least 10-15 minutes of stretching.
Lower Limb Pain Risk Factor Test
Lower limb pain can be caused by discrepancies in the available range of motion at the ankle joint – this can be checked by performing the commonly used “Lunge Test,” also called the “Toe to Wall Test.”
In this test the leading foot is placed close to the wall, then lunge forward until the knee of the leading foot touches the wall while keeping the heel down. If the knee successfully touches the wall, redo the test but move the foot a little further from the wall. Repeat the test until you are no longer able to touch the knee to the wall then measure the maximal distance that the toes can be away from the wall with the knee still touching. Then repeat for the other leg.
The Lunge Test
If there is a difference in the result for each leg of more than 10%, it is advisable to have a comprehensive assessment done to determine the cause of the imbalance – it may be due to past ankle injury, last fracture or calf tightness. A comprehensive assessment is a great test and very predictive of possible lower limb injury when training volume is increased.
- Brukner, P. and Kahn, K. (2002). Clinical Sports Medicine – Brukner and Khan, Revised Second Edition. McGraw-Hill Companies.
- Kolt G.S. & Snyder-Mackler, L. (2003). Physical Therapies in Sport and Exercise. Elsevier Science Limited.
- McCrory, M., Lowery et al. (1999). Etiologic Factors Associated with Achilles Tendonitis in Runners. Med Science Sport Exercise, 31: 1374-81.
- Nieson et al. (1992). The Effects of Eccentric Versus Concentric Exercise in the Management of Achilles Tendinitis. Clinical Journal of Sports Medicine 2. pp. 109-13.
- Zuluaga, M. et al. (1995). Sports Physiotherapy Applied Science and Practice. Pearson Professional (Australia) Pty Ltd.