Achilles rehabilitation

As  detailed  below, I have had recurring bouts with achilles tendonitis over the years.  In the notes below I describe what I did each time to come back from this injury.  I think one key is persistence in finding a solution;  each time I've had achilles problems, so far, I have been able to work through it.  The write up covers more recent bouts first with  older posts last, so it may make better sense reading it last to first.

Achilles flair up in winter 2018, fall 2019

In both the winter of 2018 and the fall of 2019 I had flair-ups ups of the left achilles.  In both cases, this happened after I had gotten lazy about doing hip/glute conditioning.  In particular, since my 2014 accident which fractured my righ acetabulum and the surgery to repair it, my right glutes and hamstrings get very weak unless I regularly do glute bridges, single leg step ups, and lunges to keep it strong. For example in Nov 2019 after my achilles got injured I found that I could not complete  a set of 10 single-leg glute bridges on my right side. Left side presented no trouble to do a set of 15.  After getting back into the routine of doing these exercises every 2 days, so that I could do sets of 20 single leg bridges, the achilles on the left side started to feel OK on runs.  My guess is that with weak hips on the right, the left calf and achilles had to work excessively and had become everstressed as a result.

Also in rehabbing through fall 2019 I started again regular eccentric heel drops (detailed in posts below), building up to sets of 30 with straight leg and bent knees, without any added weight; then transitioning to sets with weight up to 50 pounds in a backpack.  This is very effective, but without working on the hips/glutes as well, these exercises are not sufficient to rehab the achilles injury that I experience.  It also seems to be helpful to do proprioception work:  "woodpecker" balance exercises.  And hamstring and calf stretching is crucial.



Achilles rehab after re-injury in winter 2017

In winter of 2017 I ramped my mileage too quickly and re-injured my left achilles, with which I had had problems in 2004, then after AC100 in 2013, and again after my acetabulum fracture in 2014.  In March, 2017, the injury was so painful that I could not run and even walking was painful at first. I rested in for a month or so, and proceeded with the Alfredson regimen of heel drop exercises (detailed below) that had sorted me out in the past, but this time it did not seem to resolve the problem as it had in past years.  One factor was that once the achilles started improving I started immediately doing long runs again, as I had committed to pace a friend in the 2017 SD100;  these long runs would typically go well and the achilles pain was manageable, but in the days after the pain would be such that it hurt on short runs... so I got into a pattern of minimal running during the week and running long (20-28 miles) on the weekends.  Looking back on it I see that I was simply keeping the injury going with this pattern.

In the Fall 2017 I saw my PT (with whom I worked during  rehabilitation in Fall 2014 after fracturing my acetabulum). He noticed that I tend to walk and run on the outside of my left foot with my left foot rotated inwards; my right foot is typically pretty straight while walking and running.   While my right arch is relatively flat, my left arch is very high.  He also measured my leg lengths and found that  my left leg is shorter by ~ 3/8inch than my right.  His idea was that I was running on the outside of the left foot to compensate for the leg length discrepancy, and that the resulting pronation from this inverted position was causing the achilles problem.   He gave me a heel lift for my left shoe to compensate for the leg length discrepancy.  He also had me start doing "windshield washer" exercises in which I sweep the left foot outwards against a resistance band, and had me start doing "short foot" arch exercises on both feet. Finally, he told me to REST -  stop running for a few weeks to let the injury settle down.

I took about 5 weeks rest from running, during which I worked these exercises and re-started eccentric exercises for the calf/achilles, but on a weight machine initially to better control for position.  As I have found before, daily morning and evening hamstring stretches- lying on my back and using a strap of webbing to pull my leg up to vertical,  so that my leg is relaxed, is very palliative.
I bought a pair of New Balance Leadville V3s with an 8mm drop to take a  bit of stress off the achilles (I typically run in 4-6mm drop shoes).   I started walking at the beginning of January.  For about three weeks I exclusively walked and got the total weekly mileage up to ~ 30 miles per week before I did any running at all. Furthermore I tried while walking, to keep the left foot straight, which felt quite strange at first.  After getting this walking base I increased my mileage to abut 40 miles per week by adding in runs.  I have now been running at this mileage level for about 6 weeks, gradually featuring in running in place of walking;  now I am mostly running (75%) with some fast uphill walking, and the achilles seems to be fine -- It no longer hurts during or after runs.



Achilles rehab, post pelvic fracture, Fall 2014 to Winter 2015

The link below describes a modified regimen of eccentric exercises  for achilles rehabilitation  recommended by my PT in Fall 2014, following return to weight-bearing from my acetabular fracture The fracture kept me non weight-bearing  for almost 2 month (June-July 2014) causing calf atrophy on the right (fracture) leg; while overworking my good left leg.  As I got back into running in September-October, the right achilles quickly got irritated, likely due to the weakened calf muscles, according to my ortho.  The regimen recommended by my PT, starting in Nov. 2014, consisted of heel drops on a slant board, concurrent with my running training, has proven 100%  effective at returning me to service -  I was running without pain by March 2015.  The details are in the link below:
http://fredippides.blogspot.com/2015/01/starting-training-again-for-2015-ultra.html

Other elements that have helped:

1. Keep the feet under me:  Short stride, fast cadence.  I've found when the achilles are getting irritated its typically because I'm overstriding; working on a short stride with a flat ground cadence of 180 steps/min is definitely helpful.
2. I cut verticle slits in the heels of my running shoes (and street shoes) to take all pressure off the achilles area. See, http://fredippides.blogspot.com/2013/09/starting-to-make-sense.html
3. Regular hamstring stretching palliates achilles pain in my experience- morning and evening; and at the beginning, middle and after runs.
4. Alternating cold/hot therapy: If the achilles are irritated I ice them with a cold gel-pack for 15-20 minutes, then soak my feet for 15-20 minutes in hot tap water, as hot as I can stand, with a couple handfuls of baking soda tossed in. The improvement is remarkable. I believe the alternating cold/hot treatment probably improves perfusion of the achilles area, but whether this is so or not,  it unquestionably makes the achilles feel better.
5. I put on warm socks at night when I sleep. I do this on the notion that it may improve circulation and therefore healing.
6. When the achilles have been painful I sleep on my stomach; when I do so I leave my feet hanging over the edge of the bed so that the achilles is not compressed.  
7. When the achilles have been  irritated I have in the past found that putting 4-5 mm gel heel inserts in my shoes helps; this is a temporary measure.
8.  Uphill running or steep downhills provokes pain when the achilles are irritated so when while recovering from this injury I stick to running on flat ground.
9. Fast running provokes achilles pain when injured; long slow running palliates.
10. Avoid any massage on or near the achilles:  While friction massage is recommended in some quarters, my experience is that its very easy to irritate the tendon (or paratendon) by massage even if it feels better immediately afterwords.  Unlike muscle injuries I resist the temptation to try to "fix" the achilles by massage.  It tends to make matters worse.

Achilles rehab, October 2013 to Jan 2014

Starting Oct 31'13 through mid January 2014  I took a break from running to allow my achilles to heal up from the tendonitis I incurred in the 2013 AC100 race.  To rehab the achilles I  have been doing twice daily heel drops off a stair-step, doing sets with straight and bent knee, progressively adding weight in a  backpack (see below) following what I have read in many places about eccentric exercises of the calf/lower leg being the best way to rehabilitate achilles tendonitis (or achilles tendonosis).

The therapy follows findings of a Swedish medical group that found that eccentric exercises of the calf (3x 15 sets each with bent and straight knee, twice daily) got 15 of 15 injured runners back into their original training regimen, pain free, within 12 weeks.  A control group that utilized traditional PT and surgery faired not so well.  This research is reviewed in an excellent article (by a runner names John Davis) here:

http://www.runningwritings.com/2011/08/injury-series-eccentric-exercise-and.html

Another website on rehab of running caused achilles tendonitis, which has a good description of the protocol I am following is here:

http://runnersconnect.net/running-injury-prevention/achilles-tendonitis-and-insertional-achilles-tendinopathy-in-runners/

Ofcourse I started out overdoing it a touch, substituting sets of 45 for the Swedish recommendation of sets of 15.  By the end of the first week week I'd found that the achilles on both sides have been getting a bit irritated.  However,  a bit more research and a more careful reading of the articles above and I discovered that I'd  not been properly following the protocol;  its important to not use the calves/achilles on one leg to step back up but rather, place the "lifting leg" one stair-step above the exercising leg and use the quads to lift the body back up after one cycle of the heel drop.  This isolates the exercise to 100% eccentric loading of the calves and achilles.

 The gist of the idea behind this approach is that eccentric loading "poles" the achilles by preferentially tearing down weak / tangled collagen fibers such as are found in scar tissue, so that over time the achilles is remodeled with collagen aligned to the tendon and thereby repaired.  I am not clear on why eccentric loading does this preferentially over concentric loading;  but evidently this is the case.  If any readers have insight on why this is so, please leave a comment!

In any event my calves have gotten quite a bit stronger as have the arches of my feet (to my surprise, the exercises above really work my feet).

Here is the progression I followed from the outset in October through January:

Week 1:  Week ending  Nov  10th-     No weight, high reps (sets of 30), done fast.  Not correct, achilles irritated.

Week 2  Week ending   Nov 17th:  No weight, slowed down the reps to 2-3 seconds per, and stuck to sets of 15

Week 3:  Week ending Nov 24th  Added 25 pounds in backpack. 

Week 4:  Week ending  Dec 1:   50 pounds.  Mostly done on flat surface (heel drop to horizontal).

Week 5:  Week ending Dec 8:  67 pounds.  Ditto.

Week 6:  Week ending Dec 15:  77 pounds.  Ditto.

Week 7:  Week ending Dec 22:  89 pounds.  Ditto.

Week 8:  Week ending Dec 29: 100 pounds.  Ditto.

Week 9:  Week ending Jan 5:   110pounds.  Started emphasizing heel drops on step edge rather than flat surface.  Experienced morning-after soreness -  took 2 rest days.

Week 10 :  Week ending Jan 12:  reduced the weight to 85 pounds

Weeks 11-14 Alternate between 85 pounds added weight and no added weight every other day; started running.

As of April I have increased my weekly mileage gradually up to 60 miles per week and the achilles are getting progressively better.  (Post script May 3, 2014:  I ran the Leona Divide 50 last weekend and the achilles are virtually 100% now.  Counterintuitively, the race seems to have helped the achilles.  I'd noticed that after long (20+) mile runs the achilles would typically feel better and this would persist for several days.  Perhaps its due to  loooong slow runs promoting blood flow?)

Other things that I have found that have helped:

1. If the achilles is irritated after a run icing them helps, and the improvement lasts for hours.
2.  I put on warm socks at night when I sleep.  I do this on the notion that it may improve circulation and therefore healing;
3. When the achilles have been painfulI  sleep on my stomach;  when I do so I leave my feet hanging over the edge of the bed so that the achilles is not compressed;
4. I have increased my consumption of nonfat yogurt; idea being to up the protein required for healing;
5.  When the achilles are irritated I find putting 1/4 inch heel inserts on my shoes ameliorates this;  uphill running or steep downhills provokes pain when the achilles are irritated  so when while recovering from this injury I stick to running on flat ground.
6. Fast running provokes achilles pain when injured; long slow running palliates.
7. Friction massage is recommended in some quarters but my experience has been that this is something to be done rarely, if at all.  My experience is that its very easy to irritate the tendon (or paratendon) by massage even it it feels better immediately afterwords so unlike muscle injuries I resist the temptation to try to "fix" the achilles by massage.
8. When the achilles have been sore/irritated I have found that  cutting verticle slits in the heels of some of my older running shoes (and street shoes) to take all pressure off the achilles area while walking around and while running helps.
9. Finally, regular hamstring stretching palliates achilles pain in my experience-  morning and evening; and at the beginning, middle and after runs.

Below are the posts I made during the rehab period, in date order, for anyone interested  who might be experiencing a similar injury.   Remember:  Have faith!  This injury is a frustrating one that takes time..months... to heal;  but my experience is that is DOES heal.

Thursday, November 14, 2013

Achilles progress report

OK.  The last couple days I have cut the eccentric heel drops to sets of 15, but have slowed them down.  I also have stopped doing these reps with my exercising foot on on the edge of a step but rather do them with the exercising foot on flat ground.   The  non-exercising leg is positioned on a block  so that my quads on this side can lift my weight (as described in the last post).

I've noticed that the lower soleus muscles particularly seem to be developing (or firing? I feel them more that I am used to).  On the left side especially I seem to feel that the muscle is taking more of the load and the achilles tendon less so.  Both sides are tender the last couple days so today I am taking the day off.  The predictable overdoing it that I have engaged in over the last couple weeks is, I think, problematic.  After some reflection,  and reading this article,

http://www.sportsinjurybulletin.com/archive/achilles-tendinitis.html

I believe that the point is not to stress  the heck out of the already injured achilles but the teach the muscles to take the load so as to take stress off the tendon.  So less is more here;  the massively discredited notion that "anything worth doing is worth overdoing" does not apply.

Saturday, November 16, 2013

Achilles eccentric exercises: Progress report Nov 16

Switching up to 3 x 15 straight leg heel drops, 3 x 15 bent knee heel drops, each side, twice daily;  but now with 25 pounds on my back.

The eccentric heel drops are noticeably more difficult with the 25 pound weight, and I feel the exercise again in my feet/arches (as I did a week or so ago with no weight).

I tried the exercises with 50 pounds on my back but it was too much.  I could not do the exercise smoothly/ in a controlled fashion.  I will wait to build up strength with 25 pounds before attempting the higher weight.

Ready to start  heel drop on left leg.  Backpack contains 25 lbs

Eccentric exercise of left leg:  Bent knee heel drop, mid stroke.  Right foot is off the ground.

Sunday, November 24, 2013

Achilles eccentric exercises: Progress report Nov 24

Last week I continued the program of {3 sets x 15} of heel drops x 2 (straight leg, bent knee}x 2 (morning, evening}, on each leg.  Last weekend I had transitioned from no added weight to 25 pounds of weight in a backpack;  by the end of the week this had become easy.  Yesterday I transitioned to  50 pounds added in the backpack.  So far so good.  I can do the 6 sets per leg in a given session without too much difficulty but I definitely feel it again in my calf muscles and a bit in the tendon (on the right side).

I have noticed that on each side the achilles tendons are "smoothening out" -- on each side there had been a swollen section about an inch and a half up from the tendon attachment point at the heel.  On the left side particularly this has reduced quite a bit.

Yesterday I just could not resist taking a short run.  I did my usual neighborhood sidewalk run, barefoot, and went about 4 miles.  It felt fine with a couple of twinges during the run.     As was the case during the AC100 "post season" training I was doing in September, barefoot running just doesn't seem to bother my achilles tendons.  I suspect that this is because, running without shoes, I am forced into good running form due to the emphatic feedback provided by my bare feet.

Sunday, December 8, 2013

Achilles recovery- progress report Dec 8

The achilles are slowly slowly improving (I think).

I am up to 67pounds on my back while I do the twice daily sets of eccentric heel drop exercises -  no question that I am getting stronger.  I ran on Thursday and it felt fine, but the Achilles tendons on both sides are still tender to the touch.  I am about 5 weeks into a 3month eccentric heel drop strengthening program so am hopeful it will end well.

Oddly enough running is most comfortable/ least discomfort in the achilles if I run barefoot (as I have observed previously).  I think it's because it slows me down and forces good form.  On Thursday 12/5 I ran in Monrovia's Sawcut Wash, barefoot.  Running on this gravel trail felt great to my surprise.    Man it certainly improved my outlook to run.

This coming week my pal Al will bring a 35 pound weight in for me to borrow.  I have run out of weights for my backpack: 2 x 25 pound  arm curl weights plus my diving belt.