If you have pain in the mid part of your body's biggest tendon, it can be tender, frustrating and hard to get rid of. It's common in runners and those doing running sports aged between the ages of 30 and 60. It can be hard to know if you should keep moving, or 'run through' it, stop doing everything, medicate or stretch. Here are some answers.
The achilles tendon links the calf muscle bulk (gastrocnemius and soleus) to the heel bone (calcaneum). It transfers the energy from the muscles, contracts and relaxes when we walk, and stores energy. It relies on a delicate combination of resilience, strength and elastic recoil. Pain in the mid tendon (2-7 cm proximal to the tendon insertion on the heel) is referred to as 'tendinopathy'. It's associated with tenderness and, in some cases, especially more chronic ones, a thickening on the tendon itself.
Sufferers usually fall into one of 2 groups, or float between them (Cook et al, 2016).
(1) A “reactive” tendon injury
For example, you may normally do longer, slower runs, and recently hurt my achilles tendon last weekend when sprinting. The tendon was possibly not prepared to contract and stretch during the sprint. There's an acute response, with pain and inflammation.
(2) A worn-down tendon with a “sudden worsening”
For example, you've had tight calves for a long time, but it hasn't been an issue. You are doing longer runs than you would usually do in preparation for a half marathon or marathon and it's now hurting at the back of the tendon, above the heel. It can hurt during the run, but not always, and it's more painful the next day. Your calves are feeling really tight and you might have a lump or thickening on the tendon.
It's possible the connective tissue (collagen, elastin and other proteins) are not resilient enough to take the pressure of doing that bit more running and sport. The longer runs, gradients or changes in speed are tipping your tendon from 'just about coping' with the strain to 'flaring up' and going into reactive mode, giving you a 'reactive' response. This can be affected by age and sometimes, the overall structure and quality of our tendons. Reduced ankle movement when the heel strikes the ground and decreased strength in the calf and muscles which 'push off' when we run and stiffness can predispose you to this problem. It's tempting to change shoes, try a generic yoga for runners workout and reach for the compression socks, but before you do, here are some tips based on the latest research.
5 ways to solve mid achilles pain:
1. Formal diagnosis. This should be done by a trained clinician, such as a Physio or Sports Medic (not scouring the internet and runners' forums!). The key findings are symptoms related to sports activity, localised pain, thickening and tenderness. There are other issues, including calcaneal stress fractures, ankle joint and bursa problems and plantar fascia pain can present in a similar way or alongside this, and this affects treatment.
2. Understanding the problem through a better understanding of running gait, how joints and tendons work and respond to exercise, how exercise, hormones, age and speed affect muscles and tendons.
3. Managing how much pressure goes through the tendon. Changing the amount you run, speed, incline and surface can help. If you keep running, rest days, running on grass, on the flat and avoiding sprints may help. If you are still getting pain 24 hours after running, you need to look at how much you are doing and address it.
4. Reduce ankle stiffness, strengthen the calf. Physios can help with ankle mobility, and it's worth actively moving the ankle in all directions pre run. Strengthening needs to be in different ways: static contractions, contractions with heel raises, slower contractions and then, in later rehab, quicker contractions, running and jumping (plyometrics). For my favoured strengthening exercises, see Tom Goom's (aka RunningPhysio) exercise circuit here.
5. Don't OVERSTRETCH or RUB the thickened tendon. Research is clear - static, or passive stretching of the calf - placing your foot behind you and stretching, stretching over a step for 30 seconds, touching your toes or doing static holds of a Yoga downward dog - rarely play a crucial role in eliminating tendon pain. Overstretching may have contributed to the problem in the first place. Examples of overstretching include taking a longer than normal stride when sprinting or running on a greater incline or elevation range than you are used to. The problem is often a disruption of the ability of the tendon to take pressure and recoil, not just tightness. Massaging the thickened portion can just add fuel to the inflammatory fire. Many people actually report that when they stop over stretching and rubbing the injured area they get substantially better!
There is a time later in rehab where stretching helps, but not early on. A Physio can guide you on when and how to reintroduce stretching.
If all else fails:
a review with a Sports Physician, scans and additional therapies such as shock wave (done by a specialised Physio or Sports Physician) may help. Be cautious with using non steroidal anti-inflammatories and only do so under clinical direction. None of this information is a substitute for assessment and treatment from a health clinician, and all exercises should be done with caution.
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References
Cook, J., Purdam, CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathyBritish Journal of Sports Medicine 2009; 43: 409-416. https://bjsm.bmj.com/content/43/6/409
Cook J et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?British Journal of Sports Medicine 2016; 50:1187-1191. https://bjsm.bmj.com/content/50/19/1187
Murphy M, et al. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Med. 2018 Aug;48(8):1875-1891. https://pubmed.ncbi.nlm.nih.gov/29766442/
de Vos R, van der Vlist AC, et al. Dutch multidisciplinary guideline on Achilles tendinopathy
British Journal of Sports Medicine 2021; 55:1125-1134. https://pubmed.ncbi.nlm.nih.gov/34187784/
Running Physio Soleus Circuit http://www.running-physio.com/wp-content/uploads/2016/07/Photo-20160710203149361.jpg