Achilles Tendinitis (and/or Tendonosis)

I'm not a fan of these injury posts. On the one side, I do like sharing the information. On the other side, lots of what I post is first-hand information, and all that implies...

Anyway, ever since the ankle sprain last year, my achilles on that foot has been threatening to go all tendinitisy on me. I was going to do piles of research and share it with you, but my teammate Jon has had chronic problems with his achilles for years, and is a wealth of information. So I have the luxury of not writing this post myself, but instead can cobble it together from our e-mail dialog (edited lightly, emphasis added):

Jim said:

I am now on the IR (hopefully just for a week) with tendinitis in my Achilles. I have been flirting with it ever since the ankle sprain, and Easterns finally brought it on for real. Played pickup yesterday, but it was unpleasant. I'm hoping a good ice, rest, and ibu regimen will get me back on track pronto.

Jon replied:

Bummer. Take it from me, achilles problems can last forever, but hopefully this isn't the case with you. Rest is key, I think. Hopefully that will take care of it. In any event, I've attached an article and also included a link below that I thought were pretty informative with regards to the achilles tendons. Turns out there's no such thing as achilles tendonitis -- it's really a tendonosis (tendinitis implies inflamation, but there's no evidence that inflamation is part of the problem in achilles injury -- hence ice and ibuprofen aren't really helpful in this case). [from my super-quick research I think both conditions exist, but certainly where chronic injury is concerned it sounds like tendonosis is the correct term.] According to the medical literature, the only treatments with good clinical evidence of effectiveness are rest and "heavy-load eccentric calf-muscle training":

Sports Injury Bulletin - Achilles Tendinitis

I've been doing something similar to the Walt Reynolds exercise for a long time (recommended by my physical therapist), and am 4 weeks into the program from the Swedish study. It makes things worse before it makes them better, but it does seem that it's starting to having positive effects now. My physical therapist also gave me a a variety of strength and balance exercises, particularly ones to work on leg muscles that are important to stabilization, but I think these are actually pretty similar to some of the stuff you are already doing.

Jim replied:

Wow, thanks Jon! Great article. I'll have to post that on my fitness blog (which is more and more looking suspiciously like an injury blog).

So you do the Walt and Swedish exercises, and you also play? I guess what I'm asking is, you've just been playing through the pain for years, don't take rest, and have added these exercises into the mix, right?

I ask because I'm trying to figure out if I should just stop stressing the achilles (i.e. no playing) until I'm pain-free, or if I should do rehab and play simultaneously. The pickle is not wanting to fall behind on conditioning.

Jon replied:

Since it sounds like you're going to do some of these rehab exercises, and wonder whether you need to take off time from ultimate, I'll give you some more detail on how I manage the achilles problems, since it's kind of complicated.

First, back about the time when I broke my collarbone in 2001, I was struggling with a lot of pain in the achilles, and I got an appointment with a physical therapist. He made me rest completely for a few weeks, until all pain from the achilles was gone, and in the mean time made me an orthotic to control my overpronation. I think there would not be any problem with doing exercise that doesn't stress the achilles during this time (e.g. burpees, weights, maybe biking), but since I had a broken collarbone there wasn't much else I could do anyway. After the rest, he started me on an exercise that's roughly similar to the Walt exercise. The way I do the exercise is the following. I stand on, say, my right leg on the bottom step of the stairs, facing the floor (as opposed to the higher steps), and I keep my left leg straight and suspended in the air, and then I lower my left leg down slowly, keeping it straight, until the heel of my left leg touches the ground, and then lift it back up again. I repeat this for 30 reps, and then do the other leg. This works the calf muscle eccentrically, and also gets the rest of the leg involved and improves balance. Once I got good at this, I switched to a stable stool that is a bit higher than my first step, so I can get a deeper knee bend going.

After doing this for a few weeks, my PT gave me bunch of other exercises to do in addition, mostly with dumbells, for strengthening the legs and for overall body fitness. Most of these are very similar to the dumbell exercises described in Ross Enamait's book. A lot of lunges and shoulder presses and so forth. Sounds similar to what you are doing already. These exercises especially worked the hamstrings, glutes, hips, and groin.

Another exercise he gave me that is more achilles-specific is the following: Get on a treadmill and set it to maximum incline at a very low (walking) speed. Then run / hop sideways (not crossing over legs) for four minutes on each side. Kind of like how you would run sideways while positioning yourself to play defense in ultimate. This really works the calf muscles, and also works the feet and ankles in a different plane than most typical exercises. I find this one to be quite helpful, but you'd need a treadmill. You could also just do it out on the street or on a grassy field, although I think it works a lot better if you can do it uphill. I find this exercise makes a noticeable difference when I do it regularly.

After doing these routines religiously 2-3 times per week for a couple of months, I started playing ultimate again in the spring of 2002, and my achilles were completely pain free for months. But at some point in the summer, when the ground got hard and I played in a tough 2-day tournament, my achilles eventually started bothering me again. I then took a little time off from ultimate, maybe a week or two, but in the mean time continued to stick with all the rehab exercises along with interval workouts on a bike and, after a little while, light jogging. Then I came back and things were manageable. This pattern essentially repeats itself every year, and is not so bad. But it would be better if I could be pain free throughout the season.

This year, after feeling a bit of achilles soreness after WMO, I decided to get more aggressive with the rehab exercises. I've been doing the Walt-like exercise almost every day, and started doing the Swedish exercises almost twice-daily as well, and I've made sure that I do the sideways-running about 3 times a week (I often stop doing that when I switch from treadmill to outdoor running with the nice weather). I had never done the Swedish exercises before. They feel easy while you're doing them, but then I found that my calves were incredibly sore for about two weeks. I started this about 4 weeks ago, and continued to play ultimate once a week throughout. This is part of the reason I sucked at pickup a couple of weeks ago, as my calves were so sore I felt like they were going to collapse the whole time. After about a couple of weeks, the calf soreness has been gradually subsiding. My achilles were pretty sore after Saturday at Easterns, but have been rock solid and pain-free otherwise (I played Sunday with no pain). So in short, I have been playing through it while doing the rehab exercises, and I think it's working OK. We'll see what happens when the ground gets hard.

The link below from the Carleton University sports medicine department provides the details of a Swedish-style program for the achilles. In their program, you're supposed to avoid sports for two weeks while you start the calf exercises, but then you resume sports after two weeks.

Rehab for Chronic Achilles Tendinitis

It's also worth noting that in the Swedish study, they did not wait for the achilles pain to go away before starting people on the eccentric calf exercises.

Jon then followed up with this:

Ah, one crucial thing I forgot to mention in my description of the "Walt-like" exercise that I do on the bottom step. When you are standing on your right leg, and lowering your left heel to the ground, you lower the left heel by bending your right leg at the knee. And vice-versa when you stand on your left leg.

Jim asked for clarification:

You keep the foot on the step flat on the ground, right? As in, your heel stays down and your Achilles stretches as your knee flexes?

Jon replied:

That's right, you've got it exactly right. The foot on the step stays flat, and you bend the knee on that leg. You keep your other leg straight. The heel of the straight leg eventually touches the ground below the step as you bend the knee of the leg that's on the step.

There, that does it! About the only thing I found independently of Jon was a note (with no medical backup) that wearing a night split (commonly prescribed for plantar fasciitis) can also be helpful. The splint holds your foot angle at 90-degrees (or even a touch higher) keeping your achilles stretched throughout the night. Without the splint, in a relaxed state your foot hangs away from the shin, keeping the achilles in a shortened position all night. I borrowed my dad's splint (which was the thing that finally allowed him to gain ground on his plantar fasciitis after months of frustration), and I seemed to improve, but have no idea how much the splint contributed, if at all. Could have just been the rest.