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Wednesday, July 2, 2014

Achilles Tendinitis: Email Advice

Hi Dr. Blake;

I'm a marathoner who has been suffering from chronic Achilles tendonitis (from February 2013). Without going into a lot of details, let's just say I've seen podiatrists, sports therapists, etc. in the past year+, but the condition never healed because I refused to stop running. I slowly saw that my left foot was losing push-off strength and it was affecting my speed, so I've essentially been off running for the past month. I do stretching exercises twice a day and I've seen a marked improvement, but I still feel tightness, and it's likely going to take another month or two to heal...

I'm contemplating going to a running injury clinic for comprehensive evaluation, but I've been putting it off figuring there isn't a whole lot more they can do for me right now. However, as I get closer to the point where I feel like I'm healed, I want to start back slowly so I don't reinjure myself. Do you think I should be working closely with a sports physician (such as yourself) or a running injury clinic? Or would I be OK by myself, taking it slowly?

I've been spinning for exercise but I miss running SO MUCH!!! It's just killing me.

Laura (name changed)

Dear Laura, 

     Thank you Laura for the email. I hope the following advice is helpful. Glad you finally were forced to let yourself heal, but you could have produced permanent damage. It is generally hard to treat this yourself, but you are also the best judge on how treatments effect you as an individual. There are 3 phases of injury rehabilitation: Immobilization/Anti-Inflammatory (which you have placed yourself into), Restrengthening and Return to Activity. Typically the bullet points below are best helped by a trained physician, PT, and yourself as the Sports Medicine Team. You, at least, need someone at times to decide on whether or not to get an MRI, what is the exact diagnosis (could it be something more than just achilles?), how to safely strengthen the Achilles and lower extremity, should you actually be stretching at all,  is your gait off enough for shoe change/orthotic devices/gait changes, and how to safely return to activity. This is my normal day, and the day of most sports medicine specialists. From a podiatry standpoint, if you look in the member list of the American Academy of Podiatric Sports Medicine you can usually find a good one close to you. 

     For now, consider the following:

  1. Do two sided toe raises every evening until you can comfortably do 50 at a time without pain and with relative ease. Then slow start doing one sided toe raises. Do both straight knee and bent knee.The goal is 50 straight knee and 25 bent knee without pain. See my video below. Start with therabands if the toe raises are painful.

      2. Avoid Negative Heel Stretching which can overstretch the tendon. Did anyone say you were either tight or over flexibile? If they said over flexible, minimize your stretching, and use a massage stick twice daily for any calf tightness.

      3. Run every other day until soreness develops, even if that is 1 minute, once you can walk briskly for 30 minutes without any problem. Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point. 

      4. 3 times daily do either 20 minute ice pack or a full 20 minute contrast bath. This helps to manipulate the swelling within the tissue, and swelling which cuts off normal circulation within the tendon is our enemy!!!

      5. Diagnostically, if you can get an MRI, get one. Knowing exactly what is going on can be a tremendous help to us. You can definitely wait as long as month by month you are gaining strength and activity.

      6. Set Benchmarks for activity--you definitely want to do more this month than last, but it can not be alot too quickly. To re-strengthen the achilles, it can take 6-7 more months. I would be gentle to yourself these next two months adding alittle to the toe raises each week, alittle to the time at spin class, alittle more walking, etc. By the end of July you will have a strong sense of what you can and can not do, and then set new Benchmarks for toes raises, walking, cycling, elliptical, and hopefully gentle running. 

I sure hope this helps you. Rich

The patient's response:

Oh, I meant to ask for a clarification. You wrote:

"Run every other day until soreness develops, even if that is 1 minute, once you can walk briskly for 30 minutes without any problem. Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point."

I wasn't clear on what this meant. Did you mean:

#1 If you can walk briskly for half an hour without any pain/discomfort/limping, then every other day, as a test, try to run until your Achilles feels sore.
Dr Blake's comment: Yes, runners need to run, even if it is a little bit, as part of their rehab. 
Somehow the text was lost here!!
Dr Blake's comment: Definitely. Most of my patients walk or run a stationary bike to limber up before running, then normal stretching, then run. 
How should I define "soreness" for this test? Discomfort that makes me adjust my gait? And since this is a test, I assume I want to immediately stop running when I feel soreness? So this is just to check on my healing progress? ("I had to stop after 70 seconds yesterday, but today I could go for 75 seconds"?)
Dr Blake's comment: Definitely, that is the right logic. See the Good Pain vs Bad Pain post.

#2 when you say "Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point." do you mean that my exercise of choice right now should be biking 4-5 times a week, as a replacement to my running? I think that's what you mean, but I'm just making sure.
Dr Blake's comment: Definitely, biking is the best non weight bearing exercise that helps runners. 

I've been taking spin class and I have a smartphone app so I can essentially get a spin workout in by myself (the app has an audio cue from a coach so I just follow along).

Finally, I have a 10K next weekend I already registered for that I'm hoping I will be OK for (no plans to set any PRs). I also have a marathon for September but I can knock that down to a half marathon I also have half-marathon in mid-November, and then a half and and 10K in mid-January. I don't want to cancel any of those (they are big marquee events) but I can knock the September full down to a half. I don't think I have enough time to correctly train for a full marathon for September.

Thanks again!

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.