Achilles Tendinitis Prevention & Treatment
Another very interesting report, with some of the latest research findings, from Sports Injury Bulletin, James Taylor, ed. www.sportinjurybulletin.com

PREVENTION PROGRAM

    To look at the prevention of achilles injuries we must first understand that there is a symbiotic relationship that the achilles tendon has with both the calf muscles (gastrocnemius and soleus).
    EMG data shows that the calf muscles are most active just before and just after foot strike and then their key function is to control dorsiflexion and pronation. It is these two actions (performed to a lesser or greater degree depending on varying factors in the athlete's physiology) due to the amount of force and stretching that cause damage to the achilles tendon.
    As well as looking at dorsiflex­on and pronation we must also look at the kinetic chain, and if the imbalance is coming from the foot up or the pelvic girdle
down.
    The four key exercises below (designed by Walt Reynolds, a strength and conditioning spe­cialist) mimic the kinetic chain of events within the calf muscles and achilles when you run. (In­terestingly, some experts believe that calf raises do not mimic this chain.)
    •  Exercise 1. Eccentric Knee Squat
    •  Exercise 2. Balance and Eccentric Reach with Toes
    •  Exercise 3. Balance and Eccentric Reach with Knee
    •  Exercise 4. Dynamic Achilles Stretch
    The exercises should always be progressive. To make sure they are, start with exercises performed in a sagittal direction and progressing onto exercises performed in a transverse direc­tion (right to left that are more

STRENGTHENING PROGRAM

    Other factors that must be taken into consideration are incorrect running shoes, hard or uneven running surfaces and unrealistic increases of mileage / training intensity (work on a guideline of 5-10% increase in mileage per week).
    Achilles injuries can also be caused by lack of flexibility and strength in the calf muscles; this will become most apparent when running uphill.
    It is important to create a training program to increase the eccentric strength of the calf (when a muscle lengthens as it contracts) using progressively faster speeds of movement to increase the forces that the calf can handle.
    The rehabilitation exercises should take place after one or two weeks of rest once pain and inflammation have gone down.
The program below should be performed everyday:
    1. Warm-up---5-10 minutes of CV---non-weight bearing, e.g. cycling, etc.
    2. Stretching---For both gastrocnemius and soleus, perform 3 x 30secs stretches on both sides.
    3. Eccentric Program---
    •  Level 1---Perform a straight legged heel raise with un­injured leg, then place the ball of the injured leg down and lower slowly with both legs until the heels reach the floor. Progress as follows:
Drop time: 4 secs 3x10 reps. with 30 seconds rest. Drop time: 2 seconds 3 x10 reps. with 30 seconds rest. Drop time: 1 sec 3 x10 reps. with 30 seconds rest. Repeat from the beginning (as above) per­forming a bent-legged heel raise-knee should be bent 20-30 degrees.
    •  Level 2-Perform heel raises with both legs for lowering and raising phases. 3 x 10 reps with 30 seconds rest. Progress as in Level 1.
    •  Level 3-Perform heel raises with the uninjured leg on the raise phase and with the injured leg on the lower phase. 3X10reps with 30 seconds rest. Progress as in Level 1.
    •  Level 4-Perform heel raises with both legs during the raising phase with only injured leg during the lowing phase. 3 x 10 reps with 30 seconds rest. Progress as in Level 1.
    •  Level 5-Perform heel raise lowering and raising with only the injured side. 3 x 10 reps with 30 seconds rest. Progress as in Level 1.
    •  Level 6. Stretching---Follow point 2.
    Both research and clinical experi­ence by a number of experts in the field (Raphael Brandon and Harvey Wallmann) support the merits of following the above eccentric program.

SWEDISH MEDICAL RESEARCH STUDY

    Approximately 25% of athletes who suffer from chronic tendi­nitis resort to surgery, demon­strating that the traditional treat­ments are not very effective.
    The Sports Medicine Unit of the University Hospital of Northern Sweden in Umea, Sweden, is one of the first medical research studies to investigate the well known correlation between the strength of calf muscles and achilles problems.
    The investigation began with 30 athletes who had chronic achilles tendinitis being divided into 2 groups: Group One received the traditional achilles tendinitis therapy (non-steroid anti-inflammatory medications, rest, orthotics, shoe change, cortisone injections and physical therapy).
    Group Two, however, engaged in "heavy-load eccentric calf muscle training" (when a muscle lengthens as it contracts).
    The heavy-load eccentric exercises were performed seven days a week for a total of 12 weeks.
    As the patients got stronger over the weeks they were able to add light weights into the program building up to a greater load as their strength increased. As strength be­gan to build weight machines were introduced to provide additional resistance.
    Prior the this 12 weeks the athletes injured achilles leg had a considerable weaker calf than the healthy leg. What is interesting to note is that after the 12 weeks of eccentric training there was no difference, either eccentrically or concentrically. This is particularly interesting due to the fact that no concentric exercises were performed (contractions where a muscles shortens while they are contracting).
    After this 12 weeks of heavy-load eccentric exercises the athletes reported that while running pain was reduced to a near zero pain threshold (prior to the 12 weeks this pain while running had averaged a pain threshold of 81 on a scale of 1-100).
    The athletes in Group Two were back to their normal training regime and were injury /pain free. They continued to carry out the heavy-load eccentric exercises approximately twice a week.
    The athletes in Group One (who did not complete the heavy-load eccentric program) all underwent surgery. Post-surgery (even after 24 weeks) these patients were not able to rebuild the calf muscles in the afflicted leg leading to a higher likelihood of future achilles problems.
    To understand why eccentric exercises are most effective for the calf we can look at its function in running. The calf's most important role is to control dorsiflexion of the ankle during the stance phase of running. This activity is eccentric.
    If this isn't maintained, excessive dorsiflexion and pronation can occur and cannot only ruin your running economy but also put huge stress on the achilles tendon.
    The research above is very valuable but has only worked the calf in the sagittal plane (forward and back). For the achilles to be truly strong it needs to be worked in three planes, sagittal, frontal and transverse. The Walt Reynolds program carried out (documented earlier) is therefore a more complete program.
    Research shows that eccentric exercises are incredibly valuable when treating an injured achilles.
    However these programs must be followed correctly and progression is the key.

SHIN SPLINTS­--ANOTHER LOWER LEG PROBLEM

    Shin Splints is known in the medical profession as medial tibial stress syndrome (MTSS). Athletes who are involved in jumping and running sports are susceptible to this injury, though it is known to affect endurance runners the most.
    MTSS occurs because the ankle dorsiflexors are not functioning as well as they should. Another factor is the immense force that is put through the shin with every step taken when running.
A sign of a runner with weak dorsiflexors is the fact that while running his feet will make a fairly loud slapping noise on the pavement.
In contrast listen to Kenyan elite runners. Due to their incredible dorsiflexor strength they run efficiently and quietly especially noted in the stance phase of the gait cycle.

EXERCISES THAT PREVENT MTSS

    •  Wall Shin Raises (both legs)---12­15 reps working up to 3 sets
    •  Wall Shin Raises (single leg)­--Resting opposing leg gently on the wall behind-12-15 reps working up to 3 sets
    •  Heel Step-Downs---(Very effec­tive for runners) 15 reps on each leg-progressing to 3 sets
    •  Heel Step-Down---Longer Steps---15 reps on each leg­--progressing to 3 sets
    •  Heel Step-Down From High Step---15 reps on each leg­--progressing to 3 sets
    •  Heel Hops---15 reps on each leg---progressing to 3 sets
    •  Heel Hops---Increase length of hop---15 reps on each leg­--progressing to 3 sets
    •  Heel Hops---Increase speed of hops---15 reps on each leg­--progressing to 3 sets
    •  Heel Running-Start with 10 meters and build up to 20 x 3 meters (with a short break in between)
 

WARM-UPS

    •  walk on toes-20 meters
    •  walk on toes-20 meters, toes pointed out
    •  walk on toes-20 meters, toes pointed in
    •  Repeat
    •  walk on heels
    •  walk on heels-20 meters, toes pointed out
    •  Repeat
    •  Skip-20 meters, toes pointed out
    •  Skip-20 meters, toes pointed in
    •  Repeat
    •  Skip on toes for 20 meters-toes straight, out and then in
    •  Light skipping on toes 20 meters, toes straight, out and then in
    •  Rhythm bounding-short springy steps 20 meters, broken up with 20 meters of running. At least 3 sets on soft ground.
    The final two warm-up exercises require the athlete to dorsiflex as he jumps or bounces up and plantar flex as he goes down.
    •  Dorsiflexion Bounces and Rhythm Bouncing-for both these exercises you can start with 10 reps and work up to 30 reps.
    In addition to these exercises the athlete must also stretch his ankles at both end ranges.
    It is important to note that sometimes tibial stress fractures can be confused with shin splints. These can be difficult to detect without a bone scan, so if an athlete or trainer is in doubt then it is of paramount importance that you seek medical advice before resuming training.

The Achilles Tendon Length

    Researchers at the Lab for Functional Anatomy and Biomechanics at the University of Copenhagen in Denmark have found that the shorter and thicker the achilles tendon the less efficient and more injury prone it is.
    It is also noted that the Kenyan long distance runners have long thin achilles tendons making them incredibly efficient and light on their feet.
    Although these factors are partly physiological it is also down to the athlete and trainer to encourage strength and length within the achilles to offer efficiency and maximum protection.

FROM: TRACK COACH 185