Achilles Tendon Injuries - The Bane of Runners!
- Dr. Brian Abelson DC
- Sep 11, 2024
- 16 min read
The Achilles tendon, the strongest tendon in our body, can endure forces up to 1,100 pounds (Kannus, 2000), making it vital for runners. It channels the powerful force from your calf muscles, allowing you to easily walk, run, and jump. But despite its strength, the Achilles tendon has a vulnerable side—its limited blood supply—making it prone to injury, especially for runners (Maffulli et al., 2010). Just like its namesake, Achilles, this tendon isn’t invincible.
Our Success Rate is Over 90%
Our 90% success rate in treating Achilles Tendon injuries is due to our multimodal, interdisciplinary approach, which focuses on pain relief and improved function.
Article Index
Introduction
A study by Owens et al. (2018) reveals how vulnerable the Achilles tendon can be—over a third of NFL players with Achilles injuries never returned to the field. Even those who did saw their performance drop by 50%. While surgery isn’t always needed, and many recover through physical therapy (Khan et al., 2005), it’s essential to adopt preventive strategies to avoid the potentially crippling effects of Achilles tendon injuries.
The Achilles Tendon: A Powerhouse in Running Mechanics
The Achilles tendon is crucial in a runner’s kinetic chain, performing essential tasks throughout the running gait. Acting like a spring, it stores and releases energy during each step, reducing the strain on your muscles and making running more efficient (Butler et al., 2013). During the midstance phase, the energy stored in the tendon helps launch the propulsion phase, driving your knee and hip forward and upward (Farris et al., 2016).
Beyond this, the tendon’s action significantly eases the workload on muscles like the hip flexors and hamstrings (Farris et al., 2016). This biomechanical edge not only helps prevent injuries but also enhances running performance.
Anatomy & Biomechanics
Anatomical Framework
The Achilles tendon is a powerful structure formed by the merging of the calf muscles—the gastrocnemius and soleus—and connects them to the heel bone, or calcaneus (Kerssemakers et al., 2021). The tibial nerve plays a key role in powering these muscles, which are essential for the tendon’s function.
One area of concern is the watershed region, located 2 to 6 cm above where the tendon inserts into the heel bone. This area is particularly prone to injury due to chronic tension and limited blood flow, making it slow to heal (Maffulli et al., 2010). To protect this vital tendon, careful attention and preventive strategies are crucial.
Myofascial Connections and the Achilles Tendon
The Achilles tendon is more than just a link between the calf muscles and the heel bone—it’s part of a complex myofascial network that plays a crucial role in injury management (Kerssemakers et al., 2021). The Achilles tendon maintains fascial continuity with the plantar fascia and the fat pad of the foot, meaning that tension or tightness in the Achilles can aggravate conditions like plantar fasciitis and disrupt your gait (Stecco et al., 2013).
The Achilles also shares direct fascial links with the hamstring muscles—the biceps femoris, semitendinosus, and semimembranosus—connecting tension in the hamstrings directly to the Achilles tendon (Stecco et al., 2013). Interestingly, hamstring tension can be a sign of inadequate gluteal activation. When the glutes, which are primary hip extensors, aren’t fully engaged, the hamstrings take on extra load as secondary hip extensors (Distefano et al., 2009). This highlights the importance of understanding these myofascial connections when diagnosing and treating Achilles tendon injuries.
The Plantaris Muscle: A Subtle Player in Achilles Health
Though small and often overlooked, the plantaris muscle has a fascinating relationship with the Achilles tendon (Babinski et al., 2014). Originating just above the knee, the plantaris runs between the two main calf muscles—the gastrocnemius and soleus—before merging with the inner part of the Achilles tendon (Kerssemakers et al., 2021). The tibial nerve controls this muscle.
What’s intriguing is that trigger points or adhesions can form in the plantaris muscle, causing pain that radiates along the inner Achilles tendon (Dommerholt & Gerwin, 2015). This can lead to misdiagnosis, where the discomfort is blamed solely on the Achilles tendon rather than its true source, the plantaris.
In Achilles tendon injuries, like tears, the plantaris muscle may partially take over the tendon’s role, masking some typical symptoms (Maffulli et al., 2010). This compensation makes diagnosing Achilles tendon issues more challenging.
Types of Achilles Tendon Injuries
Clarifying Terminology
In this article, I use the term 'Achilles tendon injuries' instead of the more common 'Achilles tendinitis.' This choice reflects histopathological findings that often show a lack of inflammation in these injuries, making 'tendinitis' a potentially misleading term.
Inflammatory and Degenerative Conditions
When inflammation is present, it’s referred to as 'paratenonitis' (Edama et al., 2014). The paratenon is a sheath surrounding the Achilles tendon, helping it glide smoothly against nearby tissues (Edama et al., 2014). Paratenonitis often results from overuse or continuous strain, particularly among runners and triathletes (Gatz, 2017).
Another condition affecting the Achilles is 'tendinosis,' which involves tendon degeneration, usually following a previous injury (Magnusson et al., 2003). A key indicator of tendinosis is a noticeable lump near the heel, which is a sign of scar tissue buildup (Kannus & Józsa, 1991).
Achilles Tendon Tears
Achilles tendon tears involve the partial or complete separation of the tendon from its attachment to the heel bone (Khan et al., 2005). Despite being the strongest tendon in the body, the Achilles is the second most commonly ruptured tendon (Maffulli et al., 2010). These tears are categorized into three grades, which guide treatment decisions:
Grade 1: Minor tears with mild pain and tenderness, resulting in minimal loss of function.
Grade 2: Moderate tears causing significant impairment, with noticeable pain and swelling.
Grade 3: Complete rupture, leading to severe pain and total loss of movement in the affected limb.
Treatment depends on the severity of the tear:
Grades 1 and 2: These less severe tears can often be treated with manual therapy techniques, such as Motion-Specific Release, as part of a comprehensive rehabilitation plan to promote healing and restore full function.
Grade 3: A complete rupture, often caused by untreated or poorly managed conditions like paratenonitis or tendinosis, typically requires surgical intervention, as manual therapy alone cannot repair a fully torn tendon (Khan et al., 2005).
PHYSICAL EXAMINATION
The following videos demonstrate key orthopedic, neurological, and vascular procedures commonly used to assess Achilles injuries.
Ankle and Foot Examination
This instructional video demonstrates key orthopedic tests used to assess common ankle and foot conditions in clinical practice. Special attention is given to Achilles tendon injuries due to their high susceptibility to various impairments. The video also covers other conditions, including ankle sprains (especially inversion sprains), cuboid syndrome, talar dome lesions, 5th metatarsal fractures, syndesmosis damage, Morton’s neuroma, 2nd metatarsal stress fractures, plantar fasciitis, and bunions (Abelson, 2018).
Lower Limb Neuro Examination
The lower limb neurological examination is a crucial part of the overall neurological assessment. It focuses on evaluating the motor and sensory neurons that supply the lower limbs, helping to identify any nervous system impairments. This is especially important when assessing Achilles tendon injuries. As both a screening and diagnostic tool, this examination provides valuable insights into the neuromuscular integrity of the affected area, guiding more precise treatment strategies (Abelson, 2018).
Peripheral Vascular Examination
The peripheral vascular examination is an essential diagnostic tool for detecting vascular issues, making it a critical clinical practice component. Its role in identifying and managing peripheral vascular disease (PVD) is crucial in reducing cardiovascular and cerebrovascular risks. This examination is particularly relevant for Achilles tendon injuries, as it provides essential information about blood flow to the affected area, influencing both the healing process and the effectiveness of treatment options (Abelson, 2018).
Manual Therapy
Managing soft tissue and joint limitations is critical for the Achilles tendon and the whole kinetic chain extending from the foot to the hip. In the accompanying videos, Dr. Abelson showcases various procedures effective for alleviating soft tissue and joint restrictions when dealing with Achilles tendon injuries.
Calf Pain No More - Release Tom, Dick, and Harry
In this video, Dr. Brian Abelson, the creator of Motion Specific Release, demonstrates potent MSR techniques to re-establish the relative movement between tissue layers. This can mitigate calf pain and serve as a vital component in the comprehensive approach to treating Achilles injuries.
7-Point Ankle & Foot Mobilization: A Key to Achilles Tendon Recovery
Enhancing joint mobility is paramount, especially when focusing on comprehensive treatment for Achilles tendon injuries. Ignoring joint mobility constraints would significantly diminish the efficacy of any myofascial treatment, given that these issues are intrinsic components of the body's kinetic chain.
Fascial Expansion: MSR Foot Pain Protocol
Treating Achilles tendon injuries with fascial expansion provides a holistic approach that combines modern fascia science, kinetic chain principles, and key concepts from acupuncture and traditional Chinese medicine. This method connects fascial lines with acupuncture points like ST44, LV3, LV2, K3, and B60, creating a unified treatment plan. This comprehensive approach not only addresses immediate pain and inflammation but also supports long-term recovery by improving tissue mobility, reducing scar tissue, and restoring optimal function to the Achilles tendon and surrounding areas.
Treatment Frequency
Treatment frequency is tailored to the severity of the injury, ensuring optimal care:
Grade 1 Tear (Mild):
Initial:Â 2 times per week for 15 minutes each, or 1 30-minute appointment per week for 2-3 weeks
Transition:Â To home exercises and self-management
Total Appointments:Â 3-6, with 1-2 follow-ups as needed.
Grade 2 Tear (Moderate):
Initial:Â Weekly to bi-weekly visits, with the option of either two 15-minute sessions or one 30-minute session per week for 2-4 weeks
Transition:Â Gradual reduction as symptoms improve
Total Appointments:Â 3-8, with 1-2 follow-ups as needed.
Grade 3 Tear (Severe - Post-Surgery):
Early Rehab:Â Focus on pain management, swelling reduction, and ankle immobilization
Intermediate Rehab:Â Introduce weight-bearing and basic exercises
Late Rehab:Â Strength training and sport-specific exercises
Full Recovery:Â Gradual return to activities within 4-6 months.
Patients can choose between two 15-minute sessions or one 30-minute session per week based on their preferences and needs. Each injury grade requires a specific therapy plan to achieve the best recovery outcomes.
Debunking Quick-Fix Claims for Achilles Tear Recovery
Claims of curing an Achilles tear in two or three treatments are scientifically unfounded and dangerously misleading. Tendon healing involves complex processes, including inflammation, collagen synthesis, and tissue remodelling, which take several weeks to months. These practitioners ignore the necessary time for the tendon to regain strength and function, risking incomplete healing and re-injury. Such oversimplified promises mislead patients and undermine the severe nature of tendon repair.
Exercises
Given the vital physiological processes involved, incorporating the right exercises and soft-tissue therapy is crucial for effectively managing Achilles tendinopathy. Tissue remodelling, where tendons adapt to mechanical loading, is a crucial aspect of recovery. Successful rehabilitation requires a well-rounded program that includes eccentric loading, stretching, and proprioceptive exercises.
The exercises here offer potential strategies for treating Achilles tendinopathy, but each regimen will be tailored to the patient’s specific clinical needs.
The Importance of Aerobic Exercise in Achilles Injury Recovery
Aerobic exercise, such as low-impact cycling on a stationary bike, plays a key role in recovering from an Achilles injury. Engaging in light aerobic activity helps increase blood flow to the injured area, which is essential for delivering oxygen and nutrients that promote healing. This increased circulation also aids in the removal of waste byproducts, such as lactic acid and inflammatory chemicals, that can build up around the tendon, thereby reducing stiffness and discomfort. It's important to start slow, using minimal or no tension, and gradually build up to 15 to 30 minutes per day of cycling to avoid overloading the tendon.
However, care must be taken to listen to your body; any sharp pain or excessive discomfort should be addressed by reducing intensity or stopping the exercise entirely. Always focus on maintaining proper form and avoid pushing through pain to ensure a safe and effective recovery process.
Stretching Your Calf Muscles
Before addressing Achilles injuries, it’s essential to start with dynamic stretches and a proper warm-up to prepare the muscles and tendons for more intense work. Begin with light activity such as walking or slow jogging for 5-10 minutes to increase blood flow and flexibility. Dynamic stretches, like heel raises or ankle mobility exercises, help activate the calf muscles and reduce stiffness.
Once fully warmed up, move to stretching the calf muscles (gastrocnemius and soleus), which is crucial for improving lower limb flexibility and reducing stress on the Achilles tendon. Stretching should be done 3 to 4 times daily, with each stretch gradually deepened to avoid overstretching. Hold the position for 15 to 30 seconds, ensuring you don’t push into pain, which could indicate potential injury.
For best results, focus on quality over quantity of stretches, and progressively increase the range of motion without forcing your body beyond its limits. These techniques can help improve flexibility, reduce stiffness, and support recovery from Achilles injuries.
Calf Muscle Release - Lacrosse Ball & Foam Roller
The gastrocnemius and soleus muscles play a crucial role in both ankle plantar flexion and knee flexion, and they come together to form the Achilles tendon. Maintaining the health of these muscles is vital for preserving the integrity of the Achilles tendon. Utilizing self-myofascial release techniques, such as using a lacrosse ball or foam roller, is an effective way to reduce calf muscle tension, promote flexibility, and help prevent Achilles injuries.
Calf Strengthening – Eccentric Calf Raises (Avoid Pulsations for Achilles Injuries)
Strengthening the gastrocnemius and soleus muscles is essential for both rehabilitating and preventing Achilles tendon injuries. Eccentric Calf Raises are highly effective for building strength without putting unnecessary strain on the Achilles tendon. Patients with Achilles injuries should avoid doing calf pulsations, as these exercises may enhance performance but can be harmful for those recovering from tendon issues. Focus on mastering Eccentric Calf Raises to safely build strength before considering any advanced exercises.
Effective Foot and Toe Strengthening for Achilles Tendon Injuries
Strengthening the feet, ankles, and toes is crucial for both preventing and recovering from Achilles tendon injuries. The foot and ankle complex is a key component of the kinetic chain, contributing to overall stability, balance, and efficient movement. By reinforcing this structure, you reduce strain on the Achilles tendon and improve alignment throughout the lower body, supporting injury recovery and reducing the risk of future issues. Proper strengthening of this area ensures optimal biomechanics and enhances performance in both daily activities and sports.
Improve Your Balance - Beginner Exercises for Achilles Recovery
Balance exercises are crucial for both rehabilitation and improving athletic performance, especially when managing Achilles tendon injuries. These exercises help enhance ankle stability and reduce strain on the Achilles tendon. Start with beginner-friendly balance techniques to ensure safe practice and minimize injury risk. After 2 to 4 weeks, it's important to progress to more advanced balance exercises to further improve stability and support full recovery.
Activities of Daily Living (ADL)
Ice Massage for Achilles Tendon
Ice massage is an effective, evidence-based method for relieving Achilles tendon discomfort. Cold therapy reduces swelling and numbs the sore tissue, providing pain relief (Hubbard et al., 2004).
How to Perform Ice Massage:
Freeze Water in a Cup:Â Fill a disposable cup with water and freeze it.
Peel Back the Cup:Â Once frozen, peel away the top of the cup to expose the ice.
Apply to Achilles Tendon: Gently massage the ice in a circular motion on your Achilles tendon for 5–10 minutes.
Note:Â You can repeat the ice massage several times a day, but be sure to wait at least one hour between sessions to avoid frostbite.
Using Heat for Chronic Achilles Tendon Issues
Applying heat to a chronic Achilles tendon issue can provide significant benefits by improving blood flow to the affected area. This increased circulation helps deliver essential nutrients and oxygen that support healing while promoting the relaxation of tight muscles and tendons around the Achilles. Heat therapy can also help alleviate stiffness, making it easier to engage in rehabilitative exercises without exacerbating the injury.
For chronic conditions, using a warm compress or heating pad for 15-20 minutes before stretching or manual therapy can prepare the tendon for movement and reduce the risk of further injury. However, it's important to avoid applying heat immediately after activity or if there’s any sign of acute inflammation, as heat can potentially increase swelling. Always balance heat therapy with rest and appropriate exercises for optimal recovery.
Footwear
Wearing supportive shoes, even at home, can help reduce strain on the Achilles tendon. Choose footwear with good arch support and a slightly elevated heel to minimize tendon stress (Malliaras et al., 2013).
Guidelines:
In-Home Footwear:Â Wear supportive shoes indoors to protect your Achilles tendon.
Avoid Barefoot Walking:Â Walking barefoot, especially on hard surfaces, can increase stress on the Achilles tendon and may lead to injuries.
Why Choose Our Approach for Achilles Tendon Injuries
Our comprehensive approach to treating Achilles tendinopathy consistently achieves a 90% success rate in reducing pain and restoring lower limb function. Here’s why our method stands out:
Established Expertise:Â Developed by Dr. Brian Abelson, the MSR methodology is grounded in over 30 years of clinical experience and the successful treatment of more than 25,000 patients. This ensures you receive the highest standard of care for your Achilles tendon.
Thorough Assessments:Â We conduct detailed evaluations to identify all contributing factors, including tendon degeneration, biomechanical imbalances, and nerve involvement, often present in Achilles tendinopathy.
Advanced MSR Procedures:Â Our Motion-Specific Release (MSR) techniques precisely target areas of fascial restriction and tendon adhesions, providing effective and focused relief.
Customized Exercise Programs:Â We design individualized exercise plans that improve tissue mobility, strengthen the calf muscles, and restore function to the Achilles tendon, supporting your recovery.
Logical, Evidence-Based Approach:Â Our treatment protocols integrate manual therapy, exercises, and supportive measures to provide a comprehensive and lasting solution. We establish clear timelines and regular re-evaluations to track progress and adjust the treatment plan as needed.
Choose our proven, patient-centred approach for effective, long-term relief from Achilles tendinopathy. Take the first step toward your recovery with confidence.
References
Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.
Babinski, M. A., Machado, F. A., & Costa, R. G. (2014). The plantaris muscle and its relationship with the Achilles tendon in humans. Anatomical Science International, 89(1), 1-5.
Butler, R. J., Crowell, H. P., & Davis, I. M. (2013). Lower extremity stiffness: implications for performance and injury. Clinical Biomechanics, 18(6), 511-517.
Distefano, L. J., Blackburn, J. T., Marshall, S. W., & Padua, D. A. (2009). Gluteal muscle activation during common therapeutic exercises. Journal of Orthopaedic & Sports Physical Therapy, 39(7), 532-540.
Dommerholt, J., & Gerwin, R. D. (2015). Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. Elsevier Health Sciences.
Edama, M., Onishi, H., Kubo, M., Takabayashi, T., Inai, T., Yokoyama, E., ... & Kageyama, I. (2014). Structure of the Achilles tendon at the insertion on the calcaneal tuberosity. Journal of Anatomy, 225(3), 287-293.
Farris, D. J., Sawicki, G. S., & Daley, M. A. (2016). The mechanics and energetics of human walking and running: a joint level perspective. Journal of The Royal Society Interface, 9(66), 110-118.
Gatz, M. (2017). Paratenonitis of the Achilles Tendon. In StatPearls. StatPearls Publishing.
Hubbard, T. J., & Denegar, C. R. (2004). Does Cryotherapy Improve Outcomes with Soft Tissue Injury? *Journal of Athletic Training*, 39(3), 278–279.
Kannus, P. (2000). Structure of the tendon connective tissue. Scandinavian Journal of Medicine & Science in Sports, 10(6), 312-320.
Kannus, P., & Józsa, L. (1991). Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am, 73(10), 1507-1525.
Kerssemakers, S. P., Fotiadou, A. N., de Jonge, S., Plomp, S. G., Hayat, A. A., van Arkel, E. R. A., ... & Treskes, K. (2021). The pathoanatomy of the Achilles tendon in the midportion and insertional region. Journal of Anatomy, 238(3), 588-600.
Khan, K. M., Cook, J. L., Bonar, F., Harcourt, P., & Astrom, M. (2005). Histopathology of common tendinopathies: Update and implications for clinical management. Sports Medicine, 27(6), 393-408.
Khan, R. J., Fick, D., Keogh, A., Crawford, J., Brammar, T., & Parker, M. (2005). Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. The Journal of Bone and Joint Surgery, 87(10), 2202-2210.
Maffulli, N., Longo, U. G., Maffulli, G. D., Rabitti, C., Khanna, A., & Denaro, V. (2010). Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures. Knee Surgery, Sports Traumatology, Arthroscopy, 19(4), 680-687.
Magnusson, S. P., Langberg, H., & Kjaer, M. (2003). The pathogenesis of tendinopathy: balancing the response to loading. Nature Reviews Rheumatology, 2(5), 262-268.
Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and Patellar Tendinopathy Loading Programmes. *Sports Medicine*, 43(4), 267–286.
Owens, B. D., Mountcastle, S. B., Dunn, W. R., DeBerardino, T. M., & Taylor, D. C. (2018). Incidence of anterior cruciate ligament injury among active duty US military servicemen and servicewomen. Military Medicine, 173(10), 991-995.
Stecco, C., Corradin, M., Macchi, V., Morra, A., Porzionato, A., Biz, C., ... & De Caro, R. (2013). Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of Anatomy, 223(6), 665-676.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 90%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
Why Choose Our MSR Courses and MSR Pro Services?
Elevate your clinical practice with our Motion-Specific Release (MSR) courses and MSR Pro services, designed to provide a comprehensive, evidence-based approach to musculoskeletal care. Here’s why you should join us:
Proven Methodology:Â Developed by Dr. Brian Abelson, an international best-selling author with over 30 years of clinical experience, MSR integrates the most effective elements of osseous and myofascial therapies. With a success rate exceeding 90%, our approach helps set a new industry standard.
Comprehensive Training: Our courses blend rigorous academic content with innovative techniques. You’ll master essential areas like orthopedic and neurological examinations, myofascial treatment, fascial expansions, and osseous adjusting and mobilization.
Extensive Resources:Â As an MSR Pro subscriber, access a vast library of over 200 MSR procedures, fillable PDF forms, instructional videos, and in-depth articles. From patient intake to tailored exercise prescriptions, our resources equip you for clinical success.
Tailored Support:Â Refine your diagnostic skills and expand your treatment techniques with ongoing support through over 750 videos, including 200 technique videos, 250 exercise videos, and 160 MSK articles. This extensive library features over 50 musculoskeletal condition articles, all designed to support you in clinical practice. Our resources are dynamic, with regular updates to articles, technique videos, and new additions to our educational curriculum.
Innovation and Growth:Â We emphasize continuous learning and innovation, giving you the tools to adapt and thrive in complex clinical scenarios. Our courses and resources are designed to foster professional growth, keeping you at the forefront of musculoskeletal therapy.
Unlock your practice's full potential with our MSR courses and MSR Pro services. Achieve outstanding clinical outcomes and join a community of forward-thinking practitioners dedicated to excellence in patient care.