Page 1 2

Are you plagued by Achilles tendon soreness? Or do you simply want to make sure that an aching Achilles tendon never limits your ability to train and compete? In either case, read on! We have the solution to current Achilles problems - and the prophylactic for future ones.

If you've read about Achilles maladies in popular magazines and newsletters, you've probably noticed that Achilles articles follow a familiar recipe. First, they tell you that Achilles tendinitis is one of the most common injuries experienced by athletes. Then, they inform you that the throbbing Achilles soreness you may be feeling is somehow related to your training (no kidding!). And you're also told that once an Achilles problem crops up, it usually takes several weeks or more for it to subside.

If you're an Achilles victim, that last bit of news about the lingering nature of Achilles afflictions may depress you a bit, and the depression can deepen when you learn that one of the needed curatives happens to be rest. In fact, Achilles experts often recommend that you stay away from training for anywhere from two weeks to two months to allow proper healing to occur. You gradually begin to realise that the troublesome cord of tissue which connects your calf muscles to your heel may make you forfeit much of your hard-earned fitness - and may also help you gain back that unwanted weight you took so much trouble to lose.

As you survey the menu of therapies, your mood darkens even more. There are oral anti-inflammatories to reduce the pain and swelling. Ice to cool off that angry nest of connective tissue near your heel. Elevation to drain excess fluid from your Achilles back to the heart. Perhaps hydrotherapy to 'restore the blood supply to your Achilles,' even though such flows might actually enhance swelling. And there's the possibility of ultrasound to 'break down scar tissue,' perhaps some heel lifts and stretching routines to take tension off the poor Achilles, and maybe even a steroid injection in the area near (but definitely not in) the biggest tendon in your body, in hopes of getting things under control.

If the Achilles article is really up-to-date, it may even go beyond the standard recom-mendations and offer you some exercises to actually strengthen the calf and Achilles-tendon area. You'll be told that hikes in strength will help control future Achilles wear and tear, which makes you a bit hopeful. Sadly, though, most articles report that 'heel raises' and other similar exercises will be the cornerstone of your strength-upgrade solution, so you stand with your toes on a step, let your heels sink down behind you, and then begin to work away, contracting and relaxing your calf muscles and praying that you are indeed fortifying those damaged strands of tendon and minimising your future risk of injury. That's unfortunate because, as you'll see in a moment, standard exercises such as heel raises do little to control Achilles problems.

Green light?

As your reduced exercise schedule allows your tattered tendon to heal, you eventually give yourself the green light to return to training gradually. But, of course, there's one major problem: all of your rest and therapy have merely returned you to the activity which caused your Achilles problem in the first place. In essence, you're back to square one - ready to re-injure your Achilles. Since you haven't identified exactly what caused your Achilles to flare up in the first place, you're bound to repeat your previous patterns. And that lousy old Achilles is likely to get red-hot again very soon.

How do you get around this paradox? How do you make sure that all of your careful rest and therapy, the activities which were supposed to solve your Achilles problems, have not now merely brought you back to injury's doorstep? Well, to keep your Achilles tendon from acting up again, you have to identify what caused it to run amok in the first place. You must acknowledge that your Achilles-calf complex simply was too weak - too dilapidated to stand up to the forces being placed on it by your training programme.

The solution could be to train a lot less. After all, that Achilles of yours doesn't feel much stress when your feet are propped up on a cushion in front of the telly. But you don't want that. You don't want your training programme to be as weak as your Achilles; you'd like your Achilles to be as tough as your training programme.

In fact, you want to make your Achilles strong enough to stand up to whatever it is you're training for - the rigours of intense football practice, the preparation for a marathon, regular participation in squash matches, or competition on the track. Putting it a bit more eloquently, noted physical therapist Gary Gray says, 'Rehabilitation must transform the injured and inflamed Achilles tendon into tissue that successfully deals with the motions and loads of the causative activity' ('Functional Kinetic Chain Rehabilitation,' in Chain Reaction Plus: Successful Strategies for Closed Chain and Open Chain Testing and Rehabilitation, pp. 206-213, 1994).

Icing won't transform your Achilles into a tougher tendon. Anti-inflammatories won't help the Achilles deal more effectively with the high impacts, twists, and turns of training. Ultrasound isn't the panacea, nor are cortisone or hydrotherapy. Yet all of those interventions are prescribed as the 'cure' for Achilles agony. The truth is that they are merely temporary palliatives; what you really need is a nostrum that will make your Achilles tendons so fortress-like that they won't bother you again - even when you undertake very intensive training.

Unfortunately, scientific-journal articles are not very good at bringing you to that desired status. Dr. J. G. P. Williams of the Bon Secours Hospital in Buckinghamshire is considered one of the world's leading experts on Achilles tendon problems, yet his recent review, which outlined the pathology and ultrasonography of Achilles tendon lesions quite well, discussed only the following treatment options:

1. Low-intensity pulsed galvanic currents,
2. heparin treatments,
3. glycosaminoglycan polysulphate therapy,
4. steroids, and - if all else fails -
5. surgery

('Achilles Tendon Lesions in Sport,' Sports Medicine, vol. 16(3), pp. 216-220, 1993). Obviously, all of these treatments fail to identify the source of Achilles problems (can you hear an athlete saying 'Now I know how I injured my Achilles; I failed to give it its daily galvanic currents!'). Most cures for Achilles maladies merely bring athletes full circle - so that they can resume the precise activities which made their Achilles flame out.

How the Achilles works

So, let's put a bit of logical thought into the Achilles-injury treatment- and- prevention question. It stands to reason that to palliate or strengthen the Achilles tendons of athletes, you first have to understand how the Achilles and its associated calf muscles actually work when athletes move during their sports activities. If you do that, you can actually create exercises which will make the Achilles stronger while these specific activities are being carried out. Surprisingly, though, the mode of action of the Achilles and calves is actually far different than what you might expect.

If you're like most athletes, you probably think that the calf muscles and Achilles tendons provide the key propulsive force needed to stride forward when you run. That makes a certain amount of intuitive sense, since as you 'toe off' at the end of each contact with the ground, your heel rises as your foot rocks forward toward your toes. It's logical to think that the calf muscles are pulling actively on the Achilles tendon and heel at that point, lifting the heel right off the ground and helping you explode from one foot over to the other.

Except it just doesn't happen that way! EMG (electromyograph) analysis of calf-muscle activity during running reveals the following interesting points:

1. The calf muscles are most active just before footstrike, at initial footstrike, and just after footstrike occurs.
2. During the stance phase, the calf muscles actually become progressively less active.
3. Just before and at toe-off, the calf muscles are completely quiescent (in contrast to the popular belief that they are rocking the foot forward toward the toes).
4. During the 'swing' phase (when the leg moves back and then forward while the foot is off the ground), the calves don't become active again until shortly before footstrike.

This tells us that the key function of the calf muscles and Achilles tendon is not to contract vigorously to provide a highly propulsive toe-off (they can't do that since they're not active at toe-off). It's true that the calves and Achilles do help with toe-off, but this help is provided by their natural elastic recoil from a stretched position, not by active work.

No, the electromyogram data tell us that since the calves are most active just before and after footstrike, their key function is to position the foot for footstrike and then control 'dorsi-flexion' and pronation during the stance phase of running. Controlling dorsi-flexion means keeping the ankle joint from collapsing as the foot hits the ground, eg, keeping the shin and the top of the foot from getting too close together. Controlling pronation means preventing the foot from rolling too far inward - and the heel from turning too far outward after the impact between the foot and ground.

And those happen to be 'eccentric' activities of the calf muscles and their associated Achilles tendon, which means that the calf muscles are being stretched and strained by the force of ankle flexion at the same time that they're trying to shorten to control that flexion. Simultaneously, the ankle joint is rotating as the foot begins to pronate, placing a twisting and stretching force on the Achilles tendon and calf muscles as they attempt to shorten. These eccentric actions, repeated over and over again, are what actually damage the Achilles tendon.

Think of a pitcher's action

If this is hard for you to conceptualise, think about baseball pitchers and their injuries. Most pitchers' problems occur in the shoulder and 'rotator-cuff' muscles which control the shoulder blade (scapula) during throwing. You rarely hear of problems in the pectoralis and triceps muscles - the ones which actually propel the ball toward home plate at high speeds. No, the main maladies occur in those muscles which attempt to control the shoulder and keep it from being tossed toward home plate, too. These are the muscles at the back of the shoulder which tell the shoulder joint to 'come back'. Like the calf muscles during the stance phase of running, these muscles contract eccentrically (forcefully while being stretched), which is precisely why they are most likely to be injured. Stretching and twisting a muscle repeatedly while it is trying to shorten is a proven recipe for disaster - if the muscle is not ready to withstand those continued stresses.

So, what you need to do to keep your Achilles tendons out of trouble is to prepare them for the eccentric, rotational forces they are subject to as you carry out your training programme. Sorry, but the commonly prescribed heel raises won't do that. Heel raises basically omit the rotational action which is present in every step you take as you run; they only work the calf muscles and ankle in a sagittal plane (forward and backward through dorsi-flexion and plantar flexion). Heel raises also emphasise concentric activity of the calf muscles (contracting and shortening), as the calves pull the heels upward. This is totally unlike the contracting and lengthening pattern which the calf muscles actually undergo during the stance phase of running, a pattern which usually occurs about 90 times per minute on each foot as you run. Of course, another problem associated with heel raises is that they are usually carried out with both feet on the ground at one time, whereas running is a 'one-footed' activity (full body weight is supported on one foot at a time).

And utilisation of heel raises ignores the fact that rehabilitation of the Achilles tendon 'must reintegrate the injured tissue back into a more effective and efficient functional kinetic chain system,' as Gray puts it. This means getting the Achilles and calves working not in isolation but in coordinated synchrony with the muscles of the hips, knees, and feet, as they must do during running.

Continued »