Achilles tendonitis is a common injury for all athletes and fitness participants, especially those who run seriously as a sport or main fitness activity. The injury involves damage to the fibres on the Achilles tendon unit, often at the narrow point of the tendon just above the heel. This area is most at risk because it has a smaller blood supply than the rest of the tendon, and so is unable to repair itself as easily. The symptoms involves pain in the Achilles with motion, which will increase if exercise continues, tenderness to touch and often warmth and swelling to the area. Sufferers can also complain of stiffness and pain on getting up in the morning.

Achilles tendonitis is a 'chronic stress' injury. The cause of the damage to the tendon is excessive forces, where lots of little stresses accumulate to overload the tendon. This is in contrast to an 'acute stress' or 'accident'-type injury, where a single large stress causes the damage, e.g., an ankle ligament sprain.

Bad shoes can be a cause
There are a variety of factors that can lead to the repetitive excess stress. Incorrect shoes are a common cause, where the training shoe provides either insufficient support or insufficient cushioning. If an athlete suddenly develops tendonitis and he/she has been using the same shoes for a long time (over six months) or has run many miles in those shoes (over 500), then it is quite likely that the training shoes have simply worn out. Replacing the shoes will probably solve the problem. It is also possible that if the onset of tendonitis symptoms coincides with a change in training shoes, then the new shoes are probably not suitable.

Training surfaces are also related to tendonitis injuries. Running on hard surfaces, such as roads, creates greater impact forces that will stress the tendon more. Alternatively, uneven surfaces will place greater shear forces on the tendon. Shear forces are applied sideways and tendons are less strong in this direction. which can also cause overloading. This is why treadmills are often very useful for athletes with injury problems, since they are smooth but have more give than roads.

Imitate the action of the tortoise
The amount of mileage an athlete completes each week is also strongly related to Achilles tendonitis risks. Quite simply, the more miles you run, the more stress is placed on the tendon. For example, an athlete may never be injured completing a moderate 20-30 miles a week schedule, but will suffer problems if attempting 40-50 miles a week. One of the most important training principles to avoid injury is 'gradual progression'. This means any increases in mileage or intensity of training must be slow and steady, otherwise injury risks are greatly heightened. A guideline of a 5-10 per cent increase in mileage per week is a good rule of thumb. Adopting this measured approach allows the muscles and tendons time to increase their strength to cope with the extra stress. Many injuries are caused by athletes increasing volume or intensity too rapidly.

Pronation and weak calves
Individual biomechanical factors also affect the forces acting on the Achilles. For example, excessive pronation can contribute to tendonitis. Pronation is the inward movement of the rearfoot as you contact the ground during walking or running and is necessary to absorb the impact forces. However, too much pronation, or too fast, can internally rotate the lower leg excessively, which means the rearfoot does not achieve the optimum position during the pushing-off phase. To compensate for this less-efficient mechanical position, the muscles and tendons of the lower leg must work harder, and thus excessive stress can occur. For this reason, orthotics worn inside the running shoes to control the rearfoot motion can often help athletes who over-pronate.

Two other individual factors causing tendonitis can be lack of flexibility and lack of strength in the calf muscles. Tightness in the calf will lead to extra tension being placed on the Achilles tendon, during running and walking, especially up hills. Lack of strength may mean that the tendon will not be able to cope with the forces applied during movements. During running, the calf muscles are most active during the first half of the contact phase, when the muscles are absorbing the impact with the ground. At this point the calf muscles are working 'eccentrically' to control the forward motion of the lower leg. When a muscle works eccentrically, it is lengthening as it contracts, The faster this contraction, the greater the forces applied.

With this in mind, a strengthening programme for the calf muscles should focus on developing eccentric strength, using progressively faster speeds of movement to increase the forces that the calf can handle. This type of programme is 'functional', which means that it involves the same type of contraction of the calf muscles that occurs during running and so should have greater benefits for injury prevention and rehabilitation.

Here's an exercise plan
Harvey Wallmann (2000), an assistant professor of physical therapy at the University of Nevada, presents the following exercise plan to help athletes recover from Achilles tendonitis. It is based on the factors discussed above, specifically development of flexibility and eccentric strength in the calf muscles in order to increase the tendon's ability to cope with forces. The stretching component of the programme is doubly important for athletes recovering from injury because during the healing process the direction of the collagen fibres that are regenerated is dependent on the forces applied to the tendon. Gentle stress in the form of stretching will ensure the fibres are laid down in the correct alignment. Without this force during the healing process, the fibres are laid down randomly, which means that the tendon will not be as strong and the likelihood of the injury recurring is increased.

The rehabilitation process should take place after one or two weeks of rest, during which time the athlete does no activity apart from some gentle calf stretching. After this rest period the tendon should have 'healed' and any pain and inflammation should have gone. This is the time to begin strengthening the tendon.

b>Follow this workout
The workout comprises the following, and should be performed every day:

1. Warm-up
2. Stretching
3. Eccentric programme
4. Stretching

The warm-up should involve 5-10 minutes of gentle CV exercise. Ideally, this should be non-weight-bearing, e.g., cycling. The purpose of this is to warm up the muscles to prepare them for the stretching and strengthening exercise that follows. The stretching involves static stretches for both the gastrocnemius and soleus muscles. To stretch the gastrocnemius, lean forward against a wall with one leg behind you. Keep the leg completely straight, the heel on the floor and the toes pointing forward. To stretch the soleus, lean against the wall with one leg behind you but slightly closer than before. Bend the knee slightly and place your weight on the front foot, keeping your heel on the floor and toes pointing forwards. Perform three lots of 30-second stretches on each side, holding a moderate stretch each time. These stretches must not be painful.

The eccentric programme involves the simple calf-raise exercise using only body weight. The progression comes from increasing the load and speed of the eccentric phase of the movement, which is the heel-lowering phase. Each athlete must progress at his/her own speed, depending on the pain response to the workout. The last set of repetitions should feel hard but not painful. If the next day the workout feels the same or easier, then increase the difficulty the following day. Progress in this manner until you can reach the highest level outlined below, which may take from a few weeks to months, especially if you have suffered from Achilles tendonitis for a long time.

Level one
Perform a straight-legged heel raise with the uninjured leg. Place the ball of the injured leg down and lower slowly with both legs until heels reach the floor. The drop should last for four counts. Repeat 10 times. Perform three sets with 30 seconds rest between sets.

Progress by increasing the lowering speed to a count of two, and then progress to a fast drop of one count. Once this is achieved, progress to performing a bent-legged heel raise, which will place an extra load on the soleus muscle. The knee should be bent 20-30 degrees. Again, start with a slow lowering phase and gradually speed up.

Level two
Perform a heel raise with both legs for lowering and raising phases. Perform three sets of 10 reps with 30 seconds rest. Progress by increasing speed and on to the bent-legged position as in level one.

Level three
Perform the heel raise with only the uninjured leg during the raising phase and then only with the injured leg during the lowering phase, thereby focusing the eccentric load on the injured side. Perform three sets of 10 reps with 30 seconds rest. Progress the speed of lowering and the bent-legged position as level one.

Level Four
Perform the heel raise with both legs during the raising phase with only the injured leg during the lowering phase. Perform three sets of 10 reps with 30 seconds rest. Progress as level one.

Level Five
Perform the heel raise lowering and raising with only the injured side. Perform three sets of 10 reps with 30 seconds rest. Progress as level one.

This five-level progressive eccentric workout is a suitable way to strengthen the calf muscle and the Achilles tendon after an injury. In combination with the stretching exercises the workout will improve the function of the calf muscles and help the athlete back to full fitness. Wallmann claims that both research and clinical experience support the use of the programme, which I can back up anecdotally by the fact that one of my clients, who has suffered from Achilles tendonitis for years, is currently following the programme and making good progress.

Raphael Brandon achilles tendonitis