Running Injuries

Achilles Tendinopathy Injuries in Runners

Achilles Pain - Wandsworth

THE INJURY

The Achilles tendon and plantar fascia are energy-absorbing and energy-releasing structures that are working throughout each stride. They absorb the load as your foot impacts the ground (loads are often 3 times your body weight) and convert the energy to propel yourself during the push-off phase of a stride (where forces are as high as 7 times your body weight). The Achilles tendon and calf muscle are therefore an essential unit, critical for efficient and effective running. The Achilles tendon is prone to overuse purely by the nature of its function. Pain occurs because of weakness or dysfunction in the tendon rather than what was previously thought to be an inflammatory reaction. This can be a challenging area to treat due to the tendon’s poor perfusion (blood flow), which may need longer recovery periods, so it’s best to tackle this injury at the earliest point possible.

THE SYMPTOMS

  •  Pain close to the heel, which is often sharp, poking and incapacitating.
  •  Pain along the Achilles tendon, at the back of the lower leg.
  •  Occasionally there can be mild swelling at the base of the tendon (near the heel) and redness.
  •  If you pinch the Achilles and it’s very sore, then the source of the problem is likely to be the tendon.
  •  Pain during and after running (Stop! This is not an injury you can run through)
  •  In chronic cases there can be thickening or a thickened ‘lump’ along the tendon, especially when compared to the uninjured leg

 

THE CAUSE

The Achilles tendon is the extension of the calf muscles, gastrocnemius and soleus where it attaches to the back of the heel and is responsible for plantarflexion (pointing your toes). Sometimes excessively tight, weak calves are the culprit. Tight lower legs put added strain on the Achilles tendon, and over the course of many months of hard training, this overuse injury can develop. A weak posterior chain (the muscles that work together along the back of your body including the back extensors, gluteus muscles, hamstrings, calves) can also be a cause of Achilles tendinopathy. 

Constantly running on hard surfaces like concrete or asphalt can contribute to developing Achilles tendinopathy as the loads absorbed by the tendon are greater than running on grass or dirt roads. Unsupportive footwear can overburden the Achilles tendon with time, as it must work even harder to control ankle movement whilst running. 

Worn out shoes or shoes with inadequate cushioning can exacerbate Achilles tendon issues as they add no benefit in absorbing load during heel strike. Rapid increase in volume and/or intensity or training can have the same effect much more quickly, so it’s important to pay attention to both your feet and your sessions—especially when you’re training hard. Severe pronation, foot instability, a leg- length discrepancy and muscle asymmetries can also contribute to Achilles pain.

THE FIX

Rest, icing, and strapping can relieve symptoms in the early/acute stages. Reducing training intensity and volume may be required, possibly even complete rest for a few weeks depending on pain and the severity of the injury. The earlier you get treatment the shorter your time off running in the ‘long run’. Soft tissue massage can be used to release tight structures throughout the lower limb and back. Physical therapy treatment will mobilise tight structures, possibly use acupuncture and prescribe rehab exercises to strengthen your calves, hamstrings, glutes and core. Stretching is also a key component to rehab. Eccentric heel drop exercises (lengthening under load), taught by your physical therapist, will be an essential part of your recovery. Advice about your shoes, orthotics and running technique can help. Importantly, keep an eye on your training. Don’t do too much, or go too hard, too quickly.

THE PREVENTION

When people experience Achilles tendinopathy, it often starts as a simple feeling of stiffness in the tendon. If you take steps to increase flexibility, strengthen the ankle and calf muscles and decrease stress on the tendon at the first sign of stiffness, it’s possible to prevent the problem from escalating.

One of the easiest ways to prevent Achilles tendinopathy is to keep the tendon strong and flexible. Regular strengthening of the calf, especially eccentric exercises will be beneficial, along with a regular stretching programme.

It is important to strengthen the entire limb from the pelvis, core, hip, gluteus muscles and hamstrings as these will all ensure the entire kinematic chain is working efficiently and minimising overload of the Achilles tendon. Then address any underlying risk factors (like shoes, orthotics) and finally a key prevention strategy is monitoring your training capacity. Slow and steady wins the race!

 

ACHILLES TENDINOPATHY REHABILITATION

 

YOUR REHABILITATION PROGRAMME

This programme has specific exercises for Achilles Tendinopathy. Remember the key is to strengthen the calf muscle and tendon eccentrically, whilst maintaining good flexibility; and don’t forget the rest of your leg! It is important to ensure the exercises are performed with good technique and good postural control. Make sure to repeat the same number of exercises on both legs. Make sure you are always pain-free and take care not to progress too quickly. We have given suggested sets and repetitions, and the exercise routine should be performed twice a day. Remember everyone is different so your therapist may give guidance that is more specific to you.

WARM UP AND COOL DOWN

If muscles are tight, weak or injured, it is particularly important to warm up (unless advised otherwise by your practitioner) with a brisk walk or a gentle jog at a pain-free pace for 5 minutes before you start your exercises. This increases your circulation and helps prepare the muscles for the activity to come. When you have finished your exercises, end the session with a 5-minute gentle walk or slow jog to allow your heart rate to slow down gradually.

1. ECCENTRIC CALF STRENGTHENING EXERCISE

Stand with your toes on the edge of a step or a box. Hold onto something stable for support if required. We will assume the leg you are trying to strengthen is your left leg (the injured side). Lift your left leg off the step and go onto your toes on your right leg. Now place your left foot beside the right and place all your weight on your left leg. Drop your heels downwards below the level of the step. Use your right leg (non-injured leg) to lift yourself back to the start position. Make sure you keep your leg straight during the exercise. This exercise can help strengthen the calf muscle and may be useful for treating Achilles tendinopathy. Repeat 8 times | Perform both sides

2. WALKING LUNGE WITH MEDICINE BALL TWIST

Holding a medicine ball, take a step forwards, and bend your front knee past the vertical. Your back knee drops towards the floor. Always keep good alignment: your knee should stay over the 2nd toe of your foot, and never let your knee drop inwards. When you get into the lunge position, rotate your torso towards your knee. Continue into the next lunge and repeat the twist.  Repeat 12 times | Perform both sides

3. PLANK REVERSE

Lie face up, and rest on your forearms forming a bridge between your feet and your forearms (by lifting your pelvis). This is a good core and back strengthening exercise. Repeat 2 times | Hold for 60 seconds

4. MOUNTAIN JUMPER/SQUAT THRUST

Start in a press-up position, and jump both legs in towards your chest, and then jump both legs out so they are straight. This exercise is great for strength-endurance and works the whole body. Repeat 12 times

5. SOLEUS STRETCH

Stand facing a wall, place one leg in front of you and your hands flat against the wall. Keep both heels on the ground, and your front knee bent. Push your front knee forward towards the wall to feel a stretch in the lower back part of the leg (bottom of the calf muscle, known as the soleus). Repeat 3 times | Hold for 30 seconds | Perform both sides

6. FULL SQUAT SINGLE LEG CUP REACH

Place 5 cups in front of you, and stand in the middle of them. Squat down (on one leg), and reach for one cup then come up, then repeat with the second cup, etc. Be careful to maintain control of the leg, and do not perform the exercise too quickly. Always keep your foot flat on the ground, do not let your heel raise from the floor.Repeat 8 times | Perform both sides

Hamstrings Injury in Runners

Runners are often guilty of showing their hamstrings no love, until they demand it. Hamstring issues usually arise because the muscles are weak. Long and weak or short and tight hamstrings all pose injury risks, as do muscle imbalances with over-powering quadriceps on the front of your thigh.

The hamstring consists of 3 muscles, that run down the back of your thigh from your buttock to just below your knee. They work over two joints – both flexing (bending) the knee and extending (straightening) the hip joint. The hamstrings work throughout each stride but are especially active when you are bending your knee and extending your hip at the same time, for example when driving yourself up hills, and powering into the finish. Approximately 7% of running injuries are hamstring-related. Pushing through hamstring pain can morph into a debilitating tear. Running-related hamstring injuries can be one of two things: a more commonly known hamstring strain (pulled/torn muscle) or an overuse injury called hamstring tendinopathy.

Hamstring Strain

An acute injury that usually occurs during dynamic running activities: sprinting, jumping, fast stop/starts.
The strain is graded:

Grade 1 – minor tear of a few muscle fibres

Grade 2- tearing of a larger number of fibres but muscle still intact

Grade 3 – complete rupture of the muscle

Symptoms:

  •  Sudden onset of pain whilst running
  •  Sharp, stabbing, possibly even a snap or pop sound
  •  Bruising on back of the thigh Swelling
  •  Can have associated back and buttock pain
  •  In Grade 2 or 3 injuries you may have difficulty walking

Management:

Acute phase:

  •  R.I.C.E – rest, ice, compression, elevation and refer yourself to a physical therapist after 48-72 hours
  •  Physical therapy to promote tissue healing and ensure minimal scar tissue formation
  •  Massage and manual therapy to release tight surrounding structures and address any underlying back or hip issues
  • Exercise therapy – slow and progressive over stages depending on the severity of the initial tear

Rehabilitation:

  •  Strengthen pelvis and core including the gluteus (buttock) muscles as they work together with the hamstrings.
  •  Manage any muscle imbalances in weakness or flexibility through exercise correction
  •  Neural mobilisation stretches
  •  Progression to full leg strengthening exercises, squats, deadlifts and finally eccentric strengthening of the hamstring

Training:

  •  Complete rest may be advised depending on severity of injury. Otherwise reduce intensity and training volume
  •  Avoid speed and hill work
  •  Find a comfortable pace and distance that elicits no pain and stick to that 3 x week with a rest day in between
  •  Train on softer surfaces like grass and dirt roads
  •  Cross train with cycling, water running, swimming, elliptical trainer
  •  Address underlying contributing factors like biomechanics (do you need orthotics for your arches?) or a leg length discrepancy.

Hamstring Tendinopathy

An overuse/overloading of the muscle tendon attachment at the origin of the hamstring on the ischial tuberosity deep in your buttocks. History of increased load, more hill running, increased speed work, unaccustomed deep lunges, yoga and deadlifts. The tendon has poor blood flow which makes healing and recovery slow.

Symptoms:

  •  Buttock pain
  •  Point-specific pain on, or just below, the ischial tuberosity (sitting bone)
  •  Chronic stiffness
  •  Aggravated by periods of sitting and driving, deep lunges, hamstring stretches and running at high speeds and uphill
  •  Stiffness or soreness first thing in the morning followed by a ‘warming up period’ where the pain disappears
  •  Following exercise pain may be delayed by 24-48 hours

Management:

Early stages:

  •  Icing regularly through the day
  •  Stop stretching your hamstring as this compresses/squashes the tendon
  •  Sit as little as possible, use a cushion under your buttock to relieve pressure on the tendon
  • Physical therapy to mobilise tight structures and promote tissue healing using massage, acupuncture and other modalities
  • Isometric exercises 2-3 x week especially if still painful

Rehabilitation:

  •  Load modification. Manage muscle imbalances in weakness and flexibility through exercises.
  •  Strengthen the core, pelvis and gluteus (buttock) muscles
  • Neural mobilisation stretches
  • Eccentric strengthening in latter stages of rehabilitation.

Training:

  •  Complete rest may be advised depending on severity of injury. Otherwise reduce intensity and training volume
  •  Avoid speed and hill work
  •  Find a comfortable pace and distance that elicits no pain and stick to that 3 x week with a rest day in between
  •  Train on softer surfaces like grass and dirt roads
  •  Cross train with cycling, water running, swimming, elliptical trainer
  •  Address underlying contributing factors like biomechanics (do you need orthotics for your arches?) or a leg length discrepancy.

PREVENTION

Healthy hamstrings are vital for running performance. Hamstring injuries can be stubborn and take anywhere from 6 weeks to 9 months to fully recover .Prevent the injury by:

  1. Strengthening your hamstrings, back, gluteus muscles and core they work together stabilising your pelvis and pushing power through your legs when you run
  2. Good flexibility and neural mobility
  3. Regular massages to cath the niggles at early stage.
  4. Compression tights during or after running to aid blood flow and recovery
  5. Treat underlying back problems through physical therapy will help you avoid hamstring injury
  6. Eccentric strengthening is proven effective in injury recovery
    and prevention. These are advanced exercises That may need physiotherapist help for few weeks
  7. . Warm up before a run
  8. . Graduate training load and intensity increases

HAMSTRING STRETCHING

The data tells us that one of the best ways to reduce the risk of hamstring injury is to maintain flexibility in the muscles around the lower back, gluteals and upper leg (hamstrings and quadriceps). These exercises are designed to help you achieve this goal.

  • SUPINE LUMBAR TWIST STRETCH

Lying flat on your back, cross one leg over the other by twisting your hips and spine. Keep your opposite arm outstretched. You can hold on to your knee to make the stretch stronger if you feel comfortable. Repeat 3 times Hold for 20 seconds

  • DOUBLE LEG BACK STRETCH

Lie flat on your back, and bend your knees towards your chest. Hold this position and feel a gentle stretch in your back. If you get any groin pain while doing this exercise, stop and inform your therapist. Relax, and repeat as necessary. Repeat 3 times Hold for 20 seconds

  • LUMBAR AND THORACIC SIDE FLEXION SITTING

Sitting with good upright posture, run your arm down the side of the chair leg by side-bending your spine. Repeat to the other side. This is a good mobility exercise for the upper and lower back while sat down, if you feel your back is starting to get stiff.  Repeat 3 times Hold for 20 seconds Perform both sides

  • GLUTE STRETCH SUPINE 

Lie on your back, and bend your knee to 90 degrees (i.e. pointing straight up). Place your ankle across your opposite knee and pull your knee towards your chest to feel a stretch in your bottom. You can also use a towel to assist you. Repeat 3 times Perform both sides

  • EXTERNAL ROTATION TABLE GLUTE STRETCH

This is an alternate to lying on the floor. Place your foot on a table, with your leg turned inwards. Lean forwards slightly to feel a stretch in your buttock. Hold the stretch. Repeat 3 times Hold for 20 seconds Perform both sides

  • FOAM ROLLER HAMSTRING STRETCH

Sit down placing a foam roller under your Hamstrings (back of the legs). Your feet should be off the ground, and you can balance using your arms. Roll the roller up and down your Hamstrings to create a stretch. You can cross your legs to emphasise the stretch on one side.

  • HAMSTRING CONDITIONING

After ensuring that the muscles and tissues around the low back, gluteals and upper leg are flexible, the most important aspect of preventing hamstring injury is to build hamstring strength and ensure there is no neural tension in the nerves running from your spine, down your leg. These exercises will help achieve this.

  • SCIATIC NERVE GLIDE FLOSS 

Sit with good posture, and straighten your affected leg and bend your ankle towards you, as you extend your neck. Then bring your neck towards your chest as you relax the ankle. This will glide the sciatic nerve.

  • SHOULDER BRIDGE

Start position is shoulder bridge level one, with a neutral pelvis and the spine rolled away from the mat. Inhale to prepare, exhale to lengthen and straighten your leg. Avoid tilting the pelvis. Inhale and fold your leg back to the mat, ready to repeat on the opposite leg. Exhale, as you roll the spine down vertebra by vertebra to finish. Repeat 5 times Perform both sides

  • LEG SWING

Hold on to a table, and swing your leg in front of you and then behind you in a controlled way. It’s a great way to dynamically warm up your leg and hip, but also used to gain more mobility to your hip joint. As you swing your leg forward in front of you, pull your foot upwards and slouch your back and tuck chin to chest. (slump) Then as you swing leg back behind you straighten your back up. This is a dynamic nerve stretch. Repeat 5 times  Perform both sides

  • FULL SQUAT SINGLE LEG CUP REACH

Place 5 cups in front of you, and stand in the middle of them. Squat down (on one leg), and reach for one cup then come up, then repeat with the second cup, etc. Be careful to maintain control to the leg, and do not perform the exercise too quickly. Always keep your foot flat on the ground, do not let your heel raise from the floor. Repeat 5 times   Perform both sides

  • ROMANIAN DEAD LIFT

Keep your knees just slightly bent, shoulder width apart, and place a Towel rod or barbell on the blocks. Keep your back straight/flat as you bend your knees more towards the bar. Hold the bar shoulder width apart or slightly narrower, with one palm facing up, one palm down (or both palms facing down). Lift the bar up by straightening the legs and extending the back at the same time. Keep the bar close to your shins during the movement. If you lack flexibility you may need to bend your knees a little. Squeeze he shoulder blades at the top of the movement. Return to the start position. Repeat 5 times  Perform both sides

  • NORDIC HAMSTRING CURL

This exercise is best done with a training partner who anchors your feet. But it can be done at home if you can find something heavy to secure your feet under. Kneel on the ground—it’s best if it’s padded, anchor your feet and lower your body to the ground as slowly as possible keeping your back straight ie. rigid. When your hamstrings can no longer support your weight, let yourself fall to the ground, and catch yourself in a push-up position. Your goal is to control the descent for as long as possible. Start with very low repetitions ie. 2-4 repetitions a day and only build on this if and when you’re not too sore.