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Painful, Nagging Achilles Tendonitis: FIX IT for Good!

Updated: Mar 15, 2023

You've been doing a million +1 calf raises.

The straight knee and the knee bent variety.

And either your Achilles tendonitis isn't going away

Or

you keep getting Achilles tendonitis no matter how many calf raises you do…

What's a runner to do?

You're not crazy.

You're doing everything "they" tell you to.

But it's not enough.

And it's not your fault.


Important Re-Cap YOU NEED to understand:

"Several lines of evidence suggest that neural changes to the triceps surae (calf muscles) might underpin some of these chronic motor deficits

NEURAL CHANGES! This means:

  • You getting Achilles Tendonitis is NOT about muscle hypertrophy

  • It's NOT ABOUT STRENGTH!

  • you can do 10000x calf raises a day, but it's not going to matter IF your REAL underlying achilles issue has to do with neural changes.

Think about it:

  • Your calf is a lightbulb.

  • And the lamp is lighting up.

  • Doesn't matter what the wattage is on a light bulb. Doesn't matter how MANY of a lightbulbs you try!

If that lamp isn't plugged in, it's not going to work.

The mystery electrical source? YOUR BRAIN.

"In particular, it has been shown that individuals with AT have:

(a) lower contribution of gastrocnemius lateralis (GL) to produce plantar flexor force and

(b) greater levels of intra-cortical inhibition associated with lower plantar flexor endurance during single leg heel raise test when compared to controls."

WHAT DOES THIS MEAN?

Intra-cortical inhibition:

  • There is a part of your brain that helps control your calf muscles

  • Facilitated means volume turned up, activated

  • Inhibited means the volume is turned down, that part of your brain is not as activated. In fact, it's sluggish and slow.

Like a bad internet connection.

Think about it:

  • you have a really good connection which makes loading pages and streaming videos a breeze!

  • Compared to really bad wifi…and we might as well go back to the stone age of dial up.

What's going on: you've got a bad wifi connection between your calf muscles and your brain.

WHAT THIS MEANS FOR YOU: HOW TO FIX YOUR ACHILLES TENDONITIS

"Collectively, these findings suggest that changes in how the central nervous system control muscles coordination within the triceps surae (force distribution and activation) might impact load distribution to the tendon in individuals with AT. This is of particular importance because altered triceps surae coordination (due to lower individual muscle contribution to muscle force) could create uneven loading of the Achilles tendon and contribute to tendinopathy."

WHY YOU *MIGHT* BE GETTING ACHILLES TENDONITIS:

Because of the neural changes occurring both on the brain and the muscle side of things, load/work (aka the impact of running) is NOT being correctly distributed to your Achiles tendon.


WHY?

Because your LATERAL GASTROC (outside calf muscle) is NOT showing up to the party!

And with this muscle-teammate being down and out for the count, you can do all the calf raises you want, but they're not going to make a difference because the message isn't getting through.


(Not the mention, the lateral gastroc isn't recruiting the motor units it should. Read more about that HERE!)

THE BORING WAY TO FIX IT:

What You've been told BEFORE:

"Many studies have revealed that exercise therapy is beneficial for tendinopathy. For example, isometric exercise, eccentric exercise, and resistance training reduce pain and improve tendon function. Therefore, exploring exercise for tendinopathy is meaningful, as it can help patients relieve pain and improve their life quality. However, there is no clear clinical evidence to support the superiority of any specific exercise intervention, and general aspect bibliometric analysis of this global research topic associated with exercise and tendinopathy is lacking."

Translation:

  • We scientifically KNOW exercise helps with Achilles tendon issues…but we don't know for sure which exercises

  • We can follow a basic progression that we use in PT for exercises with minimal pain, despite etc:

    • 1. isometrics 2. concentrics 3. eccentrics 4. resistance training

  • But what we REALLY need, is a way to re-establish communication between that lateral gastroc, brain, and Achilles tendon

A MORE PROMISING WAY TO FIX IT:

"However, a systematic review by Murphy et al showed that heavy eccentric calf training (HECT) may be better than traditional physiotherapy, while HECT may be inferior to other exercise treatments for Achilles tendinopathy. Therefore, it is necessary to formulate individualized exercise therapy based on the type of pathological changes, functional status, and preferences of patients with tendinopathy."

TRANSLATION:

  • You've seen these. The deficit calf raises.

  • The ones where you do a calf raise on the edge of step and let your heels sink below the steps and "raise" your way up so you're standing on your tip toes again

  • These do work...BUT ONLY if your achilles tendonitis truly is a result of a strength deficits: weak calf/soleus

  • Because remember from above-if it’s a neural issues (mind-muscle connection), all the hypertrophy strength exercises in the world aren't going to help.

OPTION #1: STRONGER FEET

Beginning exercises:

  • Stand on the edge of step so you're balance on the balls of your feet. HOLD ON to a rialing, wall, etc for safety!

  • One comfortable here, walk side to side on the edge of the stair while keeping your heels parallel to the edge of the step (don't allow them to sink down or rise up)

  • Once comfortable with that exercise, balance on one leg in the same edge of step position. Hold 10secs min. Switch and repeat on the other side

  • PLEASE NOTE: these are not ALL the exercises! The rest and most effective exercises and personalized, unique tests to assess your progress are in the Stronger Feet Workshop

Remember all those other blog posts and videos talking about how important strong feet are?

Achilles Tendonitis is NO exception!


I strongly recommend checking out my Stronger Feet Workshop and STARTING HERE!


These exercises are THE place to start because they start out with activating your feet and then progress to gently isometrics-gentle foot strengthening.

But the REAL MAGIC?

Is that ALL of these Stronger Feet Exercises directly work on that neural pathway of getting your calf's foundation, your foot, talking with your brain.


THEN the exercises progress from your foot and brain talking to your calf and brain communicating, just like what we've discussed that past 2 weeks.


If that lateral gastroc/calf communication line isn't open to your brain, all the strength exercises in the world aren't going to make a difference!

OPTION #2: TOE YOGA

"Increased Flexor Hallicus Longus EMG activity has been reported in the painful side of unilateral AT presentations during isometric submaximal plantarflexion contractions, compared to asymptomatic side and to controls side."

HOW TO:

  • Stand barefoot on a smooth comfortable surface

  • WITHOUT turning your foot outwards or innerwards, lift ONLY your big toe!

  • Switch (and again without moving the rest of your foot or leg, lift ALL your other toes BUT your big toe.

  • Work on one at a time until smooth. Then alternate between the 2 versions

  • This exercise may feel impossible or like you just can't do it. (at least I did haha). It's Ok! Keep trying! You're challenging, building, growing a new neural pathway with a muscle that helps support your foot and your calf.

OPTION #3: TOES-POINTED IN CALF RAISE

"The neural drive to each individual muscles of the triceps surae can be influenced independently by strategies such as modified feet position during plantar flexion"

"Therefore, utilising strategies to increase GL recruitment and contribution during exercise is important…Performing heel raises with the foot positioned with toes pointed inwards significantly increased GL motor unit discharge rate compared to toes neutral in healthy individuals"

HOW TO:

  • Get into a normal calf raise position

  • Turn your feet inward so your toes are pointed inward

  • Perform calf raises in this position

  • Too hard? Perform with both legs

  • Too easy? Perform on one leg only-Is it harder on your R vs your L?

  • STILL too easy? Try a deficit calf raise on the stairs but in this internally rotated position

OPTIMAL CIRCUIT:

(ones specific to this blog: x3)

2. Toe Yoga

2x10 each foot

3. Toes in Calf Raise

2x12 Both legs or single leg if tolerated



As always, never hesitate to reach out with questions! Even if it's to confirm that NOW is the time to go seek out formal physical therapy.

It's time to Dare to Train Differently to improve your running performance.


Because that's what makes YOU a better runner!

Dare to Train Differently,

Marie Whitt, PT, DPT //@dr.whitt.fit


 

References:


Lower motor unit discharge rates in gastrocnemius lateralis, but not in gastrocnemius medialis or soleus, in runners with Achilles tendinopathy: a pilot study

Bibliometric Study of Exercise and Tendinopathy Research from 2001 to 2020

Management of Achilles and patellar tendinopathy: what we know, what we can do.

Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis


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