Achilles tendon flareup

[d k]

With the stay at home policy over the past couple of months, we’ve been hiking every day, varying from 5 up to 11 miles, which is more mileage than I was doing for just routine fitness,  and definitely more constant than I’ve been doing for years, having alternated with the gym up to the pandemic.  Also,  I’d been using Altra zero drop shoes for these hikes.  A few weeks ago I started noticing occasional twinges in the backs of my heels, just above and to the sides of the bump in back.  This past Monday we did a longer hike, and it was much more pronounced the next day.  Big bummer, as I was really feeling like I was getting in the best hiking shape I’d been in years.

On googling, it sounds like this may be an Achilles tendonitis/tendonosis thing. It seems to be related to increased workout intensity and increased age (who, me?).  I’ve discontinued hiking for now, and have been using a night splint on the worse of the 2 sides, as well as icing and stretching.  Oddly enough, my best college friend back in NJ texted today that she now feels something very similar.  I wonder how many people are stepping up their walking these days, with resulting similar issues?

I searched this site and came up with some helpful info.  Anything else I should consider?  I’ll probably contact someone at Kaiser next week.

https://backpackinglight.com/forums/topic/achilles-tendonitis-tendinosis/

[Mike B]

You mentioned that you have been doing these hikes in zero drop shoes as if this was something different then your usual hiking shoe. It does take time for your body to adapt to a flatter shoe if you have typically used one with a drop as you are stretching things that may have not been stretched in a long time. Tendons, ligaments and other similar tissues take longer to adapt then the muscles. You may need to just back off a little. What was the shoe that you came from?

[BC Bob]

Read through all the links I posted on Dec 21 at the other thread.  Achilles tendinopathy is not generally regarded as a tendonitis.  IMO, the icing and splinting won’t do anything for it.  And the stretching is a really bad idea.  Read the Jill Cook material at my Dec 21 post.  She is regarded as one of the top Achilles tendinopathy researchers on the planet.

I would stop using the Altras, at least until you resolve it.  As Mike mentioned, they are a zero drop shoe. IMO they are a significant part of the problem.  I would suggest a shoe with a decent (eg 8-10mm) heel drop.

 

[Matt]

Switching to Altras did the exact same thing to me!  It was temporary and resolved itself with just a little bit of rest followed by a moderated return to exercise.

After getting used to zero drop, my feet have never been happier. So, worth the effort for me.

[d k]

I’ve worn the Altras for a couple years as my casual around town shoes, and for day hikes (but not hiking every single day until recently).  I mentioned them because others seem to have associated them with similar problems.

Previously I’d used Montrail AT Plus for hiking and backpacking.  Those seemed to be custom made for my feet, but they’ve long since been discontinued and I’ve finally used up my stock of them.  I haven’t found anything yet that works as well as those.

 

[Jacob]

I’ve discontinued hiking for now, and have been using a night splint on the worse of the 2 sides, as well as icing and stretching

While the above may 100% be necessary, I think the potential pitfall to that kind of treatment that people often over look is allowing whatever you need to avoid injury to get weaker. Once people feel better they end up just hurting themselves again. If you think you know what is injured I would suggest trying to find ways of strengthening it that will avoid further injury. Maybe walking barefoot on soft flat grass or sand? A bunch of Yoga routines give the ankles and calves good exercise. Just standing around barefoot might help. Biking is mentioned in that thread you linked; I think with clip on pedals that is a good idea too.

If you reach out to experts be sure to ask what the long term outcome of their advice is; some recommend orthotics, etc knowing that the more you use them the more you will need them. You regularly getting new, stronger, orthotics in response to worsening pain every so often for the rest of your life is considered proper treatment (and is actually the better option for most people living sedentary lifestyles; think retiree who just wants 18 holes of golf pain free).  Orthotics, etc can be used to build strength/ actually rehabilitate too, which is what I think you want. Rehabilitation is technically more challenging, more painful, and less practical for most. Be sure to ask what you are signing up for.

Good luck! I hope you experience a quick recovery!

 

 

 

[d k]

Thanks, all.  I wrote to my sports med doc, and she’s out for another week, so we’ll see what she has to say.

In the meantime I won’t go overboard on any one thing, maybe do some yoga and gentle walking.

[Paul Wagner]

I think Bob has given you good advice.    I snapped my Achilles about twenty years ago, and one of the things I remember most about that unpleasant experience is the need to rest it rather than stretch it…

Zero drop shoes stretch it out.  Instead, do your hiking in four inch heels.  That should do it.

[d k]

Ha!  Finally, a chance to wear my girl shoes during this time of no social engagements or gigs!

[PaulW]

I suffered for a long time with Achilles and plantar issues, then a PT turned me on to eccentric heel drops. They are the most effective exercise I’ve come across for these issues. I do them daily along with a series of foot exercises and my feet and lower legs are healthier and more pain free than they were at half my age, which I won’t mention. :)
Also, I switch to different shoes for each hike to avoid repetitive stress issues.
BTW, that same PT was a fan of ice, but not stretching while injured, as stretching can exacerbate the condition. Good luck!

[MJ H]

+1 to switching shoes. Obviously, that’s not going to be easy on a multi-day hike, but for my daily walks (mostly on sidewalks because the local park is now impossible to keep far enough away from people that I don’t need a mask) I switch between jogging shoes, walking shoes, hiking boots (Keen), and I have recently added in a zero drop shoe just to try it out.

[Herman]

Agreed with switching shoes. I tried Altras last summer and developed tendonitis. Go with a drop of 7 mm or greater.

[BC Bob]

Here’s another journal article by Jill Cook et al. I’d highly recommend it for anyone with Achilles tendinopathy issues. You can download the full pdf. It discusses the pathology, mid vs insertional Achilles tendinopathy, and effective exercise therapy. These are among the top tendinopathy researchers anywhere.

Achilles tendinopathy: understanding the key concepts to improve clinical management
https://www.researchgate.net/publication/282001490

[d k]

That’s very helpful.  I’m guessing I have the insertional form, based on where my pain is located.  So more plantar flexion seems to be advised, rather than dorsiflexion, if I’m reading this correctly.  Paul is right about the 4-inch heels! 😄

I’ll be interested to hear what my doctor has to say.

[Diane “Piper” Soini]

5-11 miles per day? That’s a lot of miles.

I’ve suffered from painful achilles tendonosis ever since hiking the PCT back in ’09. I did not wear zero drop shoes on the PCT. I started wearing them after because they (Altras) were a lot wider than the shoes I wore on the PCT so I could finally wear something closer to my real size.

Stretching the calves has helped a little, so long as I don’t do the kind where you push against the wall to stretch. It never made it go away, though.

The night splint helped, and so did resting, but as soon as I started walking around again the pain would come back.

I’ve been walking in my neighborhood and going on backpack trips a lot this spring. I think what sort of helps is to just not walk as fast. It’s not as good exercise to walk at a leisurely pace, but I really think trying to walk fast makes me crash down too hard on the base of the achilles. So I take it easy.

What does seem to help is a daily dose of three ibuprofen. Just one dose of three. One does of three is enough to ease the pain for two days for me, so I kind of do it intermittently, a few days in a row and then I sort of forget about it until there’s a flare-up. That really seems to help me the most.

[BC Bob]

I think what sort of helps is to just not walk as fast.

Walking slower should reduce the load.

“….In vivo measurements of the Achilles tendon performed by Komi et al indicated that the Achilles tendon was loaded up to 12 times body weight during running, with the actual load being related to running speed. Their work also indicated that when walking, the force was approximately 3.5 times body weight, whereas during cycling the load was close to body weight….”

A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation
Karin Silbernagel et al.
https://www.jospt.org/doi/full/10.2519/jospt.2015.5885

[d k]

I’m impressed by your knowledge, Bob; do you work in the field of sports med/rehab or are you just an educated sufferer?

[BC Bob]

Just an educated sufferer. I’ve damaged both of them (mid-portion tendonopathies).

[Diane “Piper” Soini]

Running kind of relies on the spring effect of your achilles so it’s kind of not the same thing as just walking slower. By walking fast I will overstride and land pretty hard on the bottom of my heel. I will also push off harder when going up hills. If I relax and just go slower I seem to put a little bit less stress on things.

[d k]

I chatted with my nephew this morning; he’s an ultra runner and has had issues with his Achilles in the insertional area.  He was treated with shock wave therapy which for him seemed to knock it out pretty quickly.  He also said he found that he has Haglund’s deformity (pretty common), which is thought to predispose one to Achilles insertional issues.  He’s found that making s vertical slice in the back of the heel of his running shoes seems to help him as well with pain in that area.  And rolling his calves on a foam roller.

I don’t seem to have an issue with shoes rubbing back there (my sister, his mom, has for a long time as well).  Though that IS where I blister if my shoes don’t fit well, but I think that’s different.

My doctor responded to my email last night by pointing me to a YouTube video. https://youtu.be/qqAlt1k_-gs Somewhat disappointing, but I asked her some follow up questions. Meanwhile I think I’ll try the protocol in Bob’s most recent link.  And probably some gentle walking on level surfaces today or tomorrow.  It’s been pretty mild around the house since I started mostly just doing mild flexion/extension without loading, gentle massage, and night splint on the worse side (no more icing or extreme stretches).

Again,  I’m really grateful for everyone’s suggestions!  Thanks so much.

[d k]

Did a 2-mile stroll around the neighborhood this morning, so far so good…

[BC Bob]

I tried the rehab program in the Karin Silbernagel article a few years ago. Doing the exercises daily seemed to be too much for me but it’s hard to know.

I’ve tried various other exercise rehabs. What exercises and how often is optimal? I still haven’t figured it out. Hopefully you can figure out what works best for your situation.

More info! A decent overview video.
Jill Cook – Current concepts in tendinopathy rehabilitation
https://www.youtube.com/watch?v=-kKzoi8Zrik

[d k]

Thanks, that was enlightening.  If only she’d do one on specific exercises, and how to tailor to individual cases!  Oh well.

I found a video on the “Henderson protocol” that’s a very simple set of exercises, that mentions how to assess increasing weights used in terms of pain levels.

My walk yesterday did seem to set the pain level back about a day.  But it’s not that high a level, so perhaps I’ll try a few of the exercises.

[d k]

Oops,  Alfredson.

[BC Bob]

It’s hard to know what the appropriate rehab program should be. I’ve read Jill Cook saying there’s no “cookie cutter” approach and it depends on the individual, the specific injury and what stage it’s at, and what activity the person wants to return to.

You seem to be at an early stage of injury so I don’t know what’s appropriate. This quote below suggests that just backing off in the very early days might return the tendon to normal. I wish I’d known this. When I first felt a problem, if I just backed off what was aggravating it, perhaps it would have settled down and returned to normal.

“….For example an acute reactive tendon has the potential to revert to normal if the overload is adequately reduced or if there is ample time between loading sessions (J. Cook & Purdam, 2009). If load is not properly managed in this phase and further loading ensues, there is a high risk of pushing the pathology further down the scale into a state of dysrepair….”

Treatment of Achilles tendinopathy with combined loading programs
https://www.raynersmale.com/blog/2015/10/22/treatment-of-achilles-tendinopathy-with-combined-loading-programs

If you can find a professional (physiotherapist or sports doc) to guide you through this it would probably be wise. The difficulty is finding someone who has expertise in Achilles tendon injuries. I tried several docs and several physiotherapists and didn’t find anyone who was very helpful.

[Author]

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