Pain is the major source of confusion and patience is the major source of resolution for the achilles heel.
Pain and Function
Recent literature demonstrates the relationship between pain and function or tissue health is not straightforward. The problem is that intuitively we feel like it is. This is an evolutionary defense mechanism. If you jump from a tree and break your leg, the intense pain is usually linked to the tissue damage. This stops you moving and causing further damage and ensures you are more cautious about jumping from a tree in the future. In this scenario – pain works perfectly!
The relationship becomes less clear when the pain is, for example, less than 5 out of 10 (10 being maximum pain). This is known as chronic pain, the major source of pain experienced by the runner (most running injuries are chronic in nature)
Running with Pain
For 5-years, I had chronic achilles pain usually at ≤5/10 and for 2.5 of those years, I was able to run at a level sufficient to set personal bests over distances of 10km to half-marathon. This type of pain is present every morning, after pro-longed periods of inactivity and after most intense running efforts.
It is managed by careful load management (≤4-days per week running, heavy isometric lifts, cross-training, variability in training). The key feature of this ‘functional pain’ is that with sufficient warm-up it is not felt in sessions or races.
You learn to gain control over or to live with your pain. Pain is ever-present but you manage it rather than the other way around. The skills I learned in relation to gaining control over my pain have helped me to train and perform in the past and will do in the future.
The only downside is that I never had to address my tendon fully until my pain reached 7/10. An overly ambitious attempt to train for a sub 33-minute 10km while building marathon distance eventually tipped the balance from functional pain to ‘dysfunctional pain’. In the case of dysfunctional pain, you begin to feel it even when fully warmed up; this type of pain is closer in nature to the leg break pain i.e. you have to stop.
Addressing Achilles Pain
In March, I reached the stage of dysfunctional pain. On the plus side, I set about tackling one of the few injuries remaining that I had yet to get the better of. In an attempt to be able to race (hope more than expectation), I started with an injection around the sheath of the tendon (less risk than into the tendon). A week to 10-days later there was no change and so I set about some research.
The tendon pain I had was on the inside of the heel bone, known as insertional tendinopathy. The most promising treatment for initial symptom management was shockwave therapy. The overwhelming evidence for the long-term resolution of almost all tendon pain is progressive loading. I had 6-sessions of shockwave therapy and began my loading programme concurrently. There are several ideas about how shockwave therapy might work but there are a couple of things we can be reasonably sure it does do a) manipulate the sensation of pain (replacing it with another sensation) b) disturb tissue homeostasis (cause a physiological reaction).
In simple terms what might these two things do? I would say help to reset things. For a short-time after treatment you cannot feel your pain and therefore, walk a little more normally, which might be seen as the first step to restoring ‘normal’ movement (removing rigid compensatory movements). If you’ve stopped running but disturbed the achilles with a different kind of insult (shockwave therapy) it may kick start healing. I used it mainly to help in conjunction with the beginning of my exercise programme (the key thing).
What exercises will I do? And, am I doing them correctly?
Calf raises or heel drops. I bought a weighted vest so that each week I could progressively add two sandbags per week. I carried out 3 sets of 12 repetitions twice a day for 12-weeks (but have continued on, in week 15 now). I did it on a flat surface not to stress the heel over the edge of a step.
The real game changer was doing the exercises to a metronome. In other words having a beep every 4-seconds. You think you are doing exercises slowly and controlled (especially when you have a professional background like mine) but you’re not until you use a metronome. This standardises the time the muscle and tendon is under tension. It also helps to re-educate a more coherent movement pattern after a lot of time spent limping. I was astounded at how difficult this was with even my own body weight at the beginning.
I built up to about 14kg going up and down on one leg to the beep. After this I found it difficult to do the up part (concentric), so I lifted with both legs and lowered (eccentric) on the single leg (up to ~35kg at present).
[Side note: we took muscle thickness measures (ultrasound) and assessed muscle tone (tensiomyography) before and after the intervention. I intend to publish this data along with daily pain scores and return to running info. Subsequently, I will write more about it on this blog]
How do I get from this to running?
Pain is going to confuse your return to running. Expect flare-ups. Expect false dawns. There will be days you think you are back at square one and days you think, you are cured. Neither is true. Keep the faith that you are on a continuum of improvement.
After the initial disappointment (read about psychology of athletic injury here), I took a month off to cross-train and focus on rehabilitation (read about both here). I started back with 10 – 20 minute shuffles. About 6-weeks in, I ran 2.5 miles. I did that 3-times per week. I added a mile per week until I reached three 8-mile runs per week (barefoot on grass, maximum tendon stress gradually developed). Delaying gratification (i.e. adding 1-mile per week), is key to injury and performance (read about it here).
I then replaced one of the 8 –miles runs with a session at the track. The session includes:
Warm-up: a 2-mile barefoot warm up on the infield, step over hurdle drills, 3 x 10 ankle hops, 5 x 5 bounds, 5 x 50m max sprint.
Session: 2 x400m with 1-minute rest. (adding two 400’s each week, currently at 8).
I changed the second 8-mile run to take place over rolling hills. Nice and easy, a chance to get the legs used to up and down hill loading.
The third 8-mile run saw me add a mile per week (currently at 12) to build a long run.
During this time I decided to train for a triathlon at the end of July, so there has been plenty of swimming, cycling and S&C to supplement my week. This has allowed me to take my time with my running build up. I will race a 5-km in two weeks’ time.
How is the pain now?
Ever present. It peaks at about a 4 / 10 after track days and is often at a 1-2/ 10 after swimming or cycling days. It has been trained from dysfunctional pain to functional pain; from out of control, to in control. Currently, it is much better than it has been over the last 2.5 years, well worth the time and patience.
I will discuss this injury and many others at an event hosted by Donore Harriers Athletics Club in Dublin on July 21st. Tickets are available here.