A short & practical guide about how to deal with Achilles pain…especially geared for runners and triathletes. Not professional medical advice, simple personal opinion based on own experience, so take it with a pinch of salt.
So….what to do when you have Achilles pain?
#1 STOP! And REST, and FIX it. It sounds obvious…but athletes are pretty stubborn. And many athletes love the “no pain no gain” mantra, right? But seriously, NO, if you feel some discomfort in your Achilles, back off, PERIOD! Even if your big A race is coming in just 2 months…Yes, even if.
At this stage, it is nothing, just a simple inflammation…You can fix it in a couple of weeks. And nobody ever understand how serious it is until it is too late. (I would not be writing this post otherwise…#dumbME)
Something else you should do at that time is to figure out what triggered that pain. Is it a sudden increase in mileage? Not enough recovery in the past few days with heavy workouts, or high intensity, or change of shoes, or change of surface…?
[…] In response to the repeated trauma associated with running, specialized repair cells called fibroblasts move inside the tendon, where, in an attempt to heal the injured regions, they begin to synthesize collagen. In the early stages of tendon healing, the fibroblasts manufacture almost exclusively type 3 collagen, which is relatively weak and inflexible compared to the type 1 collagen found in healthy tendons. If everything goes right, as healing progresses, greater numbers of fibroblasts appear and collagen production shifts from type 3 to type 1. Unfortunately, many runners don’t give the tendon adequate time to remodel (which can take up to 6 months) and a series of small partial ruptures begin to occur, which can paradoxically act to lengthen the tendon—resulting in an increased range of upward motion at the ankle. At this point, pain is significant and the runner is usually forced to stop running altogether. […]
Since you are reading this post it means you did not back off and kept training through the pain. In my case, I started having pain in 2009 while training for the Ironman in Hawaii. During that year I was offered a few “elite” invitations that I did not accept as I was afraid I would/could be DQed from racing Kona in Age-Group consequently. But in 2010 I took the chances and got invited to many races, also took the IM Pro license… and kept training quite heavily (18-20 hours weekly: around 12k swim, 400k bike and 70k run). I was also coaching a few athletes and running with them was part of the deal, which I loved doing – except I was really suffering at times.
Again, despite the excitation/motivation, the right thing was to back off and fix it. Definitely. Many athletes I know or some I coach go through the same kind of process…It’s very hard to tell them to stop everything. But seriously, do it. Triathletes can still swim and bike! Take that change to become UBER cyclist.
I remember also trying to get deals from sponsors and running in NEWTON completely finished my damaged Achilles. Mind you I love these shoes, and they are GREAT! I want to say you need to have super strong CALVES (similar concept with VIBRAM, strengthen your calves before to go run with them…And start slowly, walking first, then 2-3km jog…and build gradually).
Anyway, end 2010 my Achilles is done. I have changed my stride to reduce the pain, now heel-striking as much as possible. Bad, bad, bad. Despite taking some 6-weeks period without any run, trying to fix it with physios… it is now in a degenerative state. And it is no longer an inflammation but a tendinopathy. Icing, anti-inflammatory, … does not work now. The tendon fibers are all messed up, they are not firing in sync.
2011 was basically swim and run for me. With a couple of weeks of running 30-40k, but just going from race to race without running in between. So every time you wake up, you hop, it takes 30min to warm up and you can walk normally…Same when you get off the plane (that was quite ridiculous at times when you compete at some World Champs at you hop on 1 leg the day before…).
2012 was same story, except I focused on 70.3. And even less running. End 2012 I called it a day and stop serious competition/training. And decided to fix that Achilles…
Some of the things I did in 2011, 2012, 2013, 2014, 2015, 2016 and 2017…with mixed successes are listed below. To help some runners in similar situations…(or to give some suggestions to some athletes I run with or coach – “yes, stop and fix it…” is the best advice!)
In 2013 I ran a few Ultras (100k, soft ground, slow speed…) and qualified for UTMB in Chamonix (What an awesome race that was!) In 2014, I did Ironman Zurich with a friend, and Ironman Malaysia again in 2015 but not much running. Always getting painful at some stage after 15km anyway. In 2016 I could not run at all off the bike in China 70.3 – electric discharge (it happened a couple of times in past few years…not a good feeling, and they can look for blood using Ultrasound – in my case it seems nothing was torn, yet very painful). Anyway at that time the Surgeon wanted to open…I’d still keep that option at the very very very very last resort despite successful stories (Bozzone, Brownlee, Beckham, among many others…)
That white part in the middle of your tendon…that’s no good…
Fast forward 6 months rest and PRP injection, eccentrics and more… I am back to running again, with a smile on my face! What a pleasure it is to run pain-free (at least for 30min…then I walk back home! For now!)
#1 STOP: Most important piece of advice. And also to stop, take the short-term pain (no racing/training) to get long-term benefits (i.e. pain-free running…”THE DREAM!”)
#2 REST: To me this is the most important one. Unless you ruptured or it is very severe…I believe it can be back to 80% normal if you give it time. In 2013I gave it 6 months without any running and I believe it helped tremendously. I did it again for a couple of months in the following years.
#3 ECCENTRICS: Clearly this one is VERY important. CRITICAL even. And most fo the studies I read said that for serious athletes, the classic [Alfredson protocol] 3×15 reps daily was NOT enough. Marathoners (lightweight…so imagine for heavyweight…) would go on doing 4×80 daily!
#4 STRETCHING / CORE: For some reasons loosen up my hips, glutes, quads and strengthening my hips helped significantly (I believe). FOAM ROLLER (Very painful at first and getting better and better with time). You need to be able to stand very
You need to be able to be very stable on a single leg stance, bending your knee down and up. STABILITY / STRENGTH
#4 PRP INJECTION: A simple injection. It may not work, but it cannot harm… I don’t want to jinx it since I did it in Feb. 2017 and I am running pain-free since I started jogging in April or May. I still feel some discomfort sometimes now that I try to increase the volume to 3 or 4 runs a week and more than 10k per run…but it feels different than before, and not really painful. Obviously I am nursing it and backing off as soon as I feel some level of discomfort. But all in one I would say it helped.
Despite not so strong evidences that it can help (especially for Achilles), the 3-4 months rest combined with the PRP injection, eccentrics and so on… did help.
For some reasons I did it in LA…Can give details/reasons later but not most important really.
My right Achilles was 6mm thick. My left Achilles was 9mm thick…ouch! Disorganized fibers, swollen, degenerative, not working together, not firing in sync…
Draw your blood, spin it to separate platelets and growth hormone that will boost healing. And re-inject it around your tendon, and inside as well (but very small dose as Achilles is weight-bearing and you dont want to rupture it with too much… so mostly around the tendon, many small injections…It takes less than 1h. Done.
#5 ACUPUNCTURE: Here the idea is that the tiny inflammation will induce a reaction. Not sure about the blood promoting healing in this area (no blood in Achilles tendon…slow healing…). Controversial as some specialists told me that inserting a needle inside a tendon is definitely not a good idea, since fibers are already messed-up, not a good idea to make it worse… But I did like the healing promoting part, also stimulating with electricity. I did probably 6-8 sessions and I was not doing any sport at that time, so I could not say whether it worked or not…but I’d say it helped. After the PRP injection I stopped for a while and so far I did not feel the need to go back to Acupuncture, for now.
#6 SHOCKWAVE (ESWT): I did 6 session in 2011, probably 6 in 2012 and another 5 or 6 in 2016. Expensive stuff (especially when you dont have any insurance…like 100 USD each session. And in my specific case I don’t think it made any progress. For sure it was very painful during each session which means that there is indeed something wrong in your Achilles…but yet, the micro-traumatism/ micro-inflammations would not improve the tendinopathy. I’ve read/heard about very successful treatments, but it just did not work with me this time.
#7 SURGERY: Wow, there are some horrible images and videos about Achilles surgeries…not for the faint-hearted. I won’t post any here tho. (Kudos to Surgeons / Doctors. Serious skills and focus during those interventions). Anyway I was seriously considering it for a few weeks [after 5 years of struggling with that injury…it gets really tempting…] but finally decided to give PRP injection a try first [Try all non-irreversible methods first… and only after maybe consider. Although if you can manage to run 2 or 3 times a week, 30-40k… I would be happy with that and give my best at races but would not want to go surgery anyway. As long as you can run sometimes, more or less. Fair enough.]
#8 SHOES: Broad topic. As a heavyweight runner (88kg) with Achilles injury I’d say savings 50 grams on racing flats won’t make that much of a difference in the end…Yet psychologically it feels faster and I often ended up racing on Asics DS trainers for instance (great shoes!) while I should have used Gel Nimbus instead (terrific shoes!).
HOKA allowed me to extend my running life for many years thanks to their OVERSIZED midsole. Awesome on trails and equally cushioning on roads! THANK YOU HOKA!
My favorite HOKAs – STINSON 3. The only drawback with HOKA is that you get addicted and your calves are getting really weak with so much cushioning.
Again, I strongly suggest to rotate among shoes. Nowadays, I would run short runs 5-10km on my Asics NIMBUS. I would use the STINSONS for anything longer than 12k. And I would run on Salomons (Haven’t tried the Oversize model yet – Sense Propulse) for short trails (10-15k) and Hoka for longer trails. And keep the eccentrics, strengthen both calf.
Beautiful shoes…Adizero Feather. 190 grams. Not for me tho…but I can walk with them!
#9 RUNNING FORM: Especially cadence. Heavyweight runner does not help but really, the shorter ground time contact the better…And therefore higher cadence the better, your Achilles will thank you! Target 180, but anything above 170 is already pretty good.
#10 WEIGHT: Simple, the ligher you are the less load on your Achilles and it helps with form, cadence and so many things…Not easy tho. But losing 1 or 2 kg can really make the difference between running healthy VS struggling. No kidding. Bummer…
Some of the most healing anti-inflammatory foods that you want to regularly eat include:
All types of vegetables, especially green leafy kinds — Veggies are loaded with antioxidants that fight oxidative stress, one of the primary causes of inflammation. Try to make half your plate cooked or raw veggies with every meal, aiming to regularly include kinds like kale, broccoli, spinach and other greens. Leafy and cruciferous vegetables are especially high-antioxidant foods loaded with vitamin C, vitamin K and minerals that speed up the healing process.
High-quality “clean” proteins — Protein is important to helping repair broken-down tissue throughout the body, so protein deficiency can cause weakness, delayed recovery, fatigue and bodily pains. A good rule of thumb is to try to get at least four to five ounces of quality protein per meal. Some of the best choices, which include the most easily utilized amino acids, are organic, lean proteins like wild-caught fish a great source of anti-inflammatory omega-3 fatty acids), raw dairy, cage-free eggs or grass-fed beef. Another benefit of these foods is that most pack in zinc (found in high levels in beef, pumpkin seeds and spinach); zinc benefits include tissue development and repair.
Berries — Berries are packed with vitamin C that helps with rebuilding collagen, an essential component of tissues. Other vitamin C foods include citrus fruits, squash, green veggies and bell peppers. Berries are also a great source of antioxidants that fight free radical damage, one of the causes of increased injuries into older age. Pineapple is another great fruit choice because it supplies bromelain, a compound great for treating swelling and injuries.
High-potassium and magnesium foods — Potassium-rich foods like coconut water, avocados, greens and bananas can speed healing. Magnesium found in these same foods are also important for muscle recovery, healthy circulation and helping you get good rest.
Bone broth — Bone broth naturally contains collagen, which is beneficial for healing tendons, since it’s actually what helps develop and form tissue within the body. Not only is it useful for tendonitis cases, but it can also aid in recovery from sprains, strains and ligament injuries.
On the other hand, these foods can increase inflammation and make tendonitis worse:
Alcohol and caffeine — Alcohol can prolong inflammation and promote bone loss, as can caffeine that contains certain compounds that bind to calcium. We need calcium to help heal tissue that’s been damaged, so this can stall your body from properly repairing itself — so avoid caffeine overdose and limit alcohol consumption.
Too much sodium and salt — Sodium (found in nearly all packaged foods) counteracts potassium, and too much contributes to the loss of important nutrients from your body that are needed to facilitate the healing process, so avoid high-sodium foods as much as possible.
Sugar and refined grains — High levels of added sugar can decrease immune function, slow down wound healing and increase inflammation, not to mention contribute to unwanted weight gain, which can make tendonitis symptoms worse. That means you want to kick that sugar addiction to heal your tendonitis.
Hydrogenated oils and fried foods — Just like with sugar, refined oils are found in processed foods and are known to cause inflammation since they are a source of “pro-inflammatory” omega-6 fatty acids.
#12 GRASTRON technique & GUA SHA tool: No idea whether it works/helps or not…Probably not given how deep the degeneration is… Although I never really tried.
#13 Extra SOLE: Most people wear flip flops at triathlon races…at least in Asia. In my case, I was always irritating a weak Achilles just hours before the race, by walking around in flip flops! It took me a couple of races to keep walking with thick running shoes with 6mm+ heel to toe. The same principle applies here. Don’t irriate your Achilles 24/7. Give it a break with an extra sole. Simple and efficient. Can also work in running shoes.
#14 STRASSBURG SOCK: Used it couple of times. No idea whether it works or not. Not necessarily working for Achilles…but it stretches the calf and keep the tendon stretched somehow.
#15 CHECK YOUR BIKE FIT: For triathletes keep in mind to adjust your bike fit BECAUSE of your Achilles injury (or injury prone). I trained and raced in TT position on my TT bike for several years, until 2012…before to realize that my saddle height was actually TOO HIGH and constantly irritating my Achilles, i.e. not healing for sure! And I would be fine during the bike ride, but I would get pain quicker on the run afterwards. In 2016 I could not even run as my Achilles said “no” and gave up. Next time I lowered my saddle by 1cm and I was able to run somewhat.
The initial bike fit is the ideal / optimal one. But I cannot sustain it with my Achilles. I’ve got lower my saddle height to nurse my Achilles.
#16 TENEX TX: Have not tried. Promising results with Elbows. Not sure how/whether it applies to Achilles. Link HERE.
#17 PROLOTHERAPY: not tried. Similar to PRP with Saline solution. Many good feedbacks from friends runners / hips, knees…
#18 STEM CELLS: Similar to PRP as well. More expensive. Longer treatment (i.e. 3 full days) but promising results. Could be another option to consider. Lots of great feedback.
#19 TRAINING: Obviously if you can run again, you will have to be cautious and nurse it. You might stick to 45min run max. Build up gradually (5-10% per week max). Back off at any warning sign. You might consider doubles instead of long run (10k morning and 10k evening instead of 20k long run). Adjust your training.
#20 CORTICOSTEROID INJECTIONS: Don’t do it. It will weaken your Achilles in the mid/long run. Not recommended.
#21 ORTHOKINE: Interesting. $$$. Refer to Kobe Bryant.
And the list goes on and on and on… Hopefully it helps giving you an overview of options I have considered over the past few years. Thanks for reading!