Simon Katich suffered an injury blow by limping through most of day three of the Ashes Match in Adelaide with a “heel” problem.
This was later clarified as being an Achilles swelling see -Lump on Achilles Tendon .
His pain was compounded further by knowing that he was going to have to bat for a long period to help Australia save the game.
He also managed to get himself run out in the first innings without facing a ball!

Australia’s captain Ricky Pointing later admitted that
“He’s been pretty hindered in the field.
His achilles is quite badly swollen and we have got him on and off the ground a couple of times to get some ice on it knowing that he’s got plenty of batting to do over the next couple of days.”

In fact Katich did manage to bat for a few hours until after lunch before being dismissed caught behind for 43.

The Australian Medical Team have a lot to do if they want to try and get him fit for the Third Test in Perth starting on the 16th December. It depends on how bad the Katich Achilles tendonitis injury is and whether he has had significant previous problems here. As Achilles Tendonitis is a degenerative condition this is very likely. See Achilles Tendonitis Injury- Your Top 10 Questions Answered for much more information.

What is a watershed

A watershed is not a garden water feature despite its name!
It is defined in the merriam-webster dictionary as “a crucial dividing point, line, or factor”.

Achilles Watershed

The Achilles watershed area is the area where there is a decrease in blood supply in the tendon
between 3 and 6 cm up from the attachment to the calcaneum.
The blood supply is meant to come down from the musclotendinous junction at the top,
and up from the bony attachment to the heel at the bottom.
This is represented in the diagram opposite by the blue arrows.

The area in the middle (pink) has a lower supply – the Achilles watershed area – where most ruptures take place.

This was first described in 1959 by Lagergren & Lindholm who examined the blood vessels supplying the Achilles Tendon.

This was taken on a stage further by Carr and Norris in 1989 who injected a dye into the vessels of cadavers. They concluded “there was a reduction in both the number and mean relative area of vessels in the mid-section of the tendon.”

In 2000 Stein, Laprell, Tinnemeyer and Petersen used radioisotopes to measure the intra-vascular volume of the human Achilles tendon and concluded “When the tendon was divided into three regions, we found the lowest intravascular volume in the middle region (3–6 cm above the tendon insertion).”

All of these studies used cadavers and the average age of the cadavers was early 70′s!
There is a decrease in blood supply to the Achilles Tendon with increasing age so perhaps these subjects
are not the best for the projection of results onto a fit and healthy population of athletes.

Blood flow in chronic Achilles tendinopathy disputes Achilles Watershed Area

Aström in 1994 measured blood flow and reported a significantly lower tendon blood flow at the insertion (bottom end), but otherwise even vascular distribution – no Achilles watershed area in symptom-free individuals.
More recently in 2008 an article by Knobloch stated “we found that in symptomatic tendinopathy neovascularisation is associated with a significantly increased capillary blood flow in the Achilles tendon at the point of pain” This means that there is an increase in blood flow at the mid-portion area of the Achilles tendon when painful.

What is Achilles Tendonitis / Tendinosis

Achilles Tendonitis, or more correctly Tendinosis, is thought to be caused by overuse which causes microscopic areas of damage to the tendon.
These areas of microtrauma are quite common with exercise and normal daily activities, and the body copes by repairing these damaged areas on an ongoing basis.
However the cause of Achilles tendonitis with increased running is due to the fact that this repair process is not able to cope with the repeated strains below the injury threshold of the tendon, inducing microdamage or as I will call it from now on “damage”.
This “damage” accumulates and leads to mechanical breakdown of the Achilles tendon which develops areas of degeneration – Achilles Tendinosis.

Training Causes of Achilles Tendonitis

• an increased frequency of running over a short period of time
• a sudden increase in the length and/or speed of runs
• repeated running uphill as part of a training regime
• conversely repeated runs downhill!
• running on cambered surfaces

Damage / Repair Cycle of Running

As mentioned above there is a normal ‘damage / repair’ cycle that takes place in the tendon.
If you allow enough time after a training session then there is full recovery of the “damaged” area.
This is represented diagrammatically.
The blue dotted line represents injury.
The red line represents the “damage” done by a training session.
There is enough time for full recovery to take place.

Achilles Tendonitis with Increased Running or Training Sessions

If you suddenly increase the number of runs or training sessions that you do each week then the repair part of the cycle has less time to finish its role before you start your next session.

This leads to a cumulative effect of degenerative changes taking place in the tendon.
When this reaches the blue dotted line – you feel injured and there is breakdown of the structure of the Achilles Tendon.
In simple terms degeneration (tendon breakdown) is exceeding regeneration (tendon repair).

Avoid Achilles Tendonitis with Increased Running or Training

If you were to repeat the same runs or training routine at a frequency that allows full recovery then the tendon actually gets used to the level of stress applied to it.
This reduced “damage” with each successive run is represented in the graph.
Think of this as a training effect on the tendon.
However the idea behind regular training is to get fitter and achieve more so training at the same intensity is pointless.
The key to success is to progressively increase your training in such a way that you allow the “damage” to the Achilles recover sufficiently before increasing the loads on it.
That is where cross training and structuring your workouts is essential.
The 10% rule for runners weekly mileage comes to mind.

The 10 Percent Rule for Runners

The runners 10% rule states that you should not increase your weekly mileage by more than 10% week on week.
Personally I don’t necessarily agree with that but it’s not a bad place to start.
It’s too restrictive for beginner runners and perhaps too generous for elite runners.
If you are starting out and especially if your are starting back after an injury or lay-off then my advice would be to “listen to your body”.
By that I mean if your are sore after a session then take it easy for a few days – do some cross training instead of running.
Follow hard runs with easy runs or rest days.
Space out your workouts evenly through the week or month.
Build in an “easy” week (about 70-75%) every 4-5 weeks.
If you feel tired or sore then you are doing too much – REST!!

The Achilles can actually respond to regular loads over a period of time. Some studies have shown that there is an increase in cross-sectional area of the tendon (thicker / bigger) after ongoing regular exercise. Other studies have shown a difference in cross-sectional area between the dominant and non-dominant legs of the same individual – you use the dominant leg more. Yet more studies have shown no difference at all!


The more regularly you exercise the more the tendon is able to withstand the stresses applied to it
BUT and it’s a BIG BUT ….
you need to allow for the repair part of the cycle to take place effectively.

That’s why marathon runners like Paula Radcliffe can churn out apparently massive mileages each week and stay injury-free.
However when they do get injured it takes them a long time to get back to normal because World Record holder-or-not she has to follow these same basic rules on her rehab journey back to full race fitness.

For the ANSWERS – click on the BLUE TEXT LINKS

1. Have I got an Achilles Tendonitis Injury?

What are the symptoms of Acute and Chronic Achilles Tendonitis. What is the difference between Insertional and Mid-Tendon Achilles Tendon Injuries?  These Videos will help you decide.
Click Do I Have an Achilles Tendonitis Injury?

2. Painful Achilles Tendon – How do I get rid of the pain?

How you get rid of Painful Achilles Tendons depends on how recent the injury is.
Advice is given for Acute Achilles Tendonitis including what activities to substitute for running, how to apply an Ice Block massage. Different advice is given for Chronic Achilles Tendinosis.
Click Painful Achilles Tendon – How do I get rid of the pain?

3. When can I get back to running with Achilles Tendon Problems?

How long have you had the pain in your Achilles? Less than 4 weeks? More than 4 weeks?
Have you had the Achilles pain before? Can you do 3 sets of 15 reps of the Eccentric Calf Exercise and be pain-free?
Your answers to all these questions are important…. 
Click When Can I Start Back Running with Achilles Tendon Problems?

4. Do I need to change the way I run or my running shoes?

New Running Style for Achilles Tendonitis? Does your running style predispose you to Achilles Tendon injury? Find out here by watching a cool video analysis of before and after re-training.
New Running Shoes for Achilles Tendonitis? It is recommended that you change your shoes every 300 to 500 miles. If your shoes are past this mileage they may not be providing the support and control that they did initially. It may also be that the shoes you currently use are not best suited to your foot type and style of running.
Click Do I need to change the way I run or my running shoes?

5. Will rest cure Achilles Tendonitis or do I need surgery?

My advice for what it’s worth would be to not undergo surgery until you have completed at least 8 weeks of Eccentric Calf Exercises and show no lasting signs of recovery. But read the article and make our own mind up!
Click Will rest cure Achilles Tendonitis or do I need surgery?

6. What is Achilles Tendonitis?  

Achilles Tendonitis (or its other spelling – Achilles Tendinitis) is an acute flare up of tissues around the tendon.
It is not that common! It is short lasting – only a few days.
Achilles Tendinosis however is a very common injury. It is a chronic degenerative condition lasting for ever!
It’s a bit like a puppy – not just for Christmas but for LIFE!
Click What is Achilles Tendonitis?

7. What treatment options have I for Achilles Tendonitis pain?

DIY Injury Rehab, Physiotherapy, Orthotics, Injections, Shockwave Therapy and Surgery are all discussed.
Click Achilles Tendonitis Treatment Options

8. Why do I have a painful swelling in my Achilles Tendon?

With Achilles Peritendonitis / Peritendinitis / Paratenonitis it is the tissues immediately surrounding the Achilles Tendon that become inflamed. With Achilles Tendinosis there may still be thickening of the tissues surrounding the tendon but in addition there are areas of local breakdown of the internal structure of the actual tendon itself. This can produce lumps or nodules that can be felt through the skin.
Click Lump on Achilles Tendon

9. How did I get Achilles Tendonitis?

Classically the main causes are associated with overuse. Other factors that can predispose a runner to Achilles Tendonitis problems are discussed.
As are Medical conditions associated with an increased risk of Achilles Tendonitis.
Who gets Non-Insertional Achilles Tendonitis and Insertional Achilles Tendonitis?
Click Causes of Achilles Tendonitis

10. How do I stop it coming back?

DIY Injury Rehabilitation

I will soon be producing a diyinjuryrehab.com Achilles Program that will deliver daily exercises to your Inbox for Achilles Tendonitis Treatment.

This will give you a varied but structured approach to your exercise program.

Take a look at the video opposite.
It show a very simple exercise that you should be doing for Achilles Tendonitis.

Please take the time to sign up for my Members Area – you will be notified as soon as it is released.

Physiotherapy or Sports Injury Specialist

You can expect to be thoroughly assessed.
They will look not just at your calf and leg but also your lower back, sacoiliac, hip, knee, ankle and foot joints.
They will assess muscle tone and balance for your legs and trunk.
You will be checked for shortened muscles and nerves.
They may use some manual techniques to loosen or mobilize tight structures.
Therapeutic Ultrasound, Laser or some other electrotherapy may be used to help settle inflammation if necessary.
A heel lift may be provided as a temporary measure to help with pain relief.
You can expect a combination of stretching and strengthening exercises to do at home.

Customised Orthotic Insoles

Specialized custom fitted insoles can be prescribed and made by a Podiatrist for Achilles Tendonitis treatment.
These insoles are made to exactly compensate for the structural or functional abnormalities in your foot and hindfoot.
A simple explanation would be that this helps to control any excessive pronation that may be taking place.

Investigations

ULTRASOUND SCAN
Ultrasound scanning has become very accurate recently in skilled hands.
It allows for quite accurate diagnosis of Achilles Tendinopathy.

MRI SCAN
MRI scanning may apparently finds it difficult to differentiate between symptomatic and non-symptomatic changes in the tendon. This is because there are differences in the normal anatomy of healthy tendons which the MRI picks up and may lead to possible problems. The advantages of an MRI are that they allow multiple views and sections through the tendon and allow the surgeon to build up a 3D view of the tendon before surgery which may be an Achilles Tendonitis treatment option (see below).

Injections

CORTICOSTEROID

Some Doctors still carry out injections of Corticosteroids around the paratenon as Achilles Tendonitis treatment.
There is a generally perceived risk that this may lead to further weakening the tendon and causing ruptures of the tendon.
So it depends who you see and what their particular experiences are.

SCLEROSING

Another type of injection for Achilles Tendonitis treatment is one which scleroses the new blood vessels and nerves associated with tendinopathy.
Sclerosis produces hardening and fibrosis of the tissues injected – it obliterates them.
The injections are carried out under the guidance of ultrasound for very accurate placement of the needle.
Sclerosing polidocanol injections have been shown to have good lasting effects in patients with chronic painful mid-portion Achilles tendinosis.

Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) has been around for a while but it has been reformed over the past few years. Initially you needed local anaesthetic or more for the treatment but now it can be performed without anaesthesia. It works by producing shockwaves which exert a mechanical pressure and tension force on the afflicted tissue. This Achilles Tendonitis treatment breaks down scar tissue and promotes healing.
For a much clearer and more detailed explanation see this Canadian Site – click here

Surgery

If exercise does not help or the condition is longstanding (over 6 months) then you medical practitioner may offer you surgery as the ultimate Achilles Tendonitis treatment.
There are slightly different operations but your Achilles Tendon will be examined and any partial tears will be cleaned up and repaired.
If there is a thickened paratenon this will be removed.
If there is any bony protuberances they will be removed also.
The bursa (small fluid filled sac) may also be excised if this is inflamed.

This sort of surgery may be carried out through a small cut in the skin (keyhole) or by an open approach – longer scar depending on the surgeon and the nature of the problem.
Another type of surgery produces a series of small longitudinal cuts in the tendon to allow removal of damaged areas of the tendon.
If you want specific information about the different types of surgery then I have found and excellent French Website with lots of pictures and diagrams – click here

Return to “YOUR TOP 10 QUESTIONS ANSWERED”

Classically the main causes of Achilles tendonitis are associated with training factors and overuse.
Then there are the intrinsic factors of the athlete themselves – biomechanics, muscle weakness, medical conditions, degenerative changes etc.
The extrinsic causes of Achilles tendonitis would include footwear and perhaps use of antibiotics.

Training Causes of Achilles Tendonitis

• an increased frequency of running over a short period of time
• a sudden increase in the length of runs
• a rapid and sudden increase in running speed
• repeated running uphill as part of a training regime
• conversely repeated runs downhill!

Intrinsic Causes of Achilles Tendonitis

Factors that can predispose a runner to Achilles problems are

• gait abnormalities such as :-
• excessive or poorly controlled pronation
• restricted dorsiflexion
• tight calf
• ankle joint arthritis
• age related degenerative changes in the tendon
• muscle imbalances
• weak calf muscles
• weak Tibialis Posterior muscle
• weak buttock muscles
• being overweight

Medical conditions associated with an increased risk of Achilles problems are

• rheumatoid arthritis
• gout
• pseudogout
• subtalar malalignment
• restless legs syndrome
• Haglund’s Deformity

Extrinsic Causes of Achilles Tendonitis

• inappropriate footwear
• wrong type of shoes
• worn shoes
• certain antibiotics – quinolones like
• Avelox, Ciprofloxacin, Factive, Floxin, Levaquin, Noroxin, and Proquin in the USA

Who Gets Non-Insertional Achilles Tendinosis

• Males up to 7 times more likely to get it than females
• Athletes in their 20s to 30s with high mileage
• Left leg more often than right leg (possibly due to majority being right-handed)
• Most reported injury in the over 40s group of runners

Insertional Achilles Tendonitis

• tends to occur more frequently among older athletes in their 50s and 60s
• patients tend to be overweight
• often occurs with a retrocalcaneal bursitis (inflammation of a fluid filled sac immediately behind tendon insertion)
• a Haglund’s deformity (a bony protruberance of the Calcaneum) predisposes the tendon to irritation
• more likely to occur in the cavus foot (high arched)

Return to TOP 10 QUESTIONS ANSWERED

If you have most of these symptoms then you almost certainly have Achilles Tendonitis Injury / Tendinopathy.
There are a few other problems such as sciatica and local nerve irritation that may give you similar pain but you will not get the localised swelling in the tendon.

There is one other type of Achilles Tendinosis that does not produce a thickened Achilles Tendon

Insertional Achilles Tendonitis / Tendinosis

To return to “YOUR TOP 10 QUESTIONS ANSWERED” – Click Here

This depends on your Doctor.
The pain of Achilles Tendinopathy is not from the degeneration changes in the tendon but apparently from new blood vessels and their nerve supply. These new blood vessels appear as part of the repair process.
It is thought that doing eccentric exercises may help to minimise the formation or even perhaps reduce this neovascularisation (new blood vessel growth).

The surgery strips away the paratenon which surrounds the Achilles Tendon and the surgeon may also remove any dead (necrotic) tissue and calcification in the body of the tendon. By removing the new blood vessels and their nerves the pain is diminished.

My advice for what it’s worth would be to not undergo surgery until you have completed at least 8 weeks of eccentric exercises and show no lasting signs of recovery.

Find out more about Achilles Tendon Surgery at Surgical Repair of Achilles Tendon Rupture

Does Rest Cure Achilles Tendonitis?

Rest will settle the pain of Achilles Tendinopathy.
Settling the pain is not the same as a cure!

If you haven’t done it yet read Achilles Tendonitis – What Is It?

Rest will allow the inflammation to calm down but you will still have the tendon degeneration taking place.
Type-III collagen is laid down which can’t handle the stress of running.
So as long as you don’t want to exercise properly again – rest up!

Answer

NO! NO! NO!
You need to exercise properly and stimulate repair that is strong and lasting.

To return to “YOUR TOP 10 QUESTIONS ANSWERED” – Click Here

Achilles Tendon Repair Exercises

5 minutes Twice a day

That’s all you need to do to Stimulate Achilles Tendon Repair and get rid of your Achilles pain!

Start with this exercise – the Best and Most Effective One

Jump Directly To:-

Repetitions and Progressions

Other Achilles Posts

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Read on for progressions and to find out why the exercise works.

The role of Rehab Exercises is to stimulate repair of injured tissue and create a strong and healthy scar. These exercises for the Achilles Tendon Repair apply equally to tears and strains of the Gastrocnemius muscle and the Soleus muscle.

If you applied these type of contractions to your calf muscles :-

• An Isometric contraction would be if you looped a towel over your toes and held it in both hands and then pushed against it but did not allow your ankle to move.
• A Concentric contraction would be to stand on one leg and go up onto your toes – your calf muscle is shortening and pulling your heel up.
• An Eccentric contraction of your calf muscle would be to start standing on one leg up on your toes and then to lower back down – your calf muscle is ‘paying out’ under load and lengthening as your heel is lowering.

As discussed in previous posts the role of the Achilles tendon is to store forces from the foot and transfer these forces back to the foot to help with walking and running. The calf muscles tension the Achilles in preparation for the transfer of forces from the foot – see Achilles Tendon Function. This involves the muscle working eccentrically so it makes sense to rehab the muscle in this way.

1. increased collagen production rate – see Tendon Healing in “Ruptured Achilles & Non-Surgical Treatment”
2. increase the mass of healthy tendon because of the improved production of type I collagen
3. decreased tendon thickness
4. strengthen the tendon and protect it from subsequent overuse
5. production of new blood vessels is decreased

The decrease in the production of new blood vessels (neovascularisation) is important because it is thought that nerve endings associated with these new blood vessels are responsible for the pain that you get with Achilles tendinosis.
Increased production of type-I collagen means that the healing area is much stronger and more likely to withstand the stresses of sport – a better tendon repair.

Achilles Tendon Repair – Rehab Eccentric Exercises

The exercises in the videos are shown for your left side – you obviously reverse the instructions for your right side.
Click on the video below

As explained in the video clip you take weight through your hands by leaning on a strong table or worktop.
The exercise does not have to be pain free – it is ok to feel some pain in the tendon as you do the exercise.

Again follow the progression as detailed above.
It is recommended that you continue the exercise for 12 weeks.
Remember that Achilles Tendinosis is a degenerative problem and that you need to keep loading the tendon to stimulate the repair.
If you take a break from running for more than a few days I would recommend (from personal experience) that you do these exercises or else the problem will occur on your first run back – even a gentle one!

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