Now, I don’t know you personally, but I know you just want a stronger Achilles tendon. If you’ve still got pain – read my previous article. If you don’t, here’s the disclaimer – you could have an Achilles that doesn’t play by the rules I’m going to lay down – so please, make yourself acquainted with a very experienced and highly qualified health practitioner who knows about tendons – vet them. Because… and this is important… there are medical reasons why some tendon issues appear and stick around – syndromes, arthritis’s, gouts, blood disorders, use of some antibiotics, even waist to hip ratio – if you’re carrying too much fat you should get tested for Type 2 diabetes and work on losing fat – it’s linked to more tendon problems, so… it’s not as simple as strong calves and good ankle mobility. Some of those medical things will need a straight shooting expert.
There are steps in this journey – skip them if you wish, but don’t miss them, meaning you better know you’ve got the capacity to do the step you’re missing. If you don’t, bear the brunt of the setbacks, because they are common when you skip steps. For example, if you don’t complete your Achilles rebuild all the way through strength to elastic loading, you’ll run closer to heel strike and that will inevitably overload your hamstring, take Chris Judd for example. I want you to understand how your life will change and what your future will look like as the long night of Achilles-winter comes in. There’s no skipping the night and the dawn can’t be rushed. We’re not going to go deep into the ecosystem of tendon physiology – for most of you that sort of detail is TBU – True But Useless – knowing it isn’t what gets you moving through the night of Achilles injuries. It’s up to us that do know it to guide you through it.
This is how they look – Stage 1 sees you de-load the tendon first, get strong to offset wastage, apply static then slow loads, progress the speed of isolated movements. Stage 2 will see you shift to whole body loads in “functional” positions. Stage 3 means you introduce speed of whole body loaded tasks, and then finally, stage 4 means adding elastic springy loads.
In the first part of stage 1, de-load your tendon and get control of the pain as per my previous article, and with a good sports doctor, until your pain is down at around 1/10 – where 10 is a nightmare and 0 is, well, no pain. But, even if your tendon is stubborn and the pain is taking longer than 2-3 weeks to come down that much, don’t rest your tendon longer than 3 weeks. This stage is also about re-loading your muscle to restore some strength and endurance. It’s also about restructuring the tendon in a short position. Stay away from stretching the tendon or loading it at length.
The main fibres are made from collagen, the restructuring of which is going to take at least 100 days, whether you’ve got pain or not. Collagen just gets replaced slowly.
The Achilles tendon is a bit like the grumpy dog you inherited. Give him time to settle after such an upsetting change, with occasional slow, low impulse movements. These slow, low impulse loads can be applied in a way like calf raises, more correctly heel raises, held for 30-60 seconds, for 3-4 reps, twice each day. The rationale here is to send significant signals to the whole area, maintaining stimulus in a non-elastic way. In the early days, springiness, elasticity – it’s no good – if you load the tendon in a lengthened position, expect to wake up the tendon cells – and when they wake up because of load at length, they vomit – nasty, water-attracting proteins – that cause swelling.
Impatient yet? Let me ease the pressure. If you can do 4 reps of 60 seconds isometric heel raises, on 60 seconds rest, and your tendon hasn’t reacted badly in 2 days, you can progress. Add 20kg, for 3-4 reps, twice each day. Same criteria – if there are no setbacks after 2 days, increase load towards 40kg, then 60kg. This can happen in a matter of days, all this progression. But, it could also take 2-3 months – remember the 100 day rule?
Let’s look ahead a little, towards the dawn - when you do eventually get running on the tendon, if you’re using your feet and Achilles tendons as springs, these type 2 fibres in the calf won’t be shortening as they contract – they’re going to reflexively hold (ie isometrically hold) their length under very high duress. However, since you can’t let the tendon elastically lengthen at this time, you’re going to have to stick to the non-isometric methods – up/downs - to stimulate these fibres. Once you’ve been checked the box of heel raising 60kg for 60 seconds for 4 reps, you’re going to need to shift away from the type 1 oxygen-breathing endurance-hardy cells to wake up the type 2 glycolytic muscle fibres that will be recruited in running for high intensity bursts at near maximal power.
I recommend something like 3-4 sets of 6-8 reps (taking 3-4 seconds each rep) at heel raises plus extra weight approaching or up to your own bodyweight, with a partial recovery of up to 30 seconds between sets.
Frans Bosch is a quietly spoken but exceptionally insightful and successful running coach, professor of biomechanics and motor control – I love his work, but I think he would disagree with this regime perhaps because it will generate lactic acid, which is NOT what the pennate fibres of the calf are designed for, which is isometric bursts – but we need this regime to shift the stimulus down from the 60 second isometric efforts in stage 1 whilst still maintaining a high work load – let’s do the math – 4 sets of 6 reps at 3 seconds/rep is 72 seconds time under tension – a nice progression on the 60 second isometric holds. Bosch is right that the the best stimulus is running itself, but when you’re not ready for running and you need a stimulus – this is it.
When you’ve proven your Achilles can handle the above loads, progress again to shorter holds– 1-2 seconds, higher loads, lower reps again, eg. 2-4 reps. To keep your time under tension (TUT) up, add more sets. For example, 4 reps x 2 seconds x 8 sets = 64 seconds TUT.
To account for the load change, a day on/off approach is wise.
Practically speaking, these latter stage exercises don’t have to be just heel raises – they could even look like weighted tyre drags, sled drags and in the absence of a sled, push a loaded wheelbarrow (eg. 20 to 30 kg) up a short hill. I’ve even packed a rucksack with a kettlebell and walked up short inclines. The incline and the weight of the wheelbarrow mean a 20kg load packs plenty of punch into the system, compared to a heel raise loaded with approaching-bodyweight.
Stage 3 is where speed is introduced, but you’ll have to earn the right first. See you in the next article.
Increasing Achilles Load Tolerance – part 1 – The Reset
This article speaks to those who’ve already got an Achilles tendon problem but are trying to push on with running.
First up – your Achilles tendon problem is like many others, but it’s unique to you, so it’s specific. It’s not cool to bring a general problem to a specific person, but there are common solutions. Also, there are different reasons and locations for Achilles pain – from the sore nodules in the middle of the tendon, to the creaky, mushy tendons that feel yuck when you simple move your ankle, to the ones that hurt right where the tendon attaches to your heel. Since they’re different, they have different approaches. Let’s talk about what I’ve seen most in Australian Footballers and runners – the sore nodule in the mid-tendon.
You might be able to keep going, but take the verbal medicine I’m giving you – you may absolutely need to stop running right now – at least for a short period, and quite possibly for many weeks. Coaches hate to hear you’re out of running, but they are grown ups, and you’re a grown up, so treat it right and do what’s required. Many times, the pain settles spontaneously, only to come back later.
Often, the tendon pain occurs after a temporary increase in tendon loading, for example – increase in speed, volume, frequency of running, or even something as sneaky as running on a cambered surface, like road running where the road slopes a little to drain water, then when you run back home, you cross the road only to end up having the same camber. Be careful also of the “usual run” that has no change in any of those parameters, but follows on from a period of stress in other ways, eg. when you’ve not fully recovered from a fatiguing event. Here’s the responsible advice – don’t be the person whose Achilles tendon pain comes from a medical problem where a fitness solution isn’t right. A quick check with your responsible health practitioner is the first step.
The good news is that tendons don’t like to be rested, so you’re not going to be expected to simply not do anything. They don’t get better with rest, they get better with modified load. They get better with better movement and better load tolerance in other parts of the body. They will, however, benefit from direct treatment, so get ready to step up and help your little buddy.
In the Functional Movement Systems, one of the principles that guide clinicians and coaches through injury and movement problems is the three steps paradigm of Reset, Reinforce and Reload. This applies to Achilles pain too. The Reset means when someone does something to you that removes pain or restores movement you couldn’t do yourself. With advances in self-help, we can use many tools to reset ourselves.
When it comes to pain in the tendon, for mine, it comes down to whether you have just had pain in the last 24 hours, or whether it’s been hurting beyond 2 days.
If it’s a fresh Achilles pain, within a day, the active ingredient in simple over-the-counter medicine Ibuprofen has been shown to quieten down the tendon cells that spew out a different water-attracting-protein – the reason for the swelling. You’ve got to block these cells right away – if you miss using ibuprofen straight away, you’ll have missed the opportunity to minimise the tendon swelling in the short term.
If it isn’t a fresh Achilles tendon pain, the biggest bang-for-buck thing you can do is consider, with your local doctor who’s experienced in sports injuries, the use of GTN patches. GTN, or Glycerol Tri-Nitrate, is usually used to treat angina, as it releases nitric oxide which opens blood vessels. It’s not clear why opening blood vessels helps Achilles tendon pain, but it certainly does. So many of my Australian Football player athletes with Achilles tendon pain have had their pain abolished within a couple of weeks – if you think that’s a long time, it’s not – these tendons can be painful for weeks to months. You’ll need a prescription from your doctor, who should be familiar with its use in Achilles tendon injuries. If your doctor doesn’t know about it, go to one who does, or provide them with this article to study, followed by this article about long term results.
The second best value input you can deliver is to check on the tissue quality above and below the painful part of the tendon. In simple terms, that means poke and push around the calf muscles, shin muscles and soft tissues on the sole of the foot. It’s no joke to hear that painful spots in any of these places can actually send pain to the Achilles tendon. There’s a small proportion of athletes who do some self myofascial resets, via a massage stick, a foam roller, or another self-treatment device on a sore spot nearby only to find that the movement that hurt their Achilles was now not sore, or at least less sore. For the stubborn painful spots, some western style dry needle therapy, with acupuncture needles, can enhance the treatment to these sore areas.
Alongside tissue quality, ankle joint, big toe joint, knee and hip joint mobility drills, with belts/straps/bands are not to be underestimated when it comes to altering both Achilles tendon pain and the sticky movement that is associated with it. One of the really positive benefits of the Crossfit explosion in popularity is the countless WOD (Workout Of the Day) sites that display band/strap/belt-assisted joint mobility drills – here’s one example.
The resets mentioned above are clearing the pain and resetting tissue mobility. After these passive resets, there are countless specific and general movement strategies available to clean up the limp you developed when you started with Achilles pain. That’s for part two.
Superficial massage and stick work for skin, superficial muscle spindles, ligaments and Golgi tendon organs.
Stick work, as a method, is more often than not used incorrectly. The stick, or massage devices like it, should be used with particular purpose. Here’s how to use them as designed:
Step 1: With firm pressure, roll the stick along the muscle tissue. The target tissue will present itself as sore, whilst tissue that isn’t to be treated will not be sore. Simple. In many cases, trigger points will have an area around it that gets sorer as you approach the trigger point. For many, it will be too sore to roll the stick over it with firm pressure.
Step 2: Grip the stick with pressure enough to hold it between thumb and second finger. Roll with gentle pressure over the sore tissue for up to 50 rolls. As a guide to how gentle or firm, if you are wincing, grimacing or holding breath, these behaviours provoked by pain are indicative of responses that indicate threat from pain. This is behavior contrary to modulating pain and often leads to reactive guarding.
Step 3: After 50 rolls, repeat the firm roll over the target tissue. If the above guidelines are followed, the tissue should be less sensitive.
Step 4: Repeat the above until the target tissue is no longer sore with firm pressure.
Foam rolling, ball work and deeper massage for targeting deeper tissue spindles and joint mobilisation.
Similar to the stick rolling method, foam-rolling technique should modulate pain and alter mobility of the target tissue, verified by reassessment post-technique. For many, foam rolling is pain provocative simply because the bodyweight creates firmer pressure than the stick. Use other limbs to spread the weight so that the firm pressure does not cause grimacing, wincing or breath holding. As above, such pain behaviours lead to two little known problems:
1. Prime mover contractions as part of a guarding strategy, instead of a relaxing strategy;
2. Behaviours such as grimacing, wincing and breath holding are outputs of the CNS reflective of fear.
These problems reinforce to the person that this is a behaviour to be feared, as threatening. Whilst they may induce discomfort, pain even, the use of facial “softening” and calmer breathing sends a signal that the technique is not to be feared. Such “neural tags” of pain behaviour are the wrong pathways to be stimulating. For those who use deeper techniques and feel the approach to pain is unavoidable, one can always creep up on the painful area from distally or proximally – “surrounding the dragon” and treating surrounding tissue, instead of directly provoking the painful tissue. For many seasoned athletes however, the use of these deeper techniques on painful areas can be tolerated and nullified by “poker faced” breathing techniques to reduce fear and guarding.
Yesterday I wrote about a couple of outstanding long jump case studies.
Here's one of the strategies that can work to release a handbrake on a sprinter.
Address the superficial anterior lower chain e.g. anterior hip area, thigh and tibial muscles
Purpose: to improve mobility of tissue affecting hip extension and knee flexion
Description: Use techniques to influence mechanoreceptors. In addition, perform stretching of the area in the form of contract-relax and/or hold-relax, for reciprocal inhibition and improved active patterning.
Implications: as per the Modified Thomas Test, normal hip extension is at least zero degrees and knee flexion at 90 degrees on a neutral pelvis. In terminal stance of running, as well as early swing, limited mobility at the hip and knee can cause forward pelvis collapse, changing length-tension behavior of the hamstring on the other side. In this forward collapse position, it's very difficult to store and release elastic energy again. An individual becomes very prone to groin injuries, because nothing is protected. There's no force closure there at the saroiliac joint when the pelvis collapses forwards. All forces that transmit through the pelvis can not modulated by muscles that should be reflexively and isometrically tense. So the forward collapse of the pelvis is something you don't want.
Common errors and corrections: see my notes in "techniques for influencing mechanoreceptors" re creation of pain behaviours during the technique.
Some thoughts on riding, the FCS, performance and maintenance.
Noam Chomsky was asked how he accounted for his amazing stamina and energy level at age 87. He said, "The bicycle theory. As long as you keep riding, you don't fall."
It's an absolute statement that serves to communicate a good concept. Of course, there are relative circumstances to explain when there are exceptions. Like riding a bicycle when the road is under water, for example. Or riding a bike without servicing it will eventually lead you to slow down or break a component on the bike. My colleague, Andrew Read, and I agreed on this same point a while back when we took a 2-day workshop on program design from the rocket science and caveman point of view. Our experience was that putting "money in the bank" of daily low-stress exercise contributed to resilience. A recent study has supported this experience. We both agree that whilst this is an essential component, maintenance is necessary to stay in the game, and pattern and performance testing reveals your weak links. If you want to stay on the bike, what are you doing to keep it going?
So, when should we ride and when should get off the bike? It depends on two key questions:
What are your goals and where are you now? Conceptually, where do you want to go on your bike and what will stop you from getting there?
For my SFMA and FMS colleagues, we apply this concept to the performance goals of our clients.
The new Fundamental Capacity Screen has to be on your radar. For three simple reasons:
It depends only on a) what your goals are, and b) where you are now? That's all it depends on. Our industry trends towards wanting refined, but then assuming that refined means it's not extensive enough. This stems from a culture that uses absolute terminology to sell, and relative terminology to justify deviations from absolutes. Be that as it may, the FCS is refined. It captures the capacity of elemental resources that underpin human performance. They are: motor control capacity, explosive force production capacity, energy storage and impact control, and postural integrity under load for capacity.
As a professional or screens, tests, assesses and intervenes to personally prescribe, we progress individuals along a continuum of progress towards their goal, checking where they are along the way.
Our clients will spend money on our professional services for five main reasons:
In a performance situation, saving time, money, effort and pain is about seeing through the impediments to performance by having a smarter program, right? It's easier to program for performance if you know what's weak, right? Wouldn't it be great to have a refined step that reveals weakness?
Beware what you wish for. A refined step that reveals weakness is usually considered not extensive enough.
We want simplicity but if we get it, it must have left something out.