[thomasgarrod]

Wondering if anyone has any different advice on Achilles. Have had the issue for 20 months and after raising mileage to 70 miles plus a week pain was extreme. I have been doing heavy load eccentric drops for along time with no change. Saw a specialist with reference to using peptides and he gave me a cortisone shot which didn’t help. I recently started injecting with peptides like tb500. I didn’t train for 2 weeks and the pain totally went. Did a 2 miles trail run today and pain is back just as bad. Really frustrated now as feel like have tried everything.
Only option I have next is shockwave therapy which I know is not particularly successful.
When I run longer than 2 hours pain eases.

Is there anything I have missed?? Thank you so much. Tom

Topic

[Shashi]

Shashi on January 12, 2021 at 3:51 pm #49218

Tom,

Sorry to hear about your injury. Pete will probably share his recommendations soon, in the meantime here are two forum discussions that you might find helpful –

Suspected Achilles Tendonitis Recovery Tips

Achilles Tendonitis Running Substitute

Wish you the best!

[Pete Dickinson MS,PT]

Pete Dickinson MS,PT on January 13, 2021 at 4:07 pm #49263

Tom,
So sorry to hear about your achilles tendonitis. Your experience is very typical with poor response to treatment, ongoing pain with return to significant activity. Eccentric training for this is so 1990’s. So here’s the deal, you have an injured part to the tendon, it really won’t ‘heal’. You have to slowly build up the remaining ‘good’ part to the tendon to take enough load to tolerate training etc. The key is finding a starting point, and progressing from there. Most Uphill Athletes don’t start at a low enough level of activity. The remaining good part of the tendon can’t take the load, so that the ‘bad’ part of the tendon gets involved and becomes painful. I have success with my patients starting with calf raise isometrics, 5x30sec both feet loaded. Really, isometrics. From there it gets increased to single leg, then some more dynamic movements, deadlifts/step downs…and return to sport with a walk/jog program. If you want more personalized progressions, I’m at pete@worldcup.physio. A key ingredient in all this is….patience. It takes time for the physiologic changes to occur, but they can!!
Cheers,
Pete

[rich.b]

rich.b on January 14, 2021 at 7:36 am #49286

Pete, in some cases there are good arguments for eccentric training – obviously depending on pathology. Håkan Alfredsson did a number of clinical studies involving both mid-tendon and insertional achilles tendonopathy (tendonosis rather than tendonitis), where in the majority of cases the issue was resolved following a specific 12-week protocol of eccentric loading (the first study was Alfredson et al. 1998. Am J Sports Med). His protocol is 3 sets of 15 reps of slow heel drops done 3 times per day, progressing from body weight to increasingly weighted heel drops done every day over 12 weeks. The weight is dictated by pain tolerance (I worked up to 60-70 kg added weight, beyond that was harder to do them slow). I went through his clinic a decade ago; it took at least 4 weeks to get a slight sense of improvement, but progress was steady – I did not skip even 1 rep – and it was resolved by 12 weeks and back to 100% running (100 km/week then) by that point. Compliance with the full protocol is critical.

Pete, as you emphasise, patience and persistence in following whatever rehab protocols are chosen with a therapist are essential to success.

Thomas, in your case what is ‘heavy eccentric drops’ and how consistently were you doing them?

cheers/rich

[Pete Dickinson MS,PT]

Pete Dickinson MS,PT on January 14, 2021 at 3:14 pm #49296

Rich,
Thanks for your thoughts on this! But as I said, focus on eccentrics is so 1990″s. Current research provides continued modifications in our treatment regimens. I certainly am treating differently than I did 5 years ago, as research and clinical experience add to my skill set. There are interesting studies using heavy strength loads that outperform eccentrics as a treatment for tendonitis. There is also a study that shows equivalent benefit. Want you really want to do is nail your functional progressions from a relatively pain free starting point. This will include isometrics/concentrics/eccentrics/dynamic movement/plyometrics….you get the idea. The biggest factor limiting effectiveness of treatment is self inflicted training errors due to OES (Over Enthusiasm Syndrome).
Cheers,
Pete

[rich.b]

rich.b on January 15, 2021 at 7:58 am #49308

The progress in sports science and sports medicine happens mainly in real life and not in the lab. It is when therapists like yourself and coaches find new results or patterns that science picks up those threads to explain the mechanisms.
As always, thanks for sharing your insights.
/rich

[thomasgarrod]

thomasgarrod on February 4, 2021 at 9:33 am #50438

Thank you all for your advice. I am currently having weekly radial and focused shockwave therapy. The clinician has told me to stop with any form of calf drop or isometrics for the moment and then advises starting again slowly, building in exercises after three weeks alongside weekly shockwave. I will update this if I start to see a change.
Once again thank you for your help
Tom

[Richard Park]

Richard Park on February 15, 2021 at 1:09 pm #50865

I recently read this article by Dr. Keith Baar which has some good insights into maximizing tendon recovery exercises with supplementation along with other interesting findings. The author states that ingesting 15mg gelatin and 50mg vitamin c in a drink 30 to 60 minutes before rehab exercises doubled collagen synthesis during clinical trials. It seems like a low-cost supplement with a lot of potential upside.

Minimizing Injury and Maximizing Return to Play: Lessons from Engineered Ligaments

[Pete Dickinson MS,PT]

Pete Dickinson MS,PT on March 10, 2021 at 4:20 pm #51864

Richard,
I saw that study, 18 participants with the protein from the gelatin being the helpful component. It was done with a strength intervention of eccentrics and showed increased collagen synthesis. Another study using 2.5 g hydrolysed specific collagen peptides (sCP) (n=20) also had a nice impact on pain. This may be an area to follow, but by far most of the effective studies show that higher loading of the tendon is the key factor in improving tendon pain through changes in tendon mechanical properties and morphology.
Pete

[l.tregan]

l.tregan on March 11, 2021 at 2:49 am #51890

Hi,

Something I do systematically on my shoes is cut the heelcounter into a big ‘V’, so that there is no rubbing of the shoes against the tendon. I am 100% positive that my original problem was caused – or at least triggered, maybe there was some damage and I could not feel the pain due to the low innervation of the tissue- by a new model of shoes rubbing against the tendon on the downhills (due to the angle of the ankle, the heelcounter is pushed against the tendon).

If you are not too sure if there is rubbing, one way to check is to run without socks and see if there is a blister / red skin coming up.

Great success with loaded (increasing up to 15kg backpack 😉 ) isometric holds. I try different positions until I find the spot with the most but still bearable pain. Did the 15g collagen + vitamin C thing 1h before the exercise too.

loic