5 keys to preparing well for your first marathon
Brad Beer provides his five key tips to help prepare you for your first marathon at the Gold Coast Marathon.
By Brad Beer
Achilles tendon injuries are one of the most common running injuries.
Common tendon injuries can include tendinopathies (insertional and mid-portion) and partial thickness tears. Other diagnosis can co-exist and can include: retrocalcaneal bursitis, Kager’s fat pad, and paratenonitis.
When it comes to managing tendinopathies of the achilles tendon, there are two types: insertional, and midportion.
Insertional tendon pain occurs at the interface of where the achilles tendon inserts into the heel bone (calcaneus). This type of tendon condition is ‘technically’ an ‘enthesopathy’. An enthesopathy is where there is irritation of the tendon at the enthesis, which is the region where tendon fibres become contiguous with bone cells.
Mid-portion achilles tendon pain is experienced by runners in the ‘mid-portion’ of their achilles tendon. Tendon pain in this region can be one-sided (ie the inside or outside border of the tendon), or over the belly of the tendon itself.
While management for midportion and insertional achilles tendinopathies is typically different, when it comes to the initial rehabilitation exercises required to commence rehabilitation, there can exist some overlap in the prescription of exercises.
For many runners suffering from either insertional or mid portion achilles tendinopathies, if they were equipped with the knowledge of the following key three exercises, it would allow them to make a sound start to rehabilitation. The sound start then provides the ‘launch pad’ for an effective and time sensitive rehabilitation program.
Beyond these exercises further targeted prescription of exercises will be generally required. These further exercises sit outside the scope of this blog post, which is aimed at giving runners the necessary tools to for achilles tendon rehabilitation.
While it is extremely important to be doing the correct exercises for achilles tendon rehabilitation, exercise prescription is not the sole treatment for achilles tendon pain. Manual therapy for initial pain management is important, as are the appropriate addressing of contributing factors such as running training programming, and running footwear. Read more about how to address all running injury contributory factors in the 5 steps of my first book You CAN Run Pain Free.
The below outlines the 3 key stages that a runner must progress through in order to rehabilitate an achilles tendinopathy. Keep in mind that the key concept of tendinopathy treatment is to improve the energy storage capacity of the tendon. That is the ability for the tendon and associated muscle to do work and manage load.
Management of achilles tendinopathies and tendon pain in general has changed a lot in recent years. One significant change is the emergence of isometric tendon loading as a mainstay of tendinopathy treatment. Isometric tendon loading has been found to have pain relieving effects on tendons, while simultaneously maintaining some baseline strength. Click Here to learn more.
For this reason I often refer to isometric exercise as ‘medicine’ for sore and reactive achilles tendons. It is a paramount exercise to begin with for achilles tendinoapthies.
Depending on symptoms and tendon irritability these can be performed with either double legs or a single leg. For highly irritable (reactive) achilles tendons double leg holds, of often shorter duration, and less repetitions may be performed. The position of the isometric hold can either be mid or end of range (ie right up on the toes, or half way up).
These exercises can be commenced once a runner’s pain level and the tendon’s irritability has reduced. There are no ‘hard and fast’ rules for when to start a runner on isotonic loading for the rehabilitation of achilles tendinopathy. I tend to commence runners on graduated isotonic loading once they have approximately less than 5/10 pain (or tolerable and acceptable pain to the runner) on repeated single leg calf raises, their reported morning tendon stiffness has reduced.
The chief aim of isotonic exercise is to develop strength in the tendon and the associated muscle. In the case of the achilles tendon, this is the strength of the soleous and gastrocnemius muscles which join together to form the achilles tendon.
Recurring loading, such as when walking or running does not induce enough adaptation of the tendon matrix, nor the work capacity of the muscle tendon unit. Hence heavier loads are required with the commencement of isotonic loaded exercise.
Isotonic calf raises should be performed at the mid-range of the muscle’s movement. The benefit of performing this exercise in the mid-range, is that it will avoid the compression of the tendon at end of range that can occur with exercising with heavier loads. For example at the very end range of ankle plantar flexion (toes pointed), or dorsiflexion (think letting the heel drop off the edge of a step) the achilles tendon is subject to compressive loads against the heel bone (calcaneum) which can be potentially irritating and pain producing.
Note: These exercises can be done seated if the tendon is highly irritable. Seated isotonic calf raises can serve as a stepping stone to doing the exercise in standing.
Note with isotonic calf raises be sure to avoid these common mistakes:
Remember that muscle strength changes will take time: typically 6-8 weeks, so don’t expect significant ‘overnight’ progress.
A crucial last stage of rehabilitation is the commencement and execution of what I term ‘energy storage’ tendon exercises. These exercises involve deformation of the tendon with jumping and hopping based exercises. These exercises assist the tendon to regain its capacity to absorb and then release energy via the stretch shorten cycle, that occurs when a runner lands and then pushes off at toe-off.
As a guide I will generally commence runners on these exercises when the runner is reporting minimal or markedly reduced morning stiffness in the achilles tendon on waking. In addition other criteria for commencing a runner on energy storage exercises include: when the runner has been progressing well with isotonic calf raise exercises, has very mild tenderness on palpation of the achilles tendon, and has been tolerating some running without a flare in tendon irritability and symptoms.
To begin with I will have runners complete the double leg hop protocol as outlined by Malliaris(1).
Runners can then progress to the single leg jump protocol, also designed by Malliaris.
1. Single leg step jump ups
2. The ‘hopskotch’ with an activation band.
Reproduced from Magnusson et al. (2010)
It should be noted that achilles tendinopathy rehabilitation whether for a reactive or degenerative tendon needs to be astutely managed. Tendon rehabilitation is far from ‘straightforward’. Tendon adaptation to the loads outlined above will take time.
Adequate recovery time needs to be allowed between rehabilitation exercise sessions to allow for the tendon matrix undergoing net protein (collagen-tendon building block) degradation in the 24-36 hours following the strength exercise session. See below.
If you are suffering from achilles tendon pain be sure to seek out the assistance of a sports physiotherapist to help you navigate the rehabilitation stages.
The above is a guide only, and does not take into account individual considerations.
Brad Beer is a Gold Coast based physiotherapist who throughout his career has delivered in excess of 25,000 physiotherapy consultations. In 2006, Brad founded a physiotherapy group called POGO Physio which, since inception, has treated over 16,000 people.
Recognised as a leading authority on running injury prevention and rehabilitation, Brad himself is an avid runner and is passionate about seeing people unlock their true running potential.
Brad believes that all runners can and should experience pain and injury free running. In 2015 Brad released his first book You CAN Run Pain Free! A Physio’s 5 Steps to Enjoying Injury Free and Faster Running to educate runners that it is indeed possible to enjoy the many benefits of pain free running. Brad’s clients include age group, novice, beginner, and elite athletes. Brad has assisted his clients in winning multiple Australian, world, and even Olympic medals.
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