Achilles tendinitis is a common injury for all athletes and fitness participants, especially those who run seriously as a sport or main fitness activity. It is often the result of overuse from repetitive actions seen in running and jumping sports and statistics show that it is one of the most common of all overuse injuries, accounting for 10% of all running injuries. This is a much different injury to an acute stress or accident-type injury such as an ankle ligament sprain from rolling an ankle or a collision injury often seen in sports like football. Like all overuse injuries, once it sets in it can be extremely difficult to get rid of so it is vital you prevent it from happening in the first place. Ignoring the warning signs is dangerous and can lead to full Achilles ruptures which is something that is seen a lot in professional sports like NBA basketball. I see a lot of similarities with this injury and ACL injuries in relation to the underlying cause. In order to prevent the problem you need to know what causes it. Unfortunately, it is not a simple answer to explain as the cause can differ from person to person and can be a multitude of factors you need to keep in mind. In this article I will explain the lessons I have learned from suffering and recovering from an Achilles injury myself years ago, along with research and my experience working with many complicated cases.

What Is Achilles Tendonitis?

The Achilles tendon connects muscle to bone, like other tendons, and is located at the back of the lower leg. The Achilles tendon connects the gastrocnemius and soleus muscles to the calcaneal tuberosity on the heel bone.

Tendons are the tough fibres that connect muscle to bone. While a tendon injury may seem to happen suddenly, it results from many tiny tears to the tendon that have occurred over a long period of time. I used to get confused with the different terms used to describe Achilles injuries as I wasn’t sure if it was tendonitis or tendinopathy.

Tendonitis: This means “inflammation of the tendon,” but inflammation is rarely the cause of your tendon pain.

Tendinosis: This refers to tiny tears in the tissue in and around the tendon caused by overuse.

Most health professionals will refer to it as tendinopathy.

The injury involves damage to the fibres on the Achilles tendon unit, often at the narrow point of the tendon just above the heel. This area is most at risk because it has a smaller blood supply than the rest of the tendon, and so is unable to repair itself as easily. The symptoms involve pain in the Achilles with motion and exercise if it is prolonged and it will be painful to touch. Like plantar fasciitis the stiffness and pain is worse when getting up out of the bed first thing in the morning.

Common causes of Achilles injuries include:

• Excessive pronation, producing a whipping action on the Achilles tendon during stance phase of the running action
• Poor flexibility of the ankle and Achilles tendon
• Weak calf muscles
• Poor running shoes
• Rapid increase in training load, over-training and poor recovery methods

However, while I agree all of these factors can be playing a part in creating the injury I would like to add a few other things to this list that are often overlooked.

1. Poor hip mobility
2. Poor hip movement and glute function
3. Poor running technique

Let’s discuss each of these factors in more detail so you can pinpoint where your underlying cause may be if you have the injury. And if you don’t have an existing calf injury, how you can prevent it.

Excessive Pronation

For a long time many (myself included) believed the main cause of Achilles and calf related problems was all to do with the concept of excessive pronation.  This is where there is excessive inward rotation of the foot during the stance phase running. This pronation tends to bow or twist the tendon and after several thousands of repeated foot strikes there is inevitable damage and inflammation caused to the Achilles.

Our feet are designed to do 2 critical things.

1. ABSORB shock and then.
2. Provide the ability to PUSH off the ground when we walk, run or jump.

The foot needs to act like a spring being soft flexible foot to cushion the stress of each step we make, and then instantly become stiff enough to provide enough power to move us forwards or upwards. This is also known as being able to lock the foot at one point and then being able to unlock the foot at the very next part of the movement. Problems arise if we lose either one of these two things, and ultimately lose our spring. This is where injuries will occur at other joints.

There are many different foot types, so it is important to know what type of foot you have before you do anything so you can make the correct adjustments. You can see below a very simple diagram of the different foot types. If you are the normal foot, then you have great news. If however, you are either the flat foot or the high arch you will be at risk of Achilles problems. Rigidity of the big toe and toe gripping are other give away signs there is a problem you must address at the feet. 

Flat feet are the most common of all the feet problems associated with excessive pronation and Achilles injuries. This foot is basically very unstable, has become over stretched along the bottom of the foot, which makes it almost impossible to become a rigid lever to create the "spring" and release energy the foot needs during running and jumping activities.

This foot type is the most commonly one fitted with orthotics to help correct the fallen arch. Unfortunately, this does not "fix" the problem as the foot will remain weak, and the orthotic does not provide the spring, if anything it dampens it!

Now I am not necessarily saying to get rid of your orthotics altogether. In some cases people have such weak feet that this is the best option, however it is always wise to try and correct these problems with strengthening drills first, in particular with young kids.

The key to correcting the weak foot is with improved stability strategies and strength exercises. Remember this foot type problem is all to do with instability and weakness, and like any muscle or joint it needs work. A quick note on pronation. Pronation is not bad, in fact it is absolutely essential, the problem is when you have too much of it in the case of weak feet. So understand we don't want to get rid of it altogether we just need to limit how much we have.

Watch the videos below for ideas of how to do this.

I also suggest to read these articles for more exercises and information relating to foot stability.

• Big toe mobility is everything
• Improve foot stability using the Sensa Mat

Poor Flexibility of the Ankle

Tightness in the calf will lead to extra tension being placed on the Achilles tendon, during running and walking, especially up hills.

Dorsiflexion is something we all tend to take for granted in daily life and in sport and trust me you can ask the people with walking impairments how hard it is to walk when your foot does not do this. Ankle flexibility is closely related to pronation in running, specifically if the calf muscles are tight and lack adequate dorsiflexion. This lack of mobility at the ankle will cause the foot to pronate more during running to compensate for this lack of motion.

It is very important to address mobility problems PRIOR to strengthening. Every time you improve flexibility and mobility new opportunities are created to alter and change movement patterns, and increase strength in weak and lazy muscles. For if there is a tight muscle, there is also an opposite, a weak lazy muscle.

The big mistake people make in rehab is trying to strengthen the weak muscles first. Your calf muscles may need to be strengthened, but they can never achieve their potential while they lack range of motion, timing and freedom of movement that can only be restored using flexibility and mobility methods first. All that will happen if you skip this stage is you will force the body to compensate and find another way.

You can easily assess your own ankle mobility by using the wall test shown in the video to the left and the video on the right is my preferred drill for correcting mobility restrictions at the ankle.

To see more ideas and mobility drills to use for the ankle this read the article – How to improve ankle mobility

Weak Calf Muscles

Another theory about the cause of the injury is that the tendon is unable to cope with the repeated eccentric contractions which the calf muscles must perform as the foot makes contact with the ground. Eccentric strength refers to tension being applied to a muscle as it lengthens. This is also when the muscle's force-producing capacity is at its most optimal.

If the calf muscles did not contract eccentrically when your foot hits the ground during the action of running the ankle would collapse. These eccentric contractions produce forces which may cause excessive stress on the tendon if repeated too often and the muscle is not strong enough. This is where you regularly see people prescribed calf muscle strengthening programs using exercises like calf raises to combat this problem. Using exercises with a concentric movement ignores how the muscles and tendons interact during a movement like running.

There are many problems associated with assuming Achilles injuries are all to do with calf weakness, for this could be a result of muscle inhibition from poor mobility, or poor movement from other joints compensating. Strengthening the muscle in isolation without changing these things at the same time will prove to be pointless. Blaming a single muscle like the calf for a problem in a complex pattern of movement like running is ignoring the role of multiple muscles and joints and the interaction they have as synergistic partners.

The other thing to keep in mind is that concentric strength is not of most importance when it comes to quality movement, in particular running. During the running cycle the energy from the push comes from the tendons and not from active contractions of the muscles. The muscles are still important but they are mostly concerned with eccentric contractions during the cushioning phase to control the impact with the ground.

The body is very smart and can anticipate pain before you even move. It can instantly rearrange and change motor programs and movements to protect itself from harm and is another factor to consider when observing what appears to be a tight muscle or a weak muscle. Using a thorough assessment process is essential to ensure you do not miss the protective mechanism at work in a movement. It can be difficult to spot the real problem as you will see many other things happening that are a compensation to protect the real underlying problem.

When applying strength methods specifically aiming at the calf make sure you emphasize endurance. For example, with single leg calf raises I will prefer to aim for high repetitions of low loads, over high intensity loading for maximal strength gains. Many calf related injuries occur once fatigue sets in and the calf muscles are heavily reliant on endurance. With the single leg calf raise I aim for at least 30 repetitions on each leg as an indicator of great endurance. If you fail to reach 30 reps, or if there is a difference between each leg I will know that there is a weakness that will be exposed during running or sports.

Below is a great video to watch that discusses the various things to consider when strengthening the calf muscles.

Now if you think this is all you need to do you will be very disappointed so make sure you read on.

Poor Footwear

As we have already discussed our feet and ankles are meant to withstand incredibly high forces and should provide more in terms of shock absorption than perhaps any other body part. Unfortunately, we begin to gradually lose this ability once we start wearing shoes. Over time, the feet, ankles, and toes become inhibited. And as we expose our feet to some trendy shoes with all types of padding and support, this only make matters worse and exacerbates the lazy and weak feet muscles.

Besides minimizing the ability to withstand intense ground reactive forces, the body gradually begins sending fewer and fewer signals to the feet, leading to distortions in pro-prioception and loss of innervation all the way up the kinetic chain. This is where Achilles and calf injuries are born!

I won’t go into too much detail about what shoes are best to buy, but I would encourage you to go and see a qualified Podiatrist or shoe specialist to pick the right shoe for your body, to rule this out as a potential cause.

Rapid Increases in Training Load & Over-training

This is a big factor with many distance runners and sports who play on a regular basis. The good news is the solution for this is pretty simple as all you need to do is rest more often. We all want to be the best athlete we can be but sometimes our determined focus on progression and performance can lead us to push too hard, train too long, or simply do way too much. It is in our nature to strive for progression and constant improvement which is a good thing but we can easily set goals that may be out of reach. We must respect exercise and acknowledge that recovery is equal in importance as the training itself.

With high intensity exercise like strength training and sprinting most people understand the body needs time to rest between workouts. However, with low intensity training like distance running this principle is often ignored and this is where over-training can become a real problem. At first you get away with the high volume of activity, it is only after a few months that little niggles and annoying injuries start to surface. These niggles are created from excessive training and lack of recovery and if ignored they elevate to chronic injuries that can take a long time to repair.

In order for the body to adapt, it must have a period of repair. If you cannot adapt to and cope with the physical and mental demands of training, you will quickly become exhausted. And it is in this exhaustion stage that injuries occur. There is a constant balance between training enough to produce results and allowing time for recovery so the body can adapt. Your body gets stronger when it is resting.

These are the things to keep in mind when working towards a training goal.

• If you do not train enough and the workload is insufficient to overload the body's capabilities, NO adaptations will occur!
• If the workload is too great (progressed too quickly, performed too often without adequate rest), then fatigue follows and subsequent performance will be reduced. Again NO adaptations will occur!
• Work alone is not enough to produce the best results; you need time to adapt to training stress.
• To encourage adaptation to training, it is important to plan recovery activities that reduce residual fatigue. See article - Best Foods & Methods To Promote Faster Recovery
• The sooner you recover from fatigue, and the fresher you are when you undertake a training session, the better the chance of improving and having positive adaptations.

The best part is you will remain injury free. Check out the graph below to give you an idea of what the ideal training program requires.

In addition to too many workouts is the principle of ‘gradual progression’. This means any increase in mileage or intensity of training must be slow and steady, otherwise injury risks are greatly heightened. A guideline of a 5-10% increase in mileage per week is a good rule of thumb. Adopting this measured approach allows the muscles and tendons time to increase their strength to cope with the extra stress. Many Achilles injuries in distance runners are caused by athletes increasing volume or intensity too rapidly.

I have often seen many calf injuries occur in basketball players who participate in tournaments that run for several days that require players to play multiple games on one day. As the players are not used to this type of stress and demand the muscles, tendons, and ligaments are exposed to excessive forces that can easily lead to stress injuries.

Correct training methods and programs are required to fully prepare players for this type of tournament play. You can read more about how to structure your training workload in this article – How to avoid over-training and maximize your results

If you have implemented all the changes mentioned so far there is a good chance you will be starting to get on top of your problem. However, you must continue with these last three steps to ensure it never comes back.

Hip Mobility

The hip is very often a problem for joints in the lower limb and can play a big part in directing forces into the Achilles tendon. Dr Vladimir Janda says it best, “The pelvic chain is the key in most musculoskeletal dysfunction”.

If the gluteus maximus and hip abductors do not control the hip sufficiently during the cushioning phase, then the hip may drop laterally on the swing-leg-side, or the pelvis could tilt backwards. Either of these would result in a greater inward rotation force on the knee which would result in causing a greater inward rotation of the tibia, which in turn inwardly rotates the ankle, eventually increasing the amount of pronation at the foot. Remember how I said in the introduction how closely this injury relates to ACL injuries? This is known as “the point of no return” with knee injuries, and why you see over 70% of ACL injuries sustained in non-contact situations. To protect the knee from damage the foot will compensate by pointing outwards. While this may help the knee it now causes huge problems for the ankle joint and this is where your calf and Achilles tendon are exposed to injury.

This is a perfect example of how the whole leg chain is dependent on all the links working correctly. If one area, such as the hip, does not perform its correct function, then other areas are adversely affected. Simply performing some calf stretches and calf raises will do very little to change this problem.

Where do you start, and what exercises should you use?

This is impossible to give you a definitive plan to follow for each person is different. You will need to complete a thorough assessment looking for mobility restrictions or compensatory weakness and dysfunction at the hip and pelvis. I am very suspicious of lateral pelvic tilt with a problem on one side of the body and this can be a complex problem to correct. I will often begin with simple mobility tests and exercises before progressing to more dynamic movements that mimic functional movement.

Watch the videos below to see more on this.

Once I have addressed hip mobility I must observe how the person uses the hip during movement. And one of the best ways to observe this is with the Romanian deadlift and the single leg stance.

Hip Function & Strength

Anyone who has read any of my previous articles about injury in the hip or knee region will know how much I emphasise using the Romanian deadlift (RDL) to correct movement dysfunction and muscle imbalance. The deadlift is such a great way to improve hip mobility while simultaneously improving core stability of the spine and gluteal strength of the hip.

In the rehab field the RDL is often referred to as a hip-hinge as it requires very little knee movement but a large degree of hip movement. Anyone working with lower limb injuries will know how much influence the hips have with these injuries and often tightness with the hip flexors and weakness with the hip extensors is a big part of the problem. The deadlift and in particular the RDL is a perfect remedy for these injuries as it demands hip mobility with strength from the posterior chain.

While the bilateral RDL is a great start to retraining the anterior pelvic tilt, improving hip mobility, and gluteal strength, it will have little effect on correcting the weakness permanently. Why? Firstly, it is very rare to find two hips with the identical problem and the single leg exercises expose any compensation and weakness you will not see in the bilateral exercises. Secondly, the bilateral exercise neglects the important role the feet must play in providing stability of the leg and its critical interaction with the hip during the action of walking.

This is where I progress to the single leg stance for it demands significant more stability from the feet as much as the hip and it is these areas that most lower-limb injuries like Achilles tendon and calf strains are created.  The muscles of the feet must provide adequate stability to guarantee optimal alignment of the ankle, knee, and hip when we walk.

Single Leg Stability

This is where I will use exercises like the toe touch drill or the single leg squat to find out what is going on when the person moves. They may have passed every test up to this stage where we have pulled things apart or made it simple, but now they must integrate the entire system together within a blink of an eye. It is amazing how much information a single leg exercise can reveal about where the compensation and weakness is coming from. It is also very important to understand that this movement will relate very closely to the running action. Without control of the single leg stance the person will have no chance of implementing an efficient running stride.

This is a quick summary of all the things that must happen simultaneously in the single leg squat for it to be completed correctly.

1. Foot must provide stability
2. Ankle must provide mobility
3. Knee must provide stability
4. Hips must provide mobility
5. Glutes must activate to ensure correct alignment of the lower limb
6. Thoracic spine must remain in extension
7. Brain must coordinate perfect timing of all these muscles and joints

When assessing this movement we start at the ground and work our way up, looking for clues as to where joints are not functioning correctly. What you will see is that every second joint needs mobility, and the other joints need the exact opposite being stability. In nearly every case of injury the joints needing stability are compromised, and forced into excessive movement due to a loss of mobility at the joints demanding this ability. This information is crucial to know in determining what course of action you may need to take, or what to investigate further when you see dysfunctional movement or pain.

Watch the video below as I take you through a detailed look at the single leg squat and all the things that it can influence poor movement.

I also suggest to read this article to see a more detailed explanation of all things used to correct a single leg stance – How to use the single leg squat as an assessment tool

We are nearly finished. Now we have to take a look at the running technique.

Running Technique

The impact and strain running puts on your body is substantial. With each step, up to 3 times your body weight goes through your joints. Times that by however many repetitions you do in a session (thousands), and you now begin to realise how demanding running is on the body.

Add dysfunction or poor technique to that and there is no wonder why so many people experience issues within the first 4-6 weeks once they commence or re-commence running after a lay off. Whether that be running on its own or through sport or any other activity. When looking at upright running mechanics (when into a normal running rhythm), the most common mistake people make, in my experience, is over striding which often results in a subsequent "heel strike" at ground contact. Not only is this inefficient but it can also lead to many preventable injuries.

Over-striding is when your foot contacts the ground in front of your centre of mass (in front of your hips as opposed to directly underneath) with each step. This results in a braking force which ultimately slows you down and puts more stress on joints, ligaments, and tendons.

Many runners, coaches and trainers still utilise and advocate a heel strike at ground contact. However, when you understand the function of the structures that occur at the sole of the foot and posterior (back) aspect of the lower leg (calf/ankle), it makes sense to utilise a midfoot ground contact.

Without getting overly technical, the Achilles tendon acts as a shock absorber, it recycles stored energy like a spring to protect joints up the chain and enhances running efficiency by allowing forward propulsion. In conjunction with this, the intrinsic muscles at the sole of your foot, stabilise the foot and ankle with each impact and assists in the absorption and transmission of force.

Optimal foot stability cannot be achieved with heel strikes, instead, large amounts of force are shocked into the foot and up the leg with minimal absorption as its pretty much results in bone hitting the ground.

In my opinion the most effective running technique is called the “pose method”. It involves landing on the mid-foot and underneath the same side hip at ground contact, and then using the hamstrings through a cyclic like action of the leg to propel the runner forward.

The pose method includes:

• A constant, slight forward body lean
• A mid-foot ground contact underneath the centre of mass (hip)
• A cyclic like action of the leg coming off the ground (swing phase) – pulling the leg through quickly and maintaining a bent knee throughout.
• Minimal ground contact time and increased cadence as opposed to longer strides. This allows for ground contact and reduces breaking forces, putting less strain on joints, ligaments and tendons.

Watch the videos below for explanations of how to implement this type of action.

Last but not least you must practice agility exercises that require explosive braking skills.

Agility Training

Once again this is another factor consistent with ACL injuries in sports. These are the very movements you are likely to see an injury to the knee or the Achilles occur. Being strong and able to run fast in a straight line is one thing, but being fast in multiple directions and the ability to slam the brakes on suddenly and change direction is arguably more important. There is no point developing acceleration if you cannot put the brakes on!

All of these movements are key ingredients you will require to complete the upcoming drills safely and efficiently. In every one of the videos you will hear me ramble on about "foot plant" as it is so important to executing these drills safely. The plant foot angle is intended to provide an optimal base for eccentric control of deceleration and concentric force production during the subsequent acceleration or push-off movement. If the foot plant is correct, the deceleration and the push-off movement become smoothly linked.

If the foot plant is poorly placed you will significantly increase your chance of injury and in particular to the knee and the ACL!

You may not be 100% perfect across all of these movements and that is fine, but you must have a good understanding of what good technique is, and more importantly where your weaknesses and deficits with these movements and joints are.

As long as you are working on this you can begin to introduce your agility work which if used wisely will help you to improve these areas anyway. Always remember stability is needed to gain strength, and strength is needed to produce speed and power and the ability to brake.

"Effective stopping demands a high level of eccentric strength demands. It is the proportionate bending of the ankle/knee/hip. Basic strength is a pre-requisite for force production and reduction."

Many of the exercises will demand the body to handle forces in an eccentric mode up to 12 times body-weight and be able to change direction and overcome those forces. This all must be done in tenths of a second. It is developed through exercises that develop unilateral and reciprocal leg strength.

I love to follow the BRAKES acronym I learned from Twist Conditioning when designing exercises and programs to enhance the skills of change of direction and agility.

The BRAKES acronym is as follows:

• Balance (Performance Balance)
• Reaction
• Agility
• K(q)uickness
• Explosive Speed AND Eccentric Strength

Spending time with agility exercises will improve the athlete’s ability to develop speed, quickness and agility by first learning to decelerate movement, stop, and quickly change direction. Training deceleration is essential to providing the athlete with the ability to perform instant changes of direction and explosive first step quickness without losing balance or momentum to lose an opponent. Most importantly, it will prevent injuries.

Watch the videos below for ideas of exercises to try.

I also suggest to read the article – 25 Agility Exercises to improve your ability to change direction

Special Reports with Additional Information

Below is a detailed PDF report about ACL injuries  and is the most detailed report I have ever put together relating to agility and change of direction exercises and injury prevention for sport. While I speak mainly about ACL injuries I could very easily have titled this an Achilles injury prevention program for most of the methods and exercises are identical. I originally created this report as a rehabilitation program for ACL knee injuries but decided to include a stack of additional information to use as a preventative program as well. This report provides you with detailed assessments and step by step instructions for implementing all of the mobility drills, strength exercises, functional movement patterns and agility drills seen in this article. The report to the right is the functional training free report with detailed instructions of how to improve your overall movement.

Summary

There is a lot more to preventing and correcting an Achilles injury than some calf stretches and calf raises. Like most chronic injuries there is not one single factor that creates the injury but a multitude of little ones combined together to create the perfect storm. This is why it can be very difficult to pinpoint what to do and what is really at fault for you may make incorrect conclusions based on poor results. It is only when all the factors are addressed at once that you can narrow down where the energy leak or dysfunction is coming from. I hope this article has given you some great ideas of where to look and enables you to avoid this horrible injury.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Functional Anatomy of the Pelvis and the Sacroiliac Joint - By John Gibbons
• Sporting Ankles - By Peak Performance
• Muscle testing & function - By Kendall, McCreary, Provance, Rogers, Romani
• The Vital Glutes - By John Gibbons
• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Back Pain Mechanic - by Dr Stuart McGill
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Dr Stuart McGill
• Ultimate Back Fitness & Performance - by Dr Stuart McGill
• Core Stability - by Peak Performance
• Athletic Body in Balance - by Gray Cook
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek
• Twist Conditioning Sports Strength - By Peter Twist
• Twist Conditioning Sports Movement - By Peter Twist