Measures to Strengthen and Prevent Achilles Injuries

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Hi, my name is Tony and I ruptured my Achilles tendon earlier this year. 

It was the first significant injury of my life and one that, as it happens, happens often (and without warning). Since my injury six months ago I’ve met numerous people who have gone through the same dumpster fire of an experience.¹.And as a result I’ve documented my rehab and post-surgery training via my IG account using the hashtags #findyourtrainablemenu and #achillesgate2020.

However, I figured something more in depth and robust with regards to explaining the mechanism of Achilles rupture (as well discussing prevention) could be of benefit to the masses. To that end, my fellow coaches and colleagues – Dr. Bo Bobenko and Shane McLean – offered to write something for the site to cover exactly that.

For what it’s worth: I peppered in a few comments myself along the way.

I hope it helps and enjoy.

Copyright: lassedesignen / 123RF Stock Photo

Measures to Strengthen & Prevent Achilles Injuries

When admiring yourself, flexing away, do you ever give thought to the unsung hero of muscle? You know, the things that attach the muscles to your bones: the tendons. You probably don’t give much thought, until it’s too late.

Unless you’ve had your head in the sand, you know our resident funny man and light saber fighter extraordinaire, Tony Gentilcore tore his Achilles tendon while hanging out with the in-laws in Florida six months ago

NOTE FROM TG: It’s important to remember that correlation doesn’t equal causation here. My in-laws didn’t cause my Achilles rupture…;o)²

Tony, a big strong guy with no history of serious injury performs a drill he has done before and boom, suddenly it’s not his day, week, month or even his year….

NOTE FROM TG: For those interested, HERE is a great depiction of the exercise (and mechanism) that served as the impetus to my injury.

The “Jump Back” Start

This video almost exactly showcases what happened. The only difference is that I didn’t preload my sprint with a three-hop thingamajig (just one), and in my case, once my back leg planted, I fell immediately to the ground.

Plus I may or not have been wearing a cape.

A Little Background On The Achilles Tendon

The tendon is named after the ancient Greek mythological figure Achilles (and not Brad Pitt) as it was the only part of his body that was still vulnerable after his mother had dipped him into the River Styx. Plus,  we all know where he got shot with an arrow, at least in the movie. 

The Achilles tendon is the thickest and strongest tendon in the human body. It’s the tendinous extension of the three-headed calf muscle soleus and the two-headed gastrocnemius and it inserts on the calcaneus (heel). 

The contraction of the calf muscles transfers a force through the Achilles tendon, which enables plantar flexion of the foot and allows for actions such as walking, running, jumping, bounding, sprinting, and skipping.

During these movements, the Achilles tendon is subject to the highest loads in the body, with tensile loads up to 10 times the body’s weight.

The reasons for this are twofold: First, the Achilles consists of type II fast-twitch fibers, and this elasticity allows for rapid forward and backwards movement. Secondly, the tendon type I fibers of collagen and elastin which are lined up parallel from calf to heel, are responsible for the Achilles tendon strength. (1) 

The Achilles due to its strength and its ability to handle high loads makes it a resilient tendon, which is good and bad. Good because it can handle lots of load and bad because it’s not always going to send pain signals to the brain every time something goes wrong. 

This is one reason why Achilles tears can happen without warning. 

Types Of Achilles Injuries

When your achilles hurts or you feel pain you’ll often be told ‘You got tendonitis bro’ But there are few different types of Achilles injuries besides tendonitis. 

1. Achilles Tendon Tears

This is the mack daddy of all tendon injuries and like with Tony, it often happens without warning. If you hear a pop and a pain that radiates up your lower leg, there’s no second guessing what you’ve done. 

NOTE FROM TG: The best way I can explain the sensation is that it feels like someone taking a sledgehammer right to your ankle. It doesn’t tickle.

2. Achilles Tendinopathy

Tendinopathy is a degeneration of the collagen protein fibers that form the Achilles.  Its symptoms include increasing pain at the heel, stiffness, swelling at the back of your ankle, and a grating noise or creaking feeling when moving your ankle. 

3. Achilles Tendonitis

Tendonitis is acute inflammation of the tendon and its symptoms include pain and stiffness in the morning, pain that worsens with activity, extreme pain the day after exercise. 

There are two types of Achilles tendonitis: insertional and noninsertional.

• Insertional Achilles tendonitis affects the lower portion of your tendon where it attaches to your heel bone often caused by bone spurs. 
• Noninsertional Achilles tendonitis involves fibers in the middle portion of the tendon. 

4. Achilles Tendinosis

Tendinosis is the non-inflammatory degeneration of the collagen fibers of the tendon. This includes changes to the structure or composition of the tendon that results from repetitive strains without proper healing. 

Achilles and calf tightness are common causes of Achilles tendinosis. Plus insertional Achilles tendinosis is often associated with heel spurs as it rubs against the achilles causing small tears.  

Activities That Cause Achilles Tears

Achilles tendon tears happen to people who do things where they quickly speed up, slow down, or pivot, such as:

• Running
• Gymnastics
• Dance
• Football
• Baseball
• Softball
• Basketball
• Tennis
• Fighting Zombies, Salsa Dancing, Talking About Feelings (<— things added by Tony)

Achilles tears tend to happen when you start moving suddenly as you push off and lift rather than land. Sometimes these abrupt actions can be too much for the tendon to handle. 

Here is the statistical lowdown on how tears happen. 

• 90% of injuries occur with an acceleration/deceleration movements mentioned above
• Only 15-20% of men reported any sort of heel pain/tendinosis before the injury
• 50% of men who have an Achilles Rupture had tissue degeneration before the injury
• Typically occurs 30 minutes after moving around 

Research has shown Achilles tears include clear degenerative changes before the rupture but many of the Achilles tendon ruptures occur suddenly without any preceding signs or symptoms. (2)

For instance, Tony’s tear was caused by aggressive eccentric load (jump back start) combined with poor load management  and then “jumping” right back into sprinting. 

NOTE FROM TG: Exactly. Part of the problem was sheer bad luck. But too, up until that point – eight or so weeks into pandemic quarantine – I hadn’t been doing much (if any) plyometric activity.

Unfortunately, this doesn’t count.

👇👇👇👇

 

View this post on Instagram

 

A post shared by Tony Gentilcore (@tonygentilcore)

But he wasn’t in any pain.

In his mind it was all systems go. The main point here is there’s not one definitive “cause.” of Achillies tears.  It’s equal parts shit-happens and bad luck. 

Big Picture With Tendon Pain Modulation

1. CNS Response

The CNS is incredible at responding to and adapting to pain modulation. This is a good thing to keep going and for our survival but makes understanding our tendon health much trickier because damage can exist without pain. 

2. Load Management and Exposure

This is probably the single most important component to tendon health that we should seek to understand and pay attention to. It can be intimidating to truly track your loads/exposure, but the better we get at it, the more we increase our chance of avoiding injury.

All of the research continues to bear out controlling the load on tendons is the best way to make any kind of change. The analogy I often use when explaining this to patients is the comparison to a wall that continues to take damage or have a crack and we need to keep adding spackle to it every 48 hours to reinforce it and strengthen the overall structure.

How To Prevent Achilles Tears

The experts and research are a bit mixed on this therefore the safest approach in my mind is to increase the variety of loads you place on the tendons. 

Unless training for a specific sport or activity, then we should focus on preserving the natural capacity of what the tendon is meant to do, which is to absorb and transfer forces effectively in the simplest of terms.

Pogo Jumps

Heel Taps

A Daily Routine to Incorporate Into Your Movement Prep

You need tendon loading with multiple angles and a plan for tempo for the long term. My go to is often for heavy slow resistance, four seconds eccentric, three seconds concentric, carefully plotted over 12 weeks.  There is strong research to support this concept.

A quote I really like about this:

“We start dying when we stop jumping.”

Assessment can be vital, but there is no Gold standard. Personally, I use my hands to assess pain tolerance to pressure at the tendon as one way to track progress of tendon health, but this is not well supported by research and requires me to have physical access to you which can be limiting indeed.

If you haven’t loaded the tendon recently, some easy options are 

1. Calf raises with full range of motion, faster up slower down, aiming for 20 reps per leg as a baseline for tendon health. This allows us to look for asymmetries as well as an overall deficit based on training age.

In terms of a plan to increase your activity tolerance:

Firstly, I like to think of the principle of 10% per session as a safe progression. Meaning, in terms of a weekly volume a  nice progression is to add 10% to the previous week.

Secondly, the quote that drives me here is:

“We tend to overestimate what we can accomplish in a month and underestimate what we can accomplish in a year.”

Therefore, a long term strategy for tendon health should be implemented.

Exercise Is Important But So Is Diet

It goes without saying reducing stress, sleeping soundly, and eating nutritious foods not only helps you…

…but your tendons specifically.

But I said it anyway. 

However, there are a few supplements on top of eating and sleeping well, reducing stress and moving better which help heal and keep tendons resilient.  Notice the word supplement. These should NOT be your priority to help your tendons stay healthy or heal after an injury.

Primary should always be eating real high quality foods.

The first and most obvious supplement is Vitamin C.

Vitamin C is absolutely essential for synthesis of collagen which makes the tendons type 1 slow twitch fibers strong. Pre clinical studies have shown vitamin C has the potential to accelerate bone healing after a fracture, increase type I collagen synthesis, and reduce oxidative stress after a tendon injury. (3)

Supplementing with Vitamin A helps the process of forming new tissue (collagen) and your immune system. A stronger immune system can prevent microorganisms from further damaging your tendons. 

Vitamin E has anti-inflammatory properties which helps reduce tendon inflammation, and helps the healing of damaged tendons which can lead to a reduction of tendon pain. (4)

The science and research is limited on diet and tendon health and there are probably other things out there that can help. It is an ever expanding field so stay tuned. 

NOTE FROM TG: At the moment, I like the Collagen Peptides from Momentous because they use Vitamin C, and FORTIGEL® , which is a formula designed and tested to promote collagen synthesis in tendons and ligaments. 

(👆👆👆 Discount:  GENTILCORE25 gets you 25% off your first order when you sign up for a subscription 👆👆👆)

Most collagen out there is basically like buying a pack of J-E-L-L-O, focusing on hair, skin and nails, but this stuff is solid and provides a bit more heft. 

Here’s the daily “Wolverine Cocktail” I’ve taken every day since my surgery on June 1, 2020:

• 1 Scoop Momentous Collagen
• 1 capsule each Curcumin, Boswellia, Bromelain
• 5-10g Omega 3
• 1 Energon Cube (but only every other Thursday)

I’d like to think the cocktail added an extra “x-factor” toward my recovery.

I mean, here’s me hitting a relatively easy 500×3 on my deadlifts six months later:

 

View this post on Instagram

 

A post shared by Tony Gentilcore (@tonygentilcore)

Wrapping Up

Tendon tears often happen without warning and it doesn’t discriminate on whether you’re fit or not. One moment you’re about to move quick and the next you’re on the ground. 

The best things you can do before engaging in risky tendon activities:

1. Warm up properly
2. Load the tendon appropriately
3. Reduce stress, eat and sleep better. 

But as you’ve seen by Tony’s experience, there are no guarantees. Please do your best so you don’t hear the pop from hell. 

Authors’ Bios

Shane “Balance Guy” McLean, is an A.C.E Certified Personal Trainer working deep in the heart of Louisiana with the gators.

Dr. Bo Babenko is the owner of FitCare Physio focusing on virtual health coaching and helping people attack the 5 pillars of health: movement, nutrition, recovery, mindset, connection.

References

1. Michael Wong; Achraf H. Jardaly; John Kiel.Anatomy, Bony Pelvis and Lower Limb, Achilles Tendon.
2. . T A Järvinen et al. Achilles tendon injuries. Curr Opin Rheumatol 2001 Mar;13(2):150-5
3. Nicholas N DePhillipo et al. Efficacy of Vitamin C Supplementation on Collagen Synthesis and Oxidative Stress After Musculoskeletal Injuries: A Systematic Review. Orthop J Sports Med 2018 Oct 25;6(10)
4. Christopher Tack ,Faye Shorthouse Lindsy Kass. The Physiological Mechanisms of Effect of Vitamins and Amino Acids on Tendon and Muscle Healing: A Systematic Review. Int J Sport Nutr Exerc Metab 2018 May 1;28(3):294-311.

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