How To Fix Achilles Tendonitis - Part 1: Understanding The Problem
The Achille’s Tendon is the biggest tendon in the body. Which means that it’s responsible for handing a lot of leverage when the forefoot hits the ground.
Understanding the Achilles is impossible without paying homage to the heel. Without the heel, we’re not standing, using our hands freely, or walking with minimal effort.
If you look at most other legged mammals (and birds), you see a heel that’s lifted off the ground. Essentially, their forefoot is the only touchpoint.
This gives them greater leverage for pushing off the ground in movement. Which means they have more power, explosiveness, speed, and agility.
Humans sacrificed a lot of that when our heels dropped to the ground.
But hey, we got opposable thumbs and the ability to throw, hang, and use iPhones in exchange.
However, just because our heel is on the ground does not mean the original function of the Achilles is different. It still has to handle a lot of force.
Historically, humans would have learned to stand, walk, crawl, run, skip, and jump without shoes. This means we would have developed an active forefoot.
And you don’t have to take my word for it either. Just take your shoes off and walk down a paved sidewalk or gravel road. You will naturally step more softly.
The cumulative stimulus of these small motions would add up to an incredible foot, ankle, and lower leg tissue strength.
Over the course of a typical human adolescence, we’re talking billions of foot-ground contacts. That’s a super solid tendon.
But if this was the only input, our achilles would essentially turn into bone.
Thankfully, this natural development would have happened before we had couches, 90-degree angle chairs, and uncomfortably high toilets.
Our ancestors sat on the ground. A lot. If you look at videos or pictures of people who exist outside of modernity, you see an intimate relationship with the ground.
This involved a lot of kneeling, deep squatting, lunging, and full plantar splay stretching. All fancy words for positions that get the toes and ankle in deep stretches.
This combination of high rep movement and high volume stretching would have kept the tissue of our foot, ankle, and lower leg in a sweet spot. Pliable yet strong.
It’s important to understand that the Achilles Tendon does not exist in isolation.
The modern approach to rehab likes to make things simple in the wrong way. Almost every joint, tendon, and muscle is understood through the lens of a cadaver.
Meaning, we visualize these tissues only after someone has died, had their blood drained, skin peeled back, and fat scraped away. You know, lying on a cold steel table.
While this is the best we could do for most of history (silly ethics, amiright?), it paints a very static picture of the human body.
We are taught to think of pieces of the body in isolation. THE plantar fascia. THE Achilles tendon. THE Soleus. THE ACL.
And so when something hurts, our medical professionals treat THE issue.
But the body is not a whole made up of component parts. We are not a car with an easily exchangeable oil pan or transmission fluid. We are a cohesive, fluid whole.
So, when we look at something like the Achilles tendon, we cannot think of it as separate from the plantar fascia. In fact, they are the same tissue.
Meaning, the Achilles tendon literally wraps around the heel and attaches to many different parts of the foot.
To be clear, It’s not just your Achilles Tendon. The tendon is wrapped in something called the Achilles Paratenon. And that’s covered in sticky fascia.
Just like all sticky things, fascia sticks to whatever it contacts. So, it’s not fair to think of the Achilles as a band wrapping around a corner.
It’s better to think of it like elastic cling-wrap that’s being stretched around the heel. It’s making lots of connections to the bone at many points to increase stability.
The point is that the Achilles tendon is inextricably linked to the plantar fascia.
That’s why people who have chronic Achilles issues inevitably end up with plantar fasciitis too. And why their cadavers will show a thickening in both areas.
Simply put, if your achilles is acting up, you have to address the muscles and connective tissue on the bottom of the foot too.
Additionally, you cannot think of the Achilles as separate from the calves.
But, to be more accurate, this means all of the muscles on the back of the lower leg. Smaller muscles like the plantaris can make things messy.
Muscles are tissue that we can consciously control (for the most part). Meaning, they can shorten as the fibers pull together. And they can lengthen as fibers pull apart.
In the case of the calf muscles, these bulbs taper down to a tendon on either side. One side ties the muscles into the bones around the knee. The other is the Achilles.
Generally speaking, a muscle that is weak becomes stiff. It’s simple to imagine that if we have a poor connection to it, it won’t get the active work it needs to stay supple.
So, weak calves are stiff calves. And stiff calves do exactly what they sounds like… Move poorly and create passive strain on the tendons.
But I know you might be thinking that you do so much movement on your feet. How on Earth could your calves still be weak?!?
Well, remember that most people grow up wearing shoes.
Which means that the billions of small stresses that the forefoot and calf would have actively navigated are mostly absent.
In order to reserve mental space for watching social media, the body has gotten great at simplifying repetitive movement.
In the case of walking, we roll through the heel to spread out force. And we can do this mindlessly. Literally, we have spinal reflexes that catch us if we fall.
If you couldn’t, you wouldn’t be able to scroll Instagram and walk at the same time.
Add to this the addition of thickly padded shoes with a curved sole and you get 10,000 steps a day with almost no calf engagement.
In other words, you’re on your feet all day without actively using your muscles.
This means your connective tissue and bones are picking up the brunt of the force. Hence why your knees and back can get stiff after standing or walking.
But fixing this isn’t easy because the calves are stubborn muscles.
They’re meant to take a beating so they are hard to grow. Essentially, you need lots of volume to get them to respond.
What’s worse is that when these muscles aren’t moving through a full range of motion, their associated tendons get shortchanged too.
As a result, the entire stretch of tissue from the toes to the calves hardens into a weaker, stiffer, and more fragile unit.
To be specific, this happens when special cells called fibroblasts throw down layer on layer of fascia. When we move, this fascia remodels. When we don’t, it thickens.
Think about this as snow falling on a city. When the cars drive on the main road, it doesn’t accumulate. But where there isn’t action, snow builds up and freezes over.
If we didn’t need to move, this wouldn’t be a problem. We’d just turn to bone.
But since most people want to continue running, jumping, hiking, playing sports, or walking, this increasing stiffness creates a problem. Something has to absorb force!
This means things start to tear. And this almost always happens around the tendon insertion around the bone. That’s the weakest point of the chain in most cases.
When these small tears and irritation make things sensitive at back of the heel, we call it Achilles Tendonitis. Or something like that.
If it’s at the base of the heel on the bottom of the foot, we call it Plantar Fasciitis. Or some version of that.
If we ignore these small pains and muffle the symptoms with orthotics, stiffer shoes, braces, icing, pills, and quick-fix “treatments”, the problem gets worse.
And that’s when we end up in the horror story of a full tear.
But it’s important to remember that diagnoses are just made up names to describe the sensation of irritation, fragility, and stiffness you feel.
In this case, these sensations are happening somewhere around the heel.
And rather than getting caught up in a diagnosis, it’s more effective to understand this pain as the result of underdeveloped, weak, and overloaded tissue.
In the case of the Achilles, our job is to explore to find out what part of the chain has become the weakest link. Get that moving and we remove the pressure on the system.
But we’ll cover that later in this series as we discuss the rehabilitation process.
First, let’s pause to summarize everything we just covered.
The body is one connected set of tissue. Everything impacts everything.
The modern approach is to isolate tissue and treat pain. This doesn’t work.
The Achilles tendon is directly connected to your plantar fascia.
This connective tissue attaches to the muscles of the foot and calves.
If you have a poor connection to your muscles, they get weak and stiff.
This means the tendons are not getting the stimulus they need to stay pliable.
Essentially, all of this tissue (muscle, fascia, tendon) stiffens and dehydrates.
This creates a more fragile system that is less adaptable to dynamic movement.
If you continue to strain this tissue, it tears at the attachment points.
Small tears and irritation create the nagging sensation of “tendonitis”.
Accumulation of small tears or single big impulses lead to Achilles tears.
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