Tendinopathy

[resolve10]

Took up running 10 years ago in my mid-20's. Not naturally gifted by any means, trained hard to get my 5k time down from a baseline of 27 minutes to 21 minutes. At my peak I was running around 20-25km a week spread over 3 or 4 runs, built up this slowly and followed all the usual advice. Not huge mileages by most runners' standards. My longest run was a half marathon in 2017.

I kept breaking down with a mix of achillies tendon (right leg) and adductor tendon (left leg) injuries. I could run on them but they would hurt a lot the next day, to the point that I knew it was a terrible idea to go out for a run.

I saw an NHS physio initially, who prescribed calf raises and other exercises. This worked to an extent, as in it cleared the injury after a mixture of rest & calf raises for around 2 months, but after gradually building up the running volume the same thing would happen again. The pattern tended to be 2-3 months of running followed by 2-3 months of waiting for it to settle down.

I've been stuck in this pattern for about 5 years now, my 21:00 PB was set in 2016. I've since seen a private physio, an osteopath and a running coach who all made a slight impact initially but never actually solved the issue, it always comes back eventually.

I'm now convinced the damage to the tendons is so bad that they require some kind of medical intervention, either through steroid injection or surgery. I should point out I've also had two knee surgeries in my right knee the past 15 years (ACL and partial meniscectomy) but my knee doesn't give me any grief when running.

My question is what are my chances of having anything about this done on the NHS? What would the best path be to treatment? Or are there any other alternatives I should be looking at to get this fixed?

My goal is to be able to go for a run whenever I feel like it. Currently I allow myself one 5km run a week as I know this level of activity is low enough to stop it flaring up, but I still feel the tendon pain occasionally even at this volume. Long term I'd love to get back down to low 20's 5km pace.

[sawman]

Injury basically boils down to an imbalance in load versus capacity.
Sounds like you need to get to the bottom of whats causing your lack of capacity.

https://m.youtube.com/watch?v=H1rp_v4Dr3g


Sounds like you have some adverse lower limb mechanics so maybe seeing a podiatrist / physio who is well versed in running mechanics

[resolve10]

This is the conclusion I came to a couple of years ago, and the running coach I went to specialised in this.

She filmed me from behind/side profile on our first session, and after around 8 sessions filmed me again and my form had improved to the point she didn't think there was any significant issue with it, but the injuries persisted which lead me to believe that there is unresolved damage in there that needs treating.

[sawman]

Maybe you just aint got the bones for running.

I took my lad to a knee specialist a while ago for a persistent issue, he is a rugby player but got into middle distance running during covid whilst not playing.
The prof checked knee out, mri etc no issues found and suggested that maybe as a forward he should just stop the long runs as this exposed a capacity issue. At the time he could play rugby all afternoon and do training sessions without a problem

[Bill]

2-3 months isn't enough time to rehab a chronic tendon problem (think 6+). Plus you also need to work out what else is weak. Hams and glutes are prime candidates particularly given the knee history.

Steroid injection risks a rupture and rehab post surgery is at least as onerous as sorting it conservatively. There are other options like shock wave therapy and autologous blood injections but the evidence is poor so they're private only AIUI.

You could talk/send an econsult to your GP about referral into the local orthopaedic interface service. You'll probably get to see a specialist physio who may arrange a scan but tendons take persistence and time.

[resolve10]

sawman said:

Maybe you just aint got the bones for running.

This might be the case, and if so I can make peace with that, but running really helps me unwind and I'd like to be able to do it more if it's possible.

Bill said:

2-3 months isn't enough time to rehab a chronic tendon problem (think 6+). Plus you also need to work out what else is weak. Hams and glutes are prime candidates particularly given the knee history.

Thanks. That's pretty much what my running coach said, and I spent maybe an hour a night 5 nights a week working on glute & hamstring strength, as well as the calf raises for the achillies and general strength work. I did see some improvement, but eventually my calf/achillies flared up massively and had to stop running again, at which point I gave up on it for around 6 months and didn't run at all.

I don't think there's any way I could realistically have done more strength work during that period whilst holding down a full time job. I also did a lot of cycling, maybe 50 miles a week.

The trouble I've had with both these tendon injuries is how long do you leave it before running again? I could stop running tomorrow, strength train for 6 months and then build up the running again, but if it flared up again I'd be back to square one (and have missed out on 6 months of running, albeit at reduced volume).

[sawman]

generally speaking I would be looking at flexibility of hamstrings and calf complex in preference to strength of these muscle groups, building strength and bulk in these can exacerbate any underlying tightness.

Are you desk bound during the working week?

[Biglips]

I had the exact problem you describe for many years. Both Achilles were so sore I couldn’t run. Even walking was painful at times. Like you I am not a natural runner but enjoy it and was frustrated not to be able to do it

I saw lots of people, physio, gait analysis, insoles etc. These all helped a little but didn’t really fix it.

What eventually fixed me was getting trainers with a high heel to to toe drop which seemed to take the strain off my Achilles. I wear them all the time, even at work and have given up with all other footwear. It looks terrible but I don’t care!

I have gone from being consigned to the boredom of rowing machines to running 5k a day 5 days/ week. Good luck

[resolve10]

sawman said:

generally speaking I would be looking at flexibility of hamstrings and calf complex in preference to strength of these muscle groups, building strength and bulk in these can exacerbate any underlying tightness.

Are you desk bound during the working week?

Generally yes, desk maybe 75% of my working week. Flexibility was another thing I worked on with the coach, a lot of hip work especially.

Build wise I'm around 6"1, 14st.

I knew there'd be some knowledgeable people on here hence my post. The advice is generally following what I've been told by physios, coaches, osteopaths etc. The difference is they all had a vested interest in treating me, as it meant they got paid, but is it just possible that I'm worn out and can never return to my old levels of activity?!

[Bill]

You don't necessarily need calf strength as such - that increases load in the tendon and strength will improve far quicker than tendon will recover.

I'd also suggest only doing Achilles loading 3 times a week (less if you're running...). You're aiming to promote healing rather than constantly irritate it.

[sawman]

resolve10 said:

Generally yes, desk maybe 75% of my working week. Flexibility was another thing I worked on with the coach, a lot of hip work especially.

Build wise I'm around 6"1, 14st.

I knew there'd be some knowledgeable people on here hence my post. The advice is generally following what I've been told by physios, coaches, osteopaths etc. The difference is they all had a vested interest in treating me, as it meant they got paid, but is it just possible that I'm worn out and can never return to my old levels of activity?!

I would inclined to do some low impact stretching of hams and calf a couple of times during the day. - for calf something like heel drop off a step (but not the standing on tippy toes that you might have done before), or lunge against a wall or kitchen counter top - slow in hold until you feel the burn and then slow out.

also as biglips says, shoes with forefoot drop, such as brooks ghost or adrenaline are helpful.

[Speckle]

I used to have a lot of problems with my achilles tendons through running. In the end, I had a full running mechanics assessment by a sports podiatrist and custom made orthotics which seemed to solve all my mechanical issues.

In terms of rehab when tendonitis flared up prior to this, I found a program of progressively heavier weighted heel drops coupled with rest from running to be most effective (I tried acupuncture and electrical stimulation too so, perhaps they played a part). The heel drops were recommended by my physio at the time and I would urge you to speak to yours before trying them, in case your situation is different.

I hope you solve it, it's a very frustrating injury as it takes so long to heal.

[resolve10]

Bill said:

You don't necessarily need calf strength as such - that increases load in the tendon and strength will improve far quicker than tendon will recover.

I'd also suggest only doing Achilles loading 3 times a week (less if you're running...). You're aiming to promote healing rather than constantly irritate it.

That's interesting, because I've never been told that by any of the professionals I've seen, but I did get the feeling that some of the glute exercises (squats, single leg deadlift etc) were actually aggravating my adductor injury rather than helping it.

sawman said:

I would inclined to do some low impact stretching of hams and calf a couple of times during the day. - for calf something like heel drop off a step (but not the standing on tippy toes that you might have done before), or lunge against a wall or kitchen counter top - slow in hold until you feel the burn and then slow out.

also as biglips says, shoes with forefoot drop, such as brooks ghost or adrenaline are helpful.

Interestingly I wear Brooks Adrenaline

Speckle said:

I used to have a lot of problems with my achilles tendons through running. In the end, I had a full running mechanics assessment by a sports podiatrist and custom made orthotics which seemed to solve all my mechanical issues.

In terms of rehab when tendonitis flared up prior to this, I found a program of progressively heavier weighted heel drops coupled with rest from running to be most effective (I tried acupuncture and electrical stimulation too so, perhaps they played a part). The heel drops were recommended by my physio at the time and I would urge you to speak to yours before trying them, in case your situation is different.

I hope you solve it, it's a very frustrating injury as it takes so long to heal.

Are you now able to do as much activity as you like, pain free? Pretty much everything listed in here I've tried at some point, and I can get myself back to a point where I can run 2-3 times a week with no pain, but after a couple of months at this level they creep back in slowly.

I feel like I've ran out of things to try, but I see people running marathons at 70 and think what can I be doing differently to be struggling to do a tenth of that distance at half the age. I've even looked at things like diet, vitamin supplements etc, with no real difference.

[Speckle]

resolve10 said:

Are you now able to do as much activity as you like, pain free? Pretty much everything listed in here I've tried at some point, and I can get myself back to a point where I can run 2-3 times a week with no pain, but after a couple of months at this level they creep back in slowly.

I feel like I've ran out of things to try, but I see people running marathons at 70 and think what can I be doing differently to be struggling to do a tenth of that distance at half the age. I've even looked at things like diet, vitamin supplements etc, with no real difference.

I don't run as much as I used to now but, at the time yes, the main cause of my issues was in my running gait/mechanics so, once that was identified and resolved, things improved massively.

The secondary cause of my problems was a tendency to increase mileage too quickly so, there was a genuine 'overuse' aspect in my situation. I also got into the habit of doing a couple of sets of heel drops post run, to keep the tendon strong which I feel helped too.

Everyone is different though - the cause of your problem could be something else entirely which is why some sort of professional assessment is really important.

I would see if you can find a good sports podiatrist locally, no idea if that would be available on the NHS though. My biomechanical analysis was done at active viii in Henley on Thames, in case they're local to you. If not, I'm sure there will be something similar near you.

Edited by Speckle on Thursday 1st June 12:11

[Slowboathome]

Have any of the clinicians you've consulted talked about nerve involvement or neurodynamics?

I'd be interested to hear why they believe your tendons are damaged as opposed to some nerves getting cranky because they are being stretched/twisted/squashed in a way they don't like during repetitive motion.

This might be worth it a look: https://www.sportsinjuryclinic.net/sport-injuries/...