Tuesday, June 16, 2009
Deconstructing An Injury - My 10 Years With Achilles Tendonitis
As athletes, there is nothing worse than the stabbing pain of an injury we know deep down when it hits won't be gone the next morning. But when it comes to the Achilles tendon, morning is when the pain is usually at its worst making it difficult to walk. I should know. On and off for almost 10 years I, trained and raced with what I thought and was told were bouts of Achilles tendonitis. For the record it was actually tendonosis, but I didn't understand that until much later.
For the first half of my running life, where I raced 5k's and 10k's almost every weekend, I was never injured from running. If you include the running I did for high school and college basketball, I ran for about 15 years injury free. This all changed when I was 32 when I went into a running store in Dallas and on the advice of their "shoe guru," I switched from the shoes I'd trained and raced in for several years to a more stable and straight lasted trainer. He also got me to switch from the snug fitting size 9.5 I'd always worn to a size 10.5 noting I was destined to lose some toenails if I ever tried to run a 1/2 marathon or longer race. At the time my longest runs were around 12 miles. From the entries in some old logs, I found it was somewhere between 3 and 4 weeks after switching shoes I felt that first twinge of pain just above the heel.
For the first few years after that I wasn't inconvenienced more than a couple of weeks out of the year. I'd feel the pain in my right Achilles tendon, stop running for about 3 or 4 days then go back to my routine. This all changed when I started training for triathlons. My actual running frequency decreased from 5 days per week to 3 or 4 days but the time I spent working out overall with the addition of two other sports went up. When this happened the frequency and duration of the pain went up as well.
By 2002, which was the last year I raced triathlons before taking a 5-year break, I was reduced to running twice per week with pain in both tendons. During racing season I normally did one speed session and one distance session. The pain was manageable and my racing didn't suffer too much as long as I kept the distance below 10 miles. But by the end of the racing season I spent about a month rehabilitating for the next year. My rehab typically involved rest, ice, therapeutic magnets, and acupuncture.
I found some limited relief in the earlier years I struggled with this injury using primarily ice and rest. But as time passed, I found ice became less and less effective. This is when I turned to acupuncture and magnets. As I found icing less and less helpful, I also started to do more research and learned the difference between tendonitis and tendonosis. I believe the reason icing can be a less effective protocol is where the distinction between tendonitis and tendonosis comes in. Tendonitis is marked by the presence of inflammation. Where there is inflammation, icing can be very helpful. But in the case of tendonosis, there is tissue degeneration taking place. In this case icing may only be beneficial in longer and longer durations (multiple hours versus a few minutes). Probably because the area becomes so cold the body naturally responds by sending more blood to the area to warm things back up. And increasing blood flow to the affected area is necessary for healing to occur. Possibly this is why super long icing durations may work better than shorter ones. But because inflammation isn't present and hours long ice baths can present both time and logistical challenges to busy people, I have used something as simple as aiming a strong jet in a hot tub at the affected area. Other options are to get regular cross frictions or to attach spot magnets to the tendon during sleep.
As time went on and I tried more of the treatments I found out about, I realized I was only treating the symptoms and not addressing the cause. I didn't stop racing or running during my 5 year hiatus because of Achilles problems. I had other life and health issues that led to the decision. It was in dealing with my overall health at this juncture in my life that I came to look at injuries and illness more fully with regard to the role they play in life. In a nutshell from my experiences I began to look at injuries and illnesses not as obstacles or setbacks placed in my way by a body that was not cooperating with my goals, but as my body's way of communicating to me what was truly necessary to maintain optimal health and well being. I discovered my body had a language of its own, complete with its own intelligence, and if I could learn to understand it and listen to the knowledge it conveyed I'd be the better for it.
Again, from looking at past logs, I became aware of some patterns. One was I could run as much as I wanted in the winter without pain. This was long or short, fast or slow. So, neither distance nor speed seemed a problem. I also noticed my more severe flair ups tended to come in mid July and give me trouble through October, clearing up by November. This information led me to two conclusions. One was that my hydration was deficient during the summer and that my diet was also off not providing high quality essential nutrients. In short, during the summer I ate like crap and I wasn't drinking enough water. From this perspective I became aware that when I was placing the highest demands on my body was the exact point I was paying the least attention to how I fueled and hydrated.
The hydration piece was simple to correct. Drink more clean water. Not sports drinks, but water (sports drinks have their place in training, but nothing can replace the cleansing properties of clean water). I’ve learned to pay particular attention to my water intake during the summer when I was naturally going to be more challenged to hydrate properly because of heat and increased training loads. Diet wasn't as obvious, but I made some basic assumptions just by thinking about the same challenges that were making hydration difficult. The first thing I began to notice was as my training and racing increased during the summer months the quality of my food actually started to go down. Both the increase in training and the travel associated with racing often made it harder for me to source, prepare, and eat high quality nutrient dense meals. Added to the issue of diminishing food quality was the natural occurrence of my food quantity increasing due to the greater caloric requirements necessary to support my increased activity and intensity during the season.
After I looked at the general quality of my diet (basically where I was getting my food from and what it generally consisted of) I decided to get some help in finding out whether or not I had any food sensitivities or allergies. After a couple of tests, I found I was indeed eating some things that I was either sensitive or allergic to. I took this step as a precaution after cleaning up my diet and moving it to more nutrient dense foods because even after I stopped racing, I found I still struggled with my Achilles tendons. Basically during the time I wasn’t racing, when I wasn't running at all, I was still dealing with Achilles tendon pain in both legs as bad or worse than when I was running actively.
As I said, the Achilles injury most runners face is of a degenerative nature. What this means is their tissue is somehow degrading. During exercise we basically damage our muscle tissue to a small degree, but the process of adaptation to our training stimuli repairs this damage and we come back stronger than we were previously. With the Achilles tendon this was not happening. Some of this can be attributed to the lower blood flow in the region. But for the condition to get chronic it has to be more than that or the other rehabilitative protocols would work more effectively and provide a long lasting benefit. Apparently in chronic cases the accumulated damage from training somehow goes unchecked and grows into a long-term injury.
I did some research and found that people with digestive problems or who had food allergies and or sensitivities often had higher incidences of Achilles tendon issues. This could have something to do with the body's nutrient balance, toxicity level, and/or its alkalinity. One or all of these things together could hinder the body’s overall ability to repair itself. The quality of rest may also come into play as well. When I started racing again, I began to monitor my intake of certain foods and increased the level of leafy green veggies in my diet dramatically. Based on the testing I had done, I now avoid foods that are members of the nightshade family such as eggplant, tomatoes and potatoes and I limit my intake of vinegar and alcohol, which also seems to help. But your trigger foods, if you have them, may differ. Since I began to pay particular attention to my food intake (actively addressing things such as body alkalinity, food sensitivity, proper hydration) and aggressively guarding my sleep time, I have been able to run pain free.
The last issue to address was the fit and type of shoes I was running in. Over the years, I had sized my shoes up to allow for extra room in the toe box. Because of this my shoes then stopped fitting well in the heel. I've discovered for me, a snug fitting heel is an essential component to keeping my Achilles problems at bay. I also noticed from years of selling running shoes myself that people who trained and raced in flats or the most minimal shoes tended to be injured less. This is why in addition to sizing my shoes back down to the size 9.5 I originally ran in, I started using only racing flats or the most flexible lightweight trainers for my training and racing. To prepare for the switch to wearing these types of shoes exclusively, I spent a great deal of time walking, up to 10 miles several times a week, to strengthen my feet and lower legs. I also incorporated standing and balance poses from yoga to speed up the process and aid in recovery. It is my personal belief the reason people who trained and raced in flats weren't injured was because they had developed stronger feet and lower legs -- not because they were gifted.
In the end I think finding the proper nutrient balance, amount of rest, and hydration protocol may yield more long term benefits simply because there would be less chance of one or all of them inhibiting your body's normal healing response to training and thus less chance of becoming injured in the first place. However once an injury occurs, paying close attention to these things and addressing them can speed recovery. Then all that is left to deal with are any structural (muscular or skeletal) imbalances and any equipment fit issues that may have also contributed to the injury.