Friday Q&A: Achilles Tendonitis and Tight Hamstrings

The Achilles Heel of Achilles
was Literally His Achilles Heel

Q: Tight hamstring and Achilles Heel are my problems. What would you suggest to help? I will be 70 soon. Yikes!!!! And yes, aging is affecting my practice. 

A few months on both issues. I try and keep my calf stretched and rest and take ibprofen for tendonitis of the Achilles. I do my yoga practices at home being careful in how long I hold poses. Lunges help the calf; leg stretches with my strap; walking on one side of my heel is more comfortable and going down stairs is uncomfortable for the heel. The tendon that is behind my ankles is sore. I had to change shoes so no pressure was on the tendon. My doctor diagnosed my Achilles heel last year. Not much they can do for it. As I stated before, I am a very young 70, hahaha, and have practiced for almost 13 years with my local teacher. She is retired so I am on my own. I have already hurt a hip muscle in a class I took. I do notice, practicing on our own at home can cause injuries. So that is my story. 

A: I’m going to start by discussing the tendonitis of her Achilles tendon that this reader has, and then address the issue of her tight hamstrings and how to work with those given her tendonitis. (Readers, everyone has an Achilles heel—it’s that part of the body that his mother, Thetis, held while dipping Achilles into River Styx to make him invulnerable. What the reader who submitted the question has is tendonitis in the Achilles heel. —Nina) 

The Achilles tendon is considered the thickest and one of the strongest tendons in the body. It attaches the two large muscles on the back of the calf, the gastrocnemius and the soleus, to the heel bone. If that tendon becomes inflamed and begins to break down, almost always due to overuse, we call it “tendonitis.” The inflammation of the tendon is accompanied by swelling and tenderness, making it painful to walk normally on that heel. The risk factor for developing tendonitis in this location that is most relevant here is advancing age (others include being male, obese, flat footed, some types of sports training, having high blood pressure or psoriasis, and the use of certain antibiotics). In the case of our reader, she has already been diagnosed with the condition, so what can she do to improve or heal this painful tendon? 

Well, she is already trying a few things that are a good idea from where I am sitting: regular stretching of the calf muscles, wearing appropriate shoes to cushion the tendon area, taking appropriate rest, and being careful about how long she holds her yoga poses. The one adaptation she mentions that could be problematic is walking on the side of the heel, which may be less painful in the moment, but may lead to compensations in her way of walking or gait that in turn could lead to other parts of her lower body, such as her knee, hip, or lower back pain down the line. 

In light of this, I suggest that she wear the special fitted shoes with heel cushioning and good arch support (instead of being barefooted) around the house and even when she practices yoga for a while to avoid aggravating the Achilles tendon. I have had several students with a variety of foot/ankle issues do this in class while there tissues where healing to good effect. 

In addition to these practices and cautions, I recommend: 

1. Do non-weight-bearing yoga poses to take the pressure off the Achilles tendon and allow it to rest each day. This may aid in recovery over time. These poses include those done prone or supine on the floor, for example, Reclined Hip Stretch sequence or Locust pose, and supported poses on chairs, for example, Warrior 2 version 3. However, if you are finding that you can actually do all of your standing yoga poses without worsening your tendonitis symptoms, you could skip this step. 

2. Continue to stretch your calf to affect the Achilles tendon. Yoga poses that are good for this include:

1. Warrior 1 and 2 (the back leg calf) 
2. Half and classic Downward-Facing Dog poses 
3. Reclined Leg Stretch pose, version 1 with strap on arch or ball of foot with relaxed ankle and strong downward pull on foot 
4. Lunge pose, versions 1-3, and the Dropped Knee version with back toes turned under 

Also, see Shari’s post Stretching a Tight Ankle for two targeted stretches for the two big calf muscles 

3. Add in eccentric strengthening exercises. An example of this is standing in Mountain pose and coming onto your toes by lifting both heels up as high as you comfortably can and then slowly lowering your heels to the floor. It is the slow lowering that creates this kind of strengthening. I recommend repeating this dynamically 6-8 times, and gradually adding more repetitions as tolerated.

Physical therapists have found great success using eccentric strengthening of the calves for Achilles tendonitis, with vast majority of patients seeing noticeable improvement. However, they do mention that with these types of exercises pain symptoms often worsen in the short run though they improve with continued practice. Because of this, before you practice this technique, I recommend getting guidance from a physical therapist or yoga therapist experienced in this area. So consider revisiting your physical therapist to have them teach you their way of eccentrically strengthening your calf muscles called Hakan Alfredson’s heel drop protocol exercises. 

When you get the go-ahead to practice eccentric strengthening, yoga poses you can practice to eccentrically strengthen your calf and Achilles tendon include: 

1. Mountain pose with heel lifts, as described above, lifting your heels on an inhalation and slowly lowering your heels on an exhalation, repeating 6-8 times initially and adding more repetitions over time. 
2. Dynamic Arms Overhead with heel lifts, as described for Mountain pose. See youtube.com for a video.
3. Downward-Facing Dog pose with heel lifts, as described for Mountain pose. 

Now about the tight hamstrings. Your hamstrings are the muscles that start at your sitting bones, run done the backs of the upper legs, and attach just below your knees. These muscles take your legs back, as in the back leg in Warrior 1 pose, and also help bend the knees. How can you tell if you have tight hamstrings? One way is if you cannot touch the floor in Standing Forward Bend pose without bending your knees. There are many reasons why you may have tight hamstrings, including genetic predisposition, lack of regular stretching, activities that naturally tighten hamstrings, such as running, biking, hiking, inactivity, and other conditions that could impact them, such as sciatic nerve irritation, lumbar disc disease, and nerve entrapment. If they are tight due to any of the last three reasons, please get clear input from your medical specialist regarding cautions in addressing the hamstring tightness.

Considering the Achilles tendonitis, here are several ways I’d suggest to stretch your hamstrings:

1. Reclined Legs Stretch pose, versions 1 and 3, with the strap on the arch or ball of the foot, avoiding the heel pad if the strap causes pain on the affected side. This pose also stretches the calf as I said above, so it is a two for one!  

2. Half Downward-Facing Dog pose and Downward-Facing Dog pose, as mentioned above, with attention to hamstring stretch sensations.

And if your heel is slow to recover or continues to be painful, consider a private session from an experienced yoga teacher or yoga therapist, even via Skype if no one is locally available, to have an outside set of eyes look more objectively your yoga practice to see what is helping and what might be hindering your recovery. 

Finally, although physical therapist Shelly Prosko is discussing an acute complete rupture of the Achilles tendon in her post Sudden Acute Traumatic Injury, this post could also provide you with other valuable ideas and options on the healing process, such as using the lens of the koshas through which to view your health decisions and the benefits yoga tools other than asana, such as pranayama and meditation and self-reflection, in guiding your healing.

—Baxter

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