Think its Achilles tendinitis...think again

The achilles tendon is heralded as one of the strongest tendons in the body. And it should be due to the need and its function to hold up the entire body all on its own; for example when we are up on our toes on one foot. This tendon connects the calf muscle in the back of the lower leg to the back of the heel. This muscle really does the work when we are up on our toes, but without the connection to the back of the heel by the achilles tendon, the body would not be held up. 

The demand on the achilles tendon is pretty high given the above explanation of its function. The tendon is pretty dense with fibers, but that is also has less of a blood supply due to this density of fibers. Therefor, it is not difficult to get the tendon irritable and cause an "-itis" of this tendon...Achilles tendinitis. 

A tendinitis generally occurs because of excessive muscle use while the muscle is in a more stretched position. The tendons at the end of the muscle take much more of the stress when the muscle is under load and the muscle is also stretching or lengthening. The best way to illustrate this is to picture when you go upstairs. Now picture the heel of your foot dropping off the edge of the stair just a little bit as you go up the stairs. The achilles tendon and calf are designed to take this load. However, imagine if you chose to help somebody move and they moved to an apartment on the second or third level. Now imagine carrying heavy things up stairs for a number of hours (and possibly a couple of days). This may be something you are able to do. But it is a bit towards the end of your muscle strength and certainly not what your tendon has been used to. Besides the crazy soreness you will feel for up to a week or so, tendons can be pushed to the limit and beyond in this case. Another example that may be easier to imagine is playing a pickup game of basketball for the first time in years, and then doing this more often over the following weekends. Besides other parts of the body feeling it, the planting of your foot and constantly changing directions or leaping can be enough to cause the achilles tendon to get irritated and become achilles tendinitis. 

However, when the background history of why the injury occurred (or the mechanism of injury) doesn't sound similar to the above examples, I start to wonder more about what else the painful area could actually be. In some cases (more often than you think!), the structure that lies along the outside of the achilles tendon and goes along the outside of the heel and continues along the outside of the foot is the actual problem. This is continually overlooked by so many in the healthcare field. The structure here is called the sural nerve and can act a lot like achilles tendinitis. I created a whole course to guide people through the entire process of healing from this injury, whether it is the achilles tendonitis or this nerve (the course is actually designed to replace the need to see a physiotherapist, chiropractor, podiatrist or physical therapist!).

Lets talk a little bit about this nerve because it may be why you may not be getting better. Particularly if you have already seen physicians, a physio or podiatrist. 

The sural nerve is a branch of the nervous system that starts in the lower leg, but so many of these branches originally came from the sciatic nerve. The sciatic nerve is about the size of your thumb and nearly every nerve branch from the knee down to the foot and ankle comes from this large nerve, including the sural nerve. The sciatic nerve supplies a massive portion of the outside and back of the thigh as well. 

So why is this important?

Because the nervous system is a massive structure that spans the entire body. And if one part of it is not feeling quite right or muscles are tight as they lie over the nerve in the low back, or hip, or hamstring, or IT band area (just about anywhere), then it is much easier for the nerve branches in the leg that are a part of the same structure to be more easily irritable and eventually cause pain or discomfort. The conventional understanding is that any pain down the leg which is nerve related comes from a disc problem (or something else) putting pressure on the nerve in the spine. Well, what we need to understand is the nervous system is pressure sensitive along the entire length of the nervous system. So if there is pressure on the sciatic nerve from a tight piriformis muscle in the hip (it lays directly over the sciatic nerve), or along the length of the sciatic nerve from sitting on it for too long (think of a driver or office worker), or the front edge of the chair putting extra pressure on the back of our thigh as our foot is trying to find the ground when we are sitting, all of this pressure can cause the nervous system to be more easily irritable in other areas in the leg. Remember, the sciatic nerve is about the size of your thumb, so once a nerve that large is irritated (which can often present as mere hamstring "tightness") there can be a slow cascading effect down the rest of the leg in any number of specific areas that happen to be where tendons, ligaments, muscles, joints, etc. are also located. Which area of the leg actually gets to feel the discomfort or pain has a lot to do with where there may have been a bit (and I mean a little bit) more of a strain or pressure. And in some cases this can show up where there needs to be a lot of movement of the nervous system. For example, joints like the knee, the hip, or the foot/ankle area (26 bones!) where there is A LOT of movement. 

So what do we do to make this nerve thing feel better? 

We need to make the nervous system feel better from the hip (and possibly the low back) all the way down to the achilles tendon area while we are lying down AND sitting. I discussed this in the previous post about plantar fasciitis. 

There are many ways we can decrease strain and pressure on the achilles tendon to allow it to heal quicker. Thats the easy part (after all... our body is designed to heal). But how do we do this to the nervous system?

Lets start with minimizing pressure while lying down. The sleeping position for so many pain points we deal with can be the best pain reliever, or pain generator. If, for example, we spend time sleeping on our right side and this is also the side where we feel we have "achilles tendinitis", then we need to change the side we sleep on. THIS MIGHT NOT SOUND RELEVANT. HOWEVER, this will cause indirect pressure on the sciatic nerve (remember, its nearly the size of your thumb!), for hours on end, which can make the sural nerve which lies directly along the achilles tendon more easily irritable the following day. Particularly if that area is not feeling well already.  The sleeping position essentially sets the tone for how successful the hurt area will be when you place demands on it during your activities (or lack thereof) the next day. Sleeping on the other side with a big fat pillow between your knees and feet or possibly on your back with a proper leg wedge under your legs will likely be the better options. Sleeping straight on your stomach is not an option for most people because after we age out of our teens and twenties, this ends up causing low back stiffness, discomfort or pain. 

Discussing the sleeping position and the need to pick one or two different positions and stay there, even if it isn't your preferred position, is hard for some people. I get that. However, whatever the pain point, it really just depends on how badly you want to get better. The best example I can think of is the following; imagine your go-to side for sleeping is your right side, and then also having right shoulder surgery. This will obviously cause you to reconsider doing that...obviously for quite some time. Every pain point we have needs to make us evaluate the position we chose to sleep in, and change it if necessary, if we want the problem to go away. 

The sitting position can be more easily managed. But we still need to minimize pressure on the sciatic nerve as well as around the ankle and lower leg. Are you seeing a theme here? Continuous pressure on the sciatic nerve plays a huge roll in how the rest of the leg feels. And if you primarily sit for work this can also set the stage for how your pain point will feel during that day. You can get ahead of it for the following day when you avoid sleeping positions that will bother it, but you still need to be mindful of the sitting position throughout the day, particularly if a nerve down the leg is the painful structure, and in this case the sural nerve. 

How do we minimize pressure on the sciatic nerve when we sit down? To do this, we need to put something under our feet so the thigh is lifted off of the chair. The way this looks is that the knee is higher than the hip and helps keep pressure off of the back of the thigh which is where the sciatic nerve runs. Whether we sit in a chair, table, or bench, etc. we need to consider making sure we limit pressure in the back of the thigh. Particularly where the front edge of the seat of the chair is pressing into the back of the thigh. This happens more significantly in people with shorter legs as it is a bit harder for their feet to reach the ground without putting tremendous pressure on the back of the thigh and therefor the sciatic nerve.

Now that we have covered where there is excessive pressure on the nerves when sitting and when lying down, we now need to discuss how to minimize tension or strain to the sciatic nerve when we sit down. This also needs to be addressed. And you minimize tension throughout the nervous system down the leg by NOT sitting in a "long-sit" position. This is when we sit down with our legs straight and feet out in front of us on top of a ottoman. Or any other time we sit on the ground with our feet out in front and our legs straight. It is fairly easy to minimize tension by simply bending our knees and firmly putting our feet flat on the ottoman. And when we are in a recliner and adjust the platform for our legs to the up position, we bend our knees and, again firmly put our feet flat on that platform. 

Unfortunately, we may need to shift our thinking about how important it is to sit tall. Because if we sit tall, then the sciatic nerve takes a sharper bend around the back of our hip as it goes down the thigh (try it now). This also will kind of pinch the sciatic nerve. 

A better way to make the sciatic nerve feel is to actually scoot forward just a couple of inches in the chair and allow our tailbone to tuck underneath us a bit. This will essentially look like you are reclined in a chair and slumped a bit. Because this way we are putting a bit more pressure on our tailbone (sacrum area) instead of our sciatic nerves. As a veteran physiotherapist and specialist in posture, I am giving you the green light to do this. This probably comes as a surprise to you. It always is when I say this to my clients. Another way to take care of this is to simply get up out of the chair for 30-60 seconds every 20-30 minutes or so (depending on how easily aggravated it is). A lot of problems in our legs would subside more easily if we did not sit for as long as we do. 

Earlier I mentioned the piriformis muscle. Regardless of how peculiar it sounds, if the piriformis muscle is tight, this causes more pressure on our sciatic nerve because that muscle lays directly over it. So by lengthening the piriformis muscle, this will help decrease pressure on the sciatic nerve. Because of this decrease in pressure on the nervous system, there will also be less irritability along the entire nervous system below it. Therefor the sural nerve along the achilles tendon will be less irritable. Most of the time, it is NOT just about the sleeping position, or sitting position or a couple of exercises to minimize pressure on the nervous system. There really needs to be a full court press in EVERYTHING that makes the nervous system feel better. And we can't drop the ball when we just start feeling better.

We can stretch the piriformis muscle while we are sitting or when lying down. The stretch actually looks identical when sitting or when lying down. For example, if the right side is the one that hurts, then place the heel of that right foot on top of your left knee and pull your right knee towards your left shoulder. You should feel the stretch in the back of the right hip. BUT, if you feel the area to the outside of your achilles tendon when you do this stretch then this stretch is NOT for you...yet.

The way we lie down and our sleeping position actually does matter (I'm "kicking a dead horse I know"). And when it comes to the nervous system we want to keep pressure off of the entire thing on that side from the hip (where your sciatic nerve is) all the way to the foot/ankle. This means we should sleep on the other side with a really fat pillow between our knees and feet, if we are side-sleepers. We can really pick any side as long as we are NOT allowing ourselves to sleep on the side that hurts. 

*One thing that will immediately help out is a simple tape job applied along the length of the achilles tendon, but placed just a bit to the side. You can use KT tape, kinesiology tape, or anything similar and you can typically purchase this at an athletic store, drug store or even online. Use two to three strips and make sure your foot is pointed down a bit while applying the tape. Lay down the first and last two inches of tape without stretching it. But stretch out the rest of it to about 75%+ or so. The amount of stretch just really shouldn't be 100%. Also it will help to overlap the strips by about half of the width of the tape to thicken the tape and help support the achilles tendon.

If you would like to know more about solving this problem once and for all, click on this link and I'll help you make sure it also never comes back! This video series is designed to replace the need for any one-on-one care and you get instant access to know EXACTLY what the problem is, EXACTLY why it is a problem and EXACTLY what to do about it...from anywhere in the world. And you can learn this in two days! NO MORE endless months of rehab! You get free access to it for 30 days! So if you don't like it, YOU DON'T PAY! Try it NOW for FREE!