Achilles Tendonitis
Achilles tendonitis is the bane of many runners. You should not
allow this to turn into a chronic and troubling malady leading to
moans about how it will never end, contributing to roadsides strewn
with air cushioned clad runners all with ice packs attached to
their heels. First, we will review some basic information about the
achilles tendon.
The achilles tendon is the connection between the heel and the most
powerful muscle group in the body. This has long been known as a
site prone to disabling injury. It is named after Achilles, who
according to myth was protected from wounds by being dipped in a
magical pond by his mother. She held him by the heel, which was not
immersed, and later died by an arrow wound in his heel. Although
obviously, injuries to this area must have been known for more than
2,000 years, it was first reported in the medical literature by
Ambroise Par?only 400 years ago.
The achilles tendon joins three muscles: the two heads of the
gastrocnemius and the soleus. The gastrocnemius heads arise from
the posterior portions of the femoral condyles. The soleus arises
from the posterior aspect of the tibia and fibula.
The gastrocnemius is a muscle that crosses three joints: the knee,
the ankle, and the subtalar joint. The functioning of these joints
and influence of other muscles on these joints has a significant
effect on the tension that occurs within the achilles tendon. As an
example tight hamstrings impact the functioning of the ankle joint,
the subtalar joint, and increase tension in the achilles tendon.
The soleus does not cross the knee and is a biarticualar
muscle.
The plantaris is a nearby muscle that has its separate tendon. It
arises from the lateral condyle of the femur. It has a thin tendon
that passes between the gastrocnemius and soleus and inserts into
the calcaneus. When this musclculotendinous structure is injured it
is frequently felt as a "pellet shot" in the back of the leg. The
tear is usually about eight inches below the knee joint.
The bulk of the achilles tendon inserts into the posterior superior
third of the calcaneus. Some fibers course distally and continue to
where portions of the plantar fascia insert into the plantar aspect
of the calcaneus.
The achilles tendon does not have a rich blood supply. It is not
invested within a true tendon sheath. A paratenon composed of other
soft tissue surround it. The outer layer is a portion of the deep
fascia, the middle layer is called the mesotenon and the inner
layer is a thin layer. The blood supply to the proximal portion of
the tendon comes from the branches of the muscles themselves. The
distal portion is supplied by branches from the tendon-bone
interface. The mesotenon supplies the major blood supply to the
Achilles tendon.
Contributing Factors
There are several factors that can contribute to achilles
tendonitis. First, you should know that the biggest contributor to
chronic achilles tendonitis is ignoring pain in your achillles
tendon and runing through the pain of early achilles tendonitis. If
your achilles tendon is getting sore it is time to pay attention to
it, immediately.
Sudden increases in training can contribute to achilles tendonitis.
Excessive hill running or a sudden addition of hills and speedwork
can also contribute to this problem. Two sole construction flaws
can also aggravate achilles tendonitis. The first is a sole that is
too stiff, especially at the ball of the foot. (In case you are
having difficulty locating the "ball" of your foot, I mean the part
where the toes join the foot and at which the foot bends) If this
area is stiff than the "lever arm" of the foot is longer and the
achilles tendon will be under increased tension and the calf
muscles must work harder to lift the heel off the ground.
The second contributing shoe design factor which may lead to
continuuing achilles tendon problem is excessive heel cushioning.
Air filled heels, while supposedly are now more resistant to
deformation and leaks are not good for a sore achilles tendon. The
reason for this is quite simple. If you are wearing a shoe that is
designed to give great heel shock absorption what frequently
happens is that after heel contact, the heel continues to sink
lower while the shoe is absorbing the shock. This further stretches
the achilles tendon, at a time when the leg and body are moving
forward over the foot. Change your shoes to one without this
"feature".
Of course another major factor is excessive tightness of the
posterior leg muscles, the calf muscles and the hamstrings may
contribute to prolonged achilles tendonitis. Gentle calf stretching
should be performed preventatively. During a bout of acute achilles
tendonitis, however, overly exuberant stretching should not be
performed.
Treatment
The first thing to do is to cut back your training. If you are
working out twice a day, change to once a day and take one or two
days off per week. If you are working out every day cut back to
every other day and decrease your mileage. Training modification is
essential to treatment of this potentially long lasting problem.
You should also cut back on hill work and speed work. Post running
ice may also help. Be sure to avoid excessive stretching. The first
phase of healing should be accompanied by relative rest, which
doesn't necessarily mean stopping running, but as I am emphasizing,
a cut back in training. If this does not help quickly, consider the
use of a 1/4 inch heel lift can also help. Do not start worrying if
you will become dependent on this, concentrate on getting rid of
the pain. Don't walk barefoot around your house, avoid excessively
flat shoes, such as "sneakers", tennis shoes, cross trainers,
etc.
In office treatment would initially consist of the use of the
physical therapy modalities of electrical stimulation, (HVGS, high
voltage galvanic stimulation), and ultrasound. Your sports medicine
physician should also carefully check your shoes. A heel lift can
also be used and control of excessive pronation by taping can also
be incorporated into a program of achilles tendonitis
rehabilitation therapy. Orthotics with a small heel lift are often
helpful.
Exercises to Avoid
Excessive stretching is not good for your achilles tendon. The
stretch that I most often recommend is the "wall stretch". I do not
recommend the "stair stretch", the "incline stretch", or the "put a
towel around your feet and pull up until it hurts stretch". If any
of these are working for you, that's great, you don't need any
advice. In most cases, for the patients I see, these stretches put
too much tension on the already tender achilles tendon. Contracting
the muscle when it is in a stretched position, as initial therapy
of an injured achilles tendon is not a good thing.
