Achilles Tendonitis (tendinopathy)
by Stephen M. Pribut, DPM
Symptoms and Causes:
“…the biggest contributor to chronic achilles tendonitis is ignoring pain.”
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 which is prone to disabling injury. Forces up to 12 times body weight (9kN) may arise during sprinting. This tendon 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 injuries to this area must have been known for more than 2,000 years, it was first reported in the medical literature by Ambroise Paré 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. The blood supply has been found to be weakest at a point between 2 and 6 cm above its insertion into the calcaneus. (Although Astrom found with Doppler flow measurements the least vascularity at the insertion.) 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 contiguous with a thin layer surrounding the tendon itself (epitenon). 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 achilles tendon and running 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 speed work 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 continuing 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
“…Training modification is essential.”
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.
Treatment Outline:
Relative rest (see above)
Cut back mileage
Lower intensity
Avoid hills, speedwork, plyometrics
Avoid over-stretching
Gentle stretch after warm-up
Start with Straight leg calf stretch, build up much later to bent leg, consider eccentric stretch later.
Ice Massage
10 to 20 minutes after exercise
NSAIDs
Alleve, Motrin, etc. 10 – 14 days.
Check Running Shoes
Replace if heel is worn
Replace if excessive heel shock absorption (soft air sole cushion, excessive gel shock absorption)
Replace if shoe is excessively stiff at the ”break point” (ball of foot).
Physical Therapy Modalities
HVGS (electrical stimulation)
Ultrasound
Exercise instruction: Strength and flexibility
Current Concepts
While Achilles tendon problems are widespread, the terminology used to describe them is often inaccurate and is undergoing a significant transition. First to be precise we must consider where along the course of the tendon does the problem exist. This may be in one of three main areas:
Insertion
Musculo-tendinous Juncture
Non-insertional (main body of tendon)
While the term that most people use and that most individuals will search for on the web is ”tendonitis”, most Achilles tendon problems could better be called a tendinopathy and more specifically a tendinosis and are a non-inflammatory problem of the tendon. Inflammatory cells are not found on microscopic examination.
Clinically there may be two differing entities in acute achilles tendinopathy:
Peritendonitis
Inflammation in the tissue surrounding the tendon
Often 2 – 6 cm above insertion
Possible crepitus with long standing injury (paratenon with fibrin exudate)
In chronic tendinopathy approximately 20% of the injured peritendinous area are scar forming myofibroblast cells.
Tendinosis
Impairment of circulation with resulting damage to tendon structure
Focal areas of tendon degeneration
Future Research and Solutions
Much future research and better understanding of these injuries is needed. In spite of the vagaries of scientific understanding of these entities a successful approach using training modification, stretching, strengthening and appropriate return to exercise may be undertaken. At this time there are few significant clinical studies with valid results for treatment. There is often disagreement on approach and much is likely to be changed in the future. At this point treatment and treatment recommendations for this problem remain an art practiced with varying degrees of success. When evaluating new research, it is hard to recommend major paradigm changes in thought and recommendations based on studies of fewer then 20 cases or even 50 cases.
Stretching Demonstration
As anyone knows who has spent time on my web site, I am not a fan of excessive stretching for this problem. In individuals who are experiencing pain, I advise against the stair stretch, particularly if you’ve been trying it already for 6 weeks or more and found only more pain, and no improvement. In early cases of pain, I like to restrict stretching, than graduate to the wall stretch, and then the wall stretch with a bent knee.
Roxanne Darling of Beachwalks with Rox does an excellent job of demonstrating a variety of stretches from the hard to the easy. For those without pain, you may carefully follow Rox’s example of the stair stretch if you’d like. If you have pain, skip the stair stretch for now. Start with the straight leg, wall stretch and about 3 weeks – 4 weeks later add the bent knee variation. Read this article in its entirety. In the meantime, if you need a little downtime and some chilling, visit Beachwalks With Rox for words of wisdom, thought and relaxation.
