Body Health Blog
By definition the Achilles’ heel is an area of great vulnerability. Many competitive and recreational athletes are almost as vulnerable to Achilles tendon problems as the mythological Greek warrior for whom it was named. Achilles was rumored to have killed himself when his tendinitis didn’t respond to conservative treatment and he was unable to run. Sports Medicine has advanced rapidly in the last few thousand years but Achilles tendon problems continue to be every athlete’s potential nemesis.
Everyone knows of someone who has either had an Achilles tendon problem or rupture. Since the Achilles is relied on so much for mobility, it can be one of the worst injuries to recover from. The most severe of Achilles tendon problems — a total rupture — may take up to one year to recover fully.
Any exercise causes a certain amount of damage to the body’s tissues. With time, the tissues heal and adapt, getting stronger when given adequate rest. If the tissues receive too much stress, too soon, they cannot adapt and the body’s ability to adapt is overwhelmed. Overuse injuries can be the result.
The first symptom of overuse is usually pain, which can be followed by swelling and inflammation. Rarely is an injury an isolated event. Biomechanics, flexibility, strength, poor equipment and training, or judgment errors can all compound the problem.
One of the body’s largest and toughest tendons, the Achilles is the common tendon of the calf (gastrocnemius and soleus) muscles.
Another small accessory muscle called the plantaris also contributes. The Achilles tendon begins in the middle of the lower leg at the bottom of the calf muscles. This thick, rope-like tendon inserts into the heel bone (calcaneus).
The tendon is composed of a tough fibrous tissue that has little ability to stretch or contract. Unlike other tendons, the Achilles is not surrounded by a sheath but is encompassed by deep tissue layers called peritendon, which act like an elastic covering allowing movement against surrounding tissues.
Also present are two bursae (fluid-filled sacs) between the tendon and the skin and between the tendon and heel bone. The tendon does not have as good a blood supply as a muscle. Three is a zone of relative avascularity approximately 2–6 cm above the insertion, which appears to play a role in many of the Achilles problems.
The Achilles tendon may be affected by many conditions including tendon rupture, focal degeneration, tendinosis, peritendinitis/osis, mixed lesions, insertional tendinopathies and rheumatic/metabolic causes.
Peritendinitis is an inflammation of the fibres surrounding the Achilles tendon. We now know that the condition we usually have described as “tendinitis” is actually better understood as “tendinosis,” and is not due to inflammation, but an underlying degeneration of collagen tissues in response to mechanical overuse.
Achilles Tendinopathy is usually characterized by degeneration of the tendon.
Achilles Tendinosis is the breakdown in the Achilles tendon, with small focal lesions within the tendon without an inflammatory response. The degeneration means that the tendon does not have its normal tensile strength and may be predisposed to rupture with continued sporting activity.
Partial rupture is defined as a tear involving a varying number of fibres of the tendon. Total rupture is a complete tear of the free portion of the tendon.
Mechanism of Injury
According to Drs. Davidson and Taunton of the Allan McGavin Sports Medicine Centre at UBC, trauma either to a normal or to an abnormal tendon is the cause of Achilles tendinitis. They suggest that major trauma to a normal tendon may result in complete or partial rupture and that repeated minor trauma to a normal tendon may result in Achilles peritendinitis or tendinosis.
Abrupt changes in muscle tension that occur in tennis with quick stops, starts and changes of direction when lunging for a volley or sprinting to the net for a drop shot are common examples.
As well, with running, the foot strikes the ground between 800‑1200 times per mile with a force of 2-3x body weight. This repeated impact loading can cause micro-ruptures and damage to the tendon in the avascular area mentioned earlier.
Repeated micro trauma and poor biomechanics can lead to irritation of the tendon/ peritendon and lead to tendinosis or peritendinitis. Over time, the tissue with in the tendon/tendon sheath will become weak and disorganized leading to scar tissue formation and degeneration. Further, pre-existing micro trauma and/or degeneration in the tendon can lead to a partial or full rupture. Trauma to an abnormal tendon can result in rupture or tendinosis with or without peritendinitis.
Predisposing Factors for an Achilles partial or full rupture
- Direct trauma
- Prolonged corticosteroid therapy
- Overuse of performance-enhancing drugs (i.e. muscle building steroids)
- History of gout
- History of previous Achilles tendon rupture
- Chronic Achilles tendinosis
The causes of an abnormal Achilles tendon are many and include: the presence of a collagen disorder such as rheumatoid arthritis, or ankylosing spondylitis. A condition called hyperuricemia (gout) where the body cannot adequately clear the uric acid from your system. As well, previous steroid injections to the tendon or trauma such as surgery can contribute to an abnormal tendon. Laceration or infection can cause scarring around the tendon or it may be abnormal simply from disuse atrophy.
Signs & Symptoms
Achilles problems usually present with pain, swelling and tenderness to the touch. There may be morning or pre-activity stiffness. The pain may be local or diffuse, in or around the tendon or bursae. It is made worse with activity, especially running or jumping. It usually responds well to local treatments of ice and rest. The swelling may be localized to the tendon with distinct nodules in the bursa or it may be diffuse swelling involving the whole peritendon. The tenderness may be either localized or diffuse. Over time one may experience limited power and atrophy of the calf muscle.
Keeping the Achilles Healthy
Train smart. Try to maintain a year-round fitness program and avoid sudden changes to your activity level. Tennis enthusiasts should undertake a short, pre-season conditioning program or participate in other sports. This promotes general fitness maintenance and reduces injury potential, allowing more enjoyable, safer tennis. Pre-season preparation for tennis should include all of the 5“S-P components of physical training. That means working on suppleness, stamina, strength, speed, skill and power.
As well, attention should be given to proper biomechanics and appropriate footwear.
Gradually increase the amount of activity. Avoid the temptation to play for 5 hours your first weekend out. When using running as your main training activity, increase the volume slowly about 5–10% per week to allow for the soft tissue adaptations. Make recovery days part of your schedule and alternate hard and easy days.
The sooner you pay attention to your Achilles pain the better. Do whatever is necessary early on to ensure that your activity is pain free. Stop activities that cause or aggravate your symptoms. Once you are able to run pain free, start off at half your normal distance. Continue to avoid hills and speed work since they increase the stress on the Achilles.
Stretch & Strengthen
When training for flexibility, ensure that your stretches are done both statically and dynamically. Remember to stretch without pain. If you feel pain, you are damaging fibres. In addition to your normal stretching routine, ensure extra time is spent on the gastrocnemius and soleus as well as the hamstrings. Static stretches should be held for at least 40 seconds and up to 2 minutes and repeated 2-4x per day.
The calves respond well to high repetitions of exercise. Try working up to the following calf raise routine.
- Double calf raises 2–3 x 20 reps
- Single calf raises 2–3 x 20 reps
- Eccentric drops: start with feet flat 3 x 20 reps
As strength increases suspend the heel off a stair. This should be done if the athlete is pain free.
Balance Your Routines
Balance exercises to improve your reactions and proprioception. “Crazy walks” will help improve balance and lower leg strength. Try walking for 10–20 metres on your toes and heels and the inside and outside of your feet. This is especially important after doing workouts such as cycling or in-line skating.
Correct footwear for activity is a major step in preventing excess irritation of the Achilles tendon. Orthotics may also be useful in preventing excessive ankle joint (subtalar) movement and Achilles tendon traction. Choose appropriate footwear and get proper cushioned and supportive shoes that have a strong heel counter and adequate medial arch. Heel lifts decrease pain and irritation by decreasing tension on the tendon, essentially allowing it to shorten. If using heel lifts, take extra steps to ensure the tendon is stretched properly.
Training errors should be avoided. The intensity, duration and frequency of training should be monitored and gradually progressed. Sudden increases should be avoided, as abrupt increases in training load are the number one cause of Achilles tendinopathy. Imbalance of strength and flexibility can lead to mal-alignment that can put too much stress on the Achilles tendon. Muscle strength and flexibility should be maintained through regular strengthening and stretching sessions.
After a hard workout, go stand in cold water for 10–15 minutes to decrease inflammation. Try using ice-cold water for 45–60 seconds per leg. A sport physiotherapist can prescribe exercises and modify activity to decrease pain and inflammation. As well, therapeutic modalities such as ultrasound, electrical stimulation and laser may be beneficial in providing a better healing environment for the tendon.
A consistently stiff and/or achy tendon may be a sign of an impending rupture. Chronic tendinosis can weaken the Achilles leaving it more vulnerable to rupture. A regular regimen of stretching, strengthening and early prevention may be all you need to keep an Achilles injury from sidelining you whatever your sport or activity.
Carl Petersen is Partner and Director of Elite Athlete Training at City Sports & Physiotherapy Clinics in Vancouver. He is also the Physiotherapy Consultant to the Canadian Alpine Ski Team.
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