Keeping you Bodywise: The Achilles Dilemma for Runners

by TOI Admin January 23, 2012

Woman runningBy: Phillip L. Parr, M.D.

The emphasis on cardiovascular fitness has led to an increase in the number of overuse injuries of the lower extremities, including shin splints, plantar fasciitis and Achilles tendonitis. Achilles problems are a particular problem to both elite runners and middle-aged joggers.

Injuries to the Achilles are the result of its unique anatomy and the phenomenalforces running exerts on it. It’s the largest and longest tendon in the body, and it tends to twist as it courses from its attachment to the gastrosoleousmuscle complex (the calf) to its insertion in the calcaneus (the back of theheel). This twisting results in an area of poor circulation two to six centimetersabove the tendon’s insertion at the heel – where most Achilles injuriesoccur.

Repetitive overload of the tendon, from running or jumping, or both, causes a gradual breakdown in the cross-links of the collagen (a strong, fibrous protein), with progressive disorganization and disruption of the fibers. In an attempt to heal the fibers, the body launches the inflammatory process, which results in the familiar swelling and tenderness in the area. Anatomic variations, such as forefoot varus, rigid ankles and razor-thin tendons, predispose some athletes to Achilles tendon problems.

Conservative Care

In most cases, Achilles tendonitis will respond to conservative treatment. Because persistent overload of an acutely or chronically inflamed tendon may lead to rupture, the best treatment is rest. Regular post-run icing can be helpful as both a treatment and a preventative measure, reducing swelling and allowing damaged fibers to heal better between workouts. Heel lifts can take some of the pressure off the tendon, providing short-term relief, although it’s best not to become dependent on such devises. Orthotics correct forefoot malalignment, increase cushioning and may also elevate the heel slightly. The use of anti-inflammatory medications, ultrasound and electrical stimulation can also be helpful.

Once the tendon is rested and healed enough to tolerate some stress, the most effective long-term treatment and prevention is lower-leg stretching. This can lengthen the calf muscle and thus relieve a great deal of tension on the tendon. A homemade incline board or one of several such commercial products can be extremely helpful for this kind of stretching.

Disabling symptoms that continue after an adequate period of conservative care may indicate a partial tear of the tendon. Ossification (hardening) within the tendon, which is often visible on an x-ray, always indicates a partial tear. If no ossification is present, an MRI may show partial disruption of the tendon.


Surgical Options

An athlete who has had Achilles tendonitis symptoms for quite a while – more than six months – and who doesn’t respond adequately to conservative treatment may be a candidate for surgery. The surgical procedure itself usually takes only a few minutes and is straightforward. Runners who have no tears of the tendon fibers may benefit greatly from having the thickened, chronically inflamed tendon sheath stripped; this decompresses the tendon. Assuming the athlete takes measures to avoid traumatizing the area again, the sheath will then grow back in a healthier form. The prognosis is excellent. Many runners report, after a period of rehab, that they are able to run pain free for the first time in years. Preventative icing and stretching measures can help to keep the problem from recurring.

Runners who have partial tears benefit from the excision of the torn fibers and repair of the tendon. One surgical trick is to incorporate the healthy plantaris tendon – a small, ribbon-like tendon that courses along the medial (inner) side of the Achilles – into the repair, thus reinforcing the tendon with healthy tissue.

Runners thinking about Achilles surgery should be aware that the post-operative course can be long and requires therapy. Working on strengthening the tendon in the eccentric phase – when the tendon or muscle lengthens while it contracts – is necessary to regain tensile strength and to organize the tendon fibers so that they work smoothly again. Most athletes will be able to return to previous levels of running and jumping six to eight months after surgery. With intense therapy and willingness to endure the discomfort levels required, some runners have been able to begin training again in much less time, sometimes in as little as two months.

The Pinch Test

Achilles tendonitis is easily diagnosed by clinical exam. In the acute phase, the tendon is constantly swollen and extremely painful to the touch. Runners familiar with the problem are only too aware of how a relatively gentle pinch test can make them jump up out of their seats. In more chronic cases, the tendon may be enlarged and nodular, though perhaps less tender. This phase is known as tendonitis.


Photo: Ambro


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