The Achilles tendon is the strongest tendon in the body, yet, because of
the great amount of stress it is subjected to, it is very prone to sports
injuries. These injuries can range from tendonitis to a complete rupture
and can significantly limit one's participation in sports. However, you can
often prevent Achilles injuries or lessen their severity with early
recognition and treatment.
The Achilles tendon is a thick, cordlike structure that inserts into the
back of the heel bone. Tendons attach muscle to bone. The Achilles tendon
is actually made up of the two calf muscles, the gastocnemius and soleus,
that join together two thirds of the way down the leg. Most Achilles
injuries occur about two inches above the heel bone. This is an area of the
tendon that has a relatively poor blood supply. This poor blood supply also
accounts for these injuries taking a very long time to heal. The three most
common injuries to the Achilles area are tendonitis, calf muscle tear
(tennis leg), and tendon rupture.
Achilles Tendonitis
Achilles tendonitis is an inflammation of the sheath surrounding the tendon
or the tendon itself. Symptoms usually include a burning pain or tenderness
two inches above the heel bone. You may also detect mild to moderate
swelling in the back of the leg when you compare it to the opposite leg.
There can be many causes of Achilles tendonitis, but the most common are
training errors, calf muscle inflexibility, and biomechanical abnormalities
such as excessive pronation.
Training errors may include increasing mileage or workout intensity too
rapidly or changing running terrain (i.e., hill running). Inflexibility of
the calf muscle can result from improper or inadequate stretching or
over-strengthening the calf muscle.
Biomechanical abnormalities include excessive pronation (flattening of the
arch) and leg length differences.
All of the above factors contribute to increased stress being placed on the
tendon, resulting in microtears, pain, and inflammation. Because of the
poor blood supply to this area, early treatment is necessary to prevent a
chronic injury. Initial treatment should include reducing or stopping your
sports activity for a period of time. During this time, you should be icing
the back of the Achilles two to three times a day for 15 minutes. Using
water frozen in paper cups as an ice massage is very effective.
In no case should cortisone ever be used in the area of the Achilles
tendon. Although cortisone will reduce the inflammation, it can slow or
prevent the healing of the tendon fibers, possibly resulting in a tendon
rupture.
Calf stretching should be avoided during the initial stages of the injury.
However, once the inflammation has resolved, gradual, progressive calf
stretching is an important part of the healing and rehabilitation process.
As mentioned before, Achilles tendonitis can be slow to heal. If your pain
lingers or gets worse, you should see a sports medicine physician for a
more thorough evaluation. He or she may prescribe temporary heel lifts to
reduce strain on the tendon, physical therapy, or massage therapy to speed
your recovery. In addition, a lower extremity biomechanical examination may
reveal abnormalities such as excessive pronation, limb length differences,
or other structural abnormalities that may be aggravating the Achilles
tendon. These problems can then be controlled with orthotic devices for the
feet.
Calf Muscle Tear (Tennis Leg)
Achilles tendonitis is often caused by overuse, where calf muscle tears and
tendon ruptures are a result of direct injury. Calf muscle tear is actually
a misnomer. The injury usually occurs where the calf muscle joins the
Achilles tendon on the inside part of the leg, about two-thirds of the way
down.
This injury can happen when pushing off on the leg while reaching for a
tennis shot, hence the name 'tennis leg.' Symptoms include a sensation of
being hit in the back of the leg, accompanied by pain and swelling in the
affected area. Walking will usually be painful.
Initial treatment should consist of R.I.C.E. -- rest, ice, compression, and
elevation. This injury needs to be evaluated by your sports medicine
physician. Although surgery is seldom required, temporary immobilization,
rest and physical therapy can help speed healing.
Achilles Tendon Rupture
Rupture of the Achilles tendon, although not that common, is a very serious
injury. It usually occurs from a sudden, explosive movement such as
reaching for a tennis shot, chasing a basketball rebound, or sprinting.
Usually the person will describe a feeling of being hit in the back of the
leg and hearing a pop or snap. The pain is usually severe, walking is
difficult, and it is impossible to stand on the toes of the affected leg.
Tendon ruptures seem to be most common between the ages of 35 and 45. Very
often there is a history of tight calf muscles or inflexibility, and a lack
of proper warm-up. The rupture most frequently occurs two inches above the
heel bone and may be partial or complete.
Immediate evaluation is necessary to prevent further damage and possible
permanent injury. Partial ruptures can usually be treated successfully with
a cast; however, complete ruptures may require surgery.
Prevention
Achilles tendon injuries can be very serious, resulting in long periods of
recovery. Many of these injures can be prevented by warming up
sufficiently, adequate lower leg flexibility, and training sensibly.
Warming up is important before any exercise because it prepares the body
for the activity it is about to under go. Insufficient warmup may subject
tendons and muscles to excessive stress, resulting in injury.
Sensible training can prevent Achilles injury by allowing the body to adapt
to the increasing demands placed on the tendon. Increasing running mileage
and work-out intensity should always be done on a gradual basis.
The most important preventive measure in avoiding Achilles tendon injuries,
as well as other lower extremity overuse injuries, is maintaining adequate
lower extremity flexibility. A large percentage of these overuse injuries
are directly or indirectly related to tightness of the calf muscles and
Achilles tendon. A majority of individuals experiencing Achilles tendon
ruptures have a history of Achilles tightness.
The foot must be able to bend up towards the leg 10 degrees during activity
for normal motion to occur. This motion can be restricted by tight calf
muscles. The tightness can develop from over-strengthening, wearing heels
(which acts to shorten the tendon), or heredity.
A regular stretching program that concentrates on the gastrocnemius and
soleus muscles will help allow normal motion to occur and prevent
over-stressing the Achilles tendon. Also, when this motion is not available
at the ankle, the foot will compensate by pronating excessively, which can
lead to other overuse injuries.
Many techniques have been described to stretch the lower leg . Care should
be taken to position the foot and leg correctly to achieve a satisfactory
stretch. Regardless of the technique used, the calf muscle should be
stretched 20 to 30 seconds each, alternating back and forth three times.
This only requires three to four minutes of your time and should be
performed at least two times every day, and before and after every workout.
You should not expect any immediate results. Flexibility takes time and
over-stretching can cause the same injuries that you are trying to prevent.
A regular program of lower extremity flexibility that takes only a few
minutes every day can help prevent injuries that could take months to heal.
Remember that any injury that lasts longer than seven days, gets worse or
recurs should be evaluated by your sports medicine physician.
Perry Julien, D.P.M., is a podiatrist specializing in the medical and
surgical treatment of foot and ankle problems at the Atlanta Foot and Ankle
Center in Atlanta, GA.
