Achilles tendonitis..truly, your “Achilles Heel” in running..
In Greek mythology, when Achilles was a baby, it was foretold that he would die in battle from an arrow in the foot. To prevent his death, his mother Thetis took Achilles to the River Styx which was supposed to offer powers of invincibility and dipped his body into the water. But as Thetis held Achilles by the heel, his heel was not washed over by the water of the magical river. Achilles grew up to be a man of war who survived many great battles. But one day, a poisonous arrow shot at him was lodged in his heel, killing him shortly after. Still, Achilles is remembered as one of the greatest fighters who ever lived. (..thank you Wikipedia!) The anatomical basis of Achilles’ death is more likely to have been injury to his posterior tibial artery behind the medial malleolus, in between the tendons of the flexor digitorum longus and the posterior tibial vein.
The expression “Achilles Heel” generally refers to a personal weak-link, a flaw or chink in the armor, something that tends to bring us down in our own personal way… As a runner, the Achilles tendon is frequently a source of bother, sometimes reducing the training volume just at the wrong moment in the season, sometimes truly bringing us to a screeching halt. The key in management of this tricky tendon is to understand a bit about the anatomy, pathology and rehabilitation “best-practices”.
Anatomy: The large and prominent tendon of the gastrocnemius and soleus muscles of the calf is called the tendo achilles or Achilles tendon. It is often believed in popular culture that the hero was therefore killed by being shot through this structure. However, as tendons are notably avascular, such an injury is unlikely to be fatal. However, in the myth the arrow had been covered in the blood of the Hydra, which was supposedly toxic. In runners, this tendon, being the thickest and with the largest diameter in the human body, this tendon is a major shock absorber, being the spring between the heel and the rest of the lower extremity. Upon foot-strike, the Achilles absorbs shock, and then uses its composition of collagen and elastic fibers to store, then transfer energy back to the limb for propulsion forward. The faster this happens, the more stress there is on the tendon. Do this 90 or so times per minute, each leg, for a few thousand miles or so and you get the idea. The Achilles carries a huge burden, and for the most part does it just fine. The problem occurs when the variables change, and there are really only two..
- Too much too soon: increased volume with inadequate time for tissue adaptation. The entry fee is paid, the spring is sprung, the mileage is increasing comfortably when you just try to squeeze the extra 2 miler in at the end of a long run. Or the running buddy arrives with a new friend, whose pase os 30 seconds faster that your comfort zone, but you put the pressure on a bit harder and longer than normal. Or the hill runs are just so much fun that you decide on the steeper hill for the hardest interval, instead of the mellow incline as your coach advised.
- Biomechanical stress: you are an over-pronator, a supinator, a heel striker, a forefoot striker, whatever you are, you have been doing fine until now, and then you add in point number 1 and BINGO.. you are calling my office for an appointment, and checking with Dr. Langone foe next available opening.
The Achilles is well designed to adapt to increased volume, speed and inclines given the proper circumstances, i.e., incremental stress changes, increased distance, hill workouts, with adequate recovery, adequate nutrition and appropriate mechanical demands. Unfortunately, these natural, in-build tissue mechanisms for adaptation, do not sometimes adapt to our training and racing plans. The applied loads are too great for the collagen helices to deal with, and breakdown occurs. Cross-linking of collagen becomes undone, the collagen helix on a microscopic level, begins to fray, all sorts of tissue compounds get dumped into the surrounding area of the heel-to-mid-calf, and a nice inflammatory soup begins to brew.
Thankfully, with adequate cross-training, schedule modification and plenty of ice, the majority of inflammatory Achilles tendons will settle right back down. However, when this tendon is forced to “run through the pain”, the proverbial hits the fan. The cross-linking and collagen deformation becomes more permanent, angiogenesis or blood-vessel ingrowth into the tendon occurs, and with these vessels come painful cranky nerve endings. The Achilles is no longer “hot” and inflamed, but “cold” with no inflammation present, thus non-responsive to the pounds of Advil© that you are pouring down your throat. Tendinitis has turned the corner to chronic tendinopathy. The risk of straining an unwell tendon can result in rupture, and a long, slow post-surgical recovery the following year. Don’t let this happen to you. If you are one of the unlucky ones, there is hope. While surgical excision is one of the most common procedures for management of chronic tendinopathy, physical therapy intervention is equally effective in recidivist cases. Painful, slow eccentric training can reduce the neo-vessel ingrowth, straighten out the kinky collagen, and reduce pain. While there is little evidence that many modalities are effective, new literature suggests that very low doses of pulsed ultrasound are more effective in healing tendons than traditional, full strength doses. A progressive program of VLDPUS in conjunction with total lower extremity strength training, with special attention to repeated eccentric training is the current “best-practice” for management of Achilles tendinopathy. Alteration of subtle biomechanical dysfunction needs the skill of a podiatrist with a running background. Temporary alterations in an insole inclination and tiny heel wedges can reduce strain on the Achilles by reduction of torsional stress on its fibers. A custom orthotic may be the answer for the runner chronically sidelined by Achilles pain. While injection therapy may sound like a “quick fix”, injections are fraught with problems, from infection to tendon rupture. The current evidence suggests that the injection of the currently sexy but unproven PRP/ growth factors, is limited, and no more effective than conservative care with eccentric exercises.
What can I do for my Achilles injury? Call Runners Lab for an appointment. Coach + exercise physiologist Jen will review and modify your training, Dr. Langone will review and modify your running biomechanics, and Sinéad PT will review and modify your functional movements and strength / flexibility deficits. Three heads, one purpose: to keep you running, farther, faster, fitter!