Running Injuries – Who Should I See?

Posted in Running Injuries

During the coming months I’m going to have a few articles on running related injuries
and their treatment from a podiatrist’s point of view. My hope is to provide the reader
with not only what the problems are but how you yourself can try to treat them. Sort of a
“Running Repair Manual.” These articles aren’t meant to replace your sports medicine
specialist and if you have significant pain or a problem that is over a week old and not
improving look for one the specialists outlined below.
Over the next few months you can perhaps do as I do and tear out the pages and have
them available for future use. My goal is to see you on the roads rather than needing to
see you in my office.
Running Injuries – Who Should I See?
You have begun to train seriously for that special race…Mile, 5K, 10K, marathon… and
it happens. The aching in the knee or heel, shooting pain in the midfoot or shin, lower
back pain… whatever. You read Runner’s World and you have every running book ever
written on your shelf. But even after doing the recommended RICE (rest, ice,
compression, elevation) routine, decreasing your mileage/speed and changing your shoes,
it still hurts. Now what do you do?
Whether you decide to see a podiatrist, orthopedist, chiropractor, acupuncturist or Voo
Doo doctor, there are a few things you should look for and avoid when seeking treatment.
Things to Know About Your Doctor
1. What do other runners think about him? Perhaps one of the best ways to find
out about a doctor is to ask other runners that have had injuries and see who they
liked. If you look in the yellow pages, you can see “Sports Medicine Specialist’s”
galore. Also, being a member of a sports medicine board does not mean they are
qualified…it just means they paid their application fee and maybe took a test. Ask the
other runners at your local Y, the running store, or perhaps call the local Track Club.
The runner’s grapevine is a pretty reliable source
2. Does he run? I recommend that the doctor you see have some experience with
running. He does not need to be a sub 2:20 marathoner but I feel that runners are
generally more empathetic and knowledgeable regarding running related problems.
Things Your Doctor Should Look At
You have finally selected a doctor. I am a firm believer in not being passive in the
treatment process. If he/she does not ask you, maybe you should have him look at or
ask about:
1. Your running log. Overuse injuries are some of the most common I see and
they are frequently associated with changes in mileage or speed, surfaces you
run on, or number and frequency of races.

2. Your running shoes (training and racing). He should look at wear patterns
and ask how many miles you have on them. He can also determine if they are
appropriate for any biomechanical related problems you have.
3. The way you…stand, walk, run. By just looking at someone in a chair you
cannot fully appreciate what happens when they are standing or in motion.
4. Previous injuries. Even though you may not have had the exact same injury,
many injuries are related to biomechanical abnormalities and may be
associated with an overall larger problem that can be addressed.
   Things to Avoid
1. Surgery. With athletic people, surgery should be a last resort. Almost every
injury seen has a surgical solution and some surgical solutions give a quicker
result than conservative treatment, but surgery has many drawbacks for
athletes. Most conservative treatment programs allow the runner to continue
to be somewhat active. Surgery dramatically slows the runner down, keeping
them off the roads or track. Also, a surgical complication in a runner – and
even the greatest surgeons have them – is devastating. The same complication
for a non-active person has a much reduced effect on the person. If your
doctor recommends surgery, I would get at least one second opinion from a
doctor who runs.
2. The non-listening doctor. Doctors are busy people. That does not give them
the right to dismiss your problems as insignificant. One of my professors in
podiatry school told me that the two toughest groups of people to treat are
runners and teachers. They take up too much time by asking questions and do
not want to slow down. (By the way, I have been both.) But remember, if your
doctor does not have the time for your problem, find one who does.
3. The “quit running” treatment plan. I am not talking about the short term
cessation from running, I am talking about the doctor who says “if it hurts to
run, then stop running!” If your doctor recommends some time off, he should
give you some alternatives such as water running, bicycling, or rehabilitation
exercises. If he tells you to stop for good, look elsewhere.
You are armed with the information, now it is your turn. Just remember, if
you do not ask questions and offer information, you may not get the answers
you need. I will see you at that special race and hopefully we will be toeing
the line healthy and ready to race.
Bill Johncock, DPM
Carolina Podiatry Center
Hickory, NC
Dr. Johncock is a podiatrist who has been running for over 25 years and
became involved in his profession through his own running related injuries.
He has completed over 50 marathons including a 2:34 P.R.

Forefoot Pain – Part I

Posted in Forefoot

This article is going to look at pain in the forefoot or the so called “ball” of the
foot. As with the last couple articles, we’ll look at some of the causes for the problem,
how it may manifest itself in regard to symptoms, how you can try to treat it yourself and
some treatments your sports medicine physician may recommend if necessary.
Family doctors frequently send patients to my office with a diagnosis of
“metatarsalgia”. Well the foot guys, like myself, don’t tend to like that diagnosis. Not
because it’s bad, but it doesn’t really describe what the true problem is. The metatarsals
are the long bones in the foot that connect the thicker middle section of the arch to the
toes. The joints where the metatarsal bones connect to the toes is the “ball” of the foot or
the metatarsal-phalangeal joints (MPJ’s). The “algia” part of the word means pain. So
“metatarsalgia” just means pain in the area of the metatarsals. It doesn’t say if the pain
due to any of a number of problems.
We’ll look at some of the more common causes for “metatarsalgia” such as
Morton’s neuromas, stress fractures of the metatarsals and capsulitis/bursitis.
We all have nerves running between our metatarsal bones and then separating out
into branches to give sensation to the adjacent sides of the toes. These nerves can become
irritated and then with time become thickened and enlarged due to either chronic
irritation or trauma. The enlarged portion of nerve is called a neuroma. This can occur
between any two metatarsals, but most commonly occurs between the third and fourth. A
neuroma in this area is called a “Morton’s” neuroma. Why Dr. Morton wanted it named
after him is subject for debate.
Symptoms associated with a neuroma may include sharp or shooting pain,
numbness, pins and needle sensation or, at times, a “popping” or “clicking” sensation.
Many runners describe it as feeling like a sock is wadded up under the toes or ball even
though it isn’t. It is frequently temporarily relieved by removing the shoes and massaging
the area.
Neuromas can be caused, as mentioned earlier, by trauma or chronic irritation.
Chronic irritation can be in the form of wearing shoes that are not wide enough in the
forefoot area causing compression of nerve. The irritation may also occur from abnormal
mechanics of the foot causing excess motion of the metatarsal bones such as in a
overpronated foot.
Self – Treatment
First, be sure all your shoes, not just your running shoes, have adequate
forefoot width. When fitting shoes, be sure to have them fitted at the end of the
day and/or after running. Since the foot naturally swells with activity, if you try it
first thing it may actually become too small after running. Ladies, stay away from
the heels and narrow toed shoes.
Second, try this trick. Go to pharmacy and purchase a “metatarsal pad”.
With the use of the pad, as they say in realty, everything is “location, location, location.” To ensure it is in the correct location, make a mark with lipstick (guys
ask the ladies first before you borrow it) or some other marker just behind the ball
area on the bottom of the foot. Pull out an insole from a running shoe on the
affected side and place it on the floor. Now stand on the insole and the mark
should be transferred from your foot to the insole. Place the wide end of the
metatarsal pad along this line and put the narrow part toward your heel. The pad
should be just behind the ball of the foot and not directly beneath the nerve. The
concept is to spread the metatarsal bones apart and take the pressure off the nerve.
If placed directly under the inflammed portion of the nerve it will only increase
the pain rather than relieve it. You may wish to try metatarsal pads in your other
shoes as well. You can also try to put a piece of cotton between the toes to reduce
the pressure on the neuroma and spread the metatarsal bones as well.
Finally, after your runs or if inflamed by activity, ice the area 15 minutes.
Physician Treatment
Your sports medicine physician may try custom molded orthotics if you
have mild but not complete relief with your home-made insert or if they feel you
have a biomechanical problem.
In addition, two types of injections may be considered. Cortisone
injections attempt to shrink the swelling around the nerve. Meanwhile alcohol
schlerosing injections, that attempt to kill the nerve altogether, may also be
Finally, if conservative treatment options have been exhausted, surgical
excision and removal of the enlarged portion of the nerve may be required.

Stress fractures, as the name infers, are cracks or breaks in the bone due to excess
cumulative stress to bone due to repetitive microtrauma (as in absorbing trauma due to
running many miles on hard surfaces). Over training or wearing inappropriate or worn
out shoes due to inadequate cushioning and support can cause this to occur.
The metatarsal bones are particularly susceptible to stress fractures due to their
size (relatively thin) and the amount of weight and force they receive. The second, third
and fourth metatarsals are particularly in danger of fracture, although it can occur in any
Symptoms associated with a stress fracture include pain and swelling in the area
just behind the ball of the foot. Usually both top and bottom. Usually the pain is localized
to a small area but with compensation can cause pain in other areas as well in later stages.
Standard x-rays may not initially pick up the fracture and may take two weeks or
more to be seen. At this time the body produces extra calcium around the area to bridge
and stabilize the fracture called a bone callus. Sometimes a bone scan or MRI are
required to confirm the fracture, but many times if the doctor feels that is the correct
diagnosis they’ll treat it like a stress fracture for couple weeks, then take follow-up x-rays
to confirm the diagnosis.
A stress fracture is a real fracture and can displace and create other long
term problems if not treated appropriately. The first thing to do is to stop
running. This is typically six to eight weeks to allow healing of the bone. A cast is
not usually required but a surgical shoe may be recommended to further
immobilize the area. The symptoms of a stress fracture, a neuroma and the next to
be discussed capsulitis are similar in nature. So if you are not improving despite
the outlined self-treatment protocols, I suggest seeing your local sports medicine
specialist for an evaluation. In the mean time, swimming, pool running and
cycling can help to maintain sanity and aerobic fitness.
Surrounding the joint connecting the metatarsal bone and the toe bone (metatarsal
phalangeal joint or MPJ), is a fibrous tissue which holds the fluid that lubricates the joint.
This fibrous tissue is called the capsule. If there is too much pressure beneath the MPJ’s,
the capsule becomes inflamed and thus we give it the name of capsulitis. Some
physicians feel that a fluid filled sac or “bursa” develops as well, while others argue this
is not true. Either way, if your doctor says capsulitis or metatarsal bursitis, he’s talking
about the same thing.
This can be caused by the chronic repetitive stress of running. It can also be
related to a bone that is too long or sits too low (plantarflexed). It may also result if you
have a contracted toe or “hammertoe”. This also causes a downward pressure at the MPJ.
Once again, be careful of worn out or inappropriate shoes and big increases in
mileage or speedwork.
Symptoms may include swelling and pain, this time directly beneath the end of
the metatarsal bone at the MPJ rather than behind it as is usually the case in a stress
fracture. You may also have a callous or thickening of the skin in the area. It is usually
painful when you go to push off or “propel” yourself during running and walking.
Self – Treatment
Look back earlier in the article where I discuss the self-treatment of
neuromas. Now make the same modifications to your running shoe insole as
previously with the lipstick and metatarsal pad.
Now that you have the metatarsal pad in the correct location make one
more modification. Take the lipstick or marker back out and feel the tender spot
on the bottom of the foot and make a circle around it. Now step back down on the
insole and you should have a circle on it. Take a pair scissors and cut out a hole
right through the insole. This will allow the pressure to be taken off the inflamed
capsule and allow it to heal. You may need to enlarge or change the location of
the hole if you still feel significant pressure in the area. I would use an insole from
an old pair or running shoes so if you need to try again it won’t be a big deal. You
can also use a U-shaped pad around the area of tenderness and tape or use
adhesive to keep it in place directly to the bottom of the foot. This needs to be replaced daily so it is not a good “long term” solution. Also, be sure to ice the
area for 15-20 minutes two-three times per day and especially after running.
At times over-the-counter anti-inflammatories can be beneficial, such as
ibuprofen or Aleve, but be careful not to use these just before a run as they also
serve as an analgesic and eliminate the pain. You may think this would be good
but pain is our body’s mechanism of letting us know something is wrong and we
can do damage and not know it. Also, if you any history of stomach, liver or heart
dysfunction, it is important to contact a physician before trying these medications.

Physician Treatment
Treatment may include orthotics devices with special accommodations,
similar to your homemade insole to take the pressure off the area. With a custom
orthotic, the correction and accommodation can be much more exact.
The physician may attempt ways to decrease the inflammation in the area
with oral medications or cortisone injections.
Rarely is surgery indicated unless, as mentioned earlier, a hammertoe is
present and causing continuous pressure. I would definitely exhaust conservative
treatment before “going under the knife” for this particular problem.
Forefoot pain can come in a variety of causes and it is important to determine this
to achieve proper treatment. Because you may be dealing with a stress fracture or
creating further aggravation of the neuroma or capsulitis, if you continue to have
symptoms despite conservative treatment, it is important to seek out the advice of your
sports medicine physician.
See you on the roads!

Managing Achilles Tendon Disorders Part 3

Posted in Achilles Tendon

carolina podiatry center

Other Treatment Your Doctor May Prescribe
1) Achilles Tendonitis – Physical Therapy, Massage Therapy, Immobilization, Orthotics and Night
Splints if chronic. Possible MRI to evaluate the area.
2) Insertional Tendonitis – If enlargement exists, pad area as discussed. If overpronating, using a
shoe and possibly an orthotic to reduce motion creating friction. Last resort: surgery to remove
enlarged portion of bone, if present. Future ?: Shock Wave Therapy?
3) Rupture of Achilles – Partial: Possible cast. Complete: Possible Surgery. Usually followed-up
with physical therapy.
For All Forms of Achilles Injury
1) Ice – Fifteen minutes initially, three times a day. Later, use ice especially after activity.
2) Don’t go barefoot – even around the house.
3) No speedwork or hillwork – Depending upon type and severity of injury.
Remember: Self-treatment is not meant to replace a sports medicine professional. If symptoms
persist or you have pain causing you to alter your normal running gate, see a professional.

Managing Achilles Tendon Disorders – Part II

Posted in Achilles Tendon

Last month, we looked at Achilles tendon disorders from the standpoint of the anatomy of this area and how different forms of these disorders tend to manifest themselves in the forms of symptoms.
This article is going to focus on some self treatment you can try on your own as well as some
alternative forms of treatment your sports medicine specialist may recommend.
Self -Treatment
When it comes to self treatment, many times the same form of treatment may or may not be
beneficial depending on the form of Achilles disorder you have.
At the end of the article, I will summarize the different forms of treatment, whether it may be beneficial
for your type of problem and when you may want to start. These are not hard and fast rules, but can provide an outline for you.
One constant with many forms of self treatment may be some period of rest. One can always
supplement your period of non-running with swimming or water running to help maintain your fitness as well as your sanity.
A. Achilles Tendonitis
Once again, as discussed in last months article, this form of Achilles tendon injury usually occurs
about two inches above the heel bone. You may find swelling when compared to the other leg in the
same region. Because of the poor blood supply to the area, it is important to initiate treatment
immediately to prevent the tendonitis from becoming chronic.
Evaluate the area
With your thumb and forefinger, pinch along the Achilles tendon. Start down close to the heel,
working your way up toward where the tendon enters the calf muscle. If you feel swelling and
pain, you likely have Achilles tendonitis.
Early Treatment
Stop running. (This is where you rip out this page and throw it in the trash, right?) I recommend taking at least two to three days off completely. During this time you should ice the area 15-20 minutes two to three times a day. Use ice packs or massage the area with a Styrofoam or Dixie cup filled with water and frozen, peeling off the top layer of paper as you go. Do not stretch the area during this initial period because you only serve to keep the area inflamed and may risk further damaging the

Next, use heel lifts to take the stress off the Achilles. Use a ¼ inch non-compressible material. In your running shoes I recommend placing the lift under your existing insoles. I have found the following to work well; take the insoles from a couple pairs of old running shoes and cut straight across about three inches from the back of the insole. Two layers will be about ¼ inch.  Two layers will be about ¼ inch. You can use any other non-compressible material you have around the house. Be sure to do this on the non-affected leg as well, otherwise you will be creating an imbalance which may result in further injuries. It is important not to walk around without your shoes, even in the house (except when taking a bath or
shower). The farther the heel must go to reach the ground, the greater stretch and re-irritation of the Achilles.

If you return to running and have no significant pain or alteration of running gait, do no speedwork or hillwork for at least three weeks. If you return to running but continue to have pain such that it causes you to alter your normal running gait, then your better off not running. If you continue to have pain despite time off, ice and heel lifts, then it is best to seek a sports medicine physicianfor a more thorough evaluation.
Possible Medical Options
Treatment may include physical therapy, non-steroidal anti-inflammatory medications (NSAID’s),
massage therapy, night splints and possible cast immobilization. If biomechanical abnormalities are present such as overpronation, leg length differences or other pathology is present, orthotics may be required. Also, an MRI may be recommended to further evaluate the extent of damage and
possible tears. Surgery may be considered as a last option.

B. Insertional Achilles Tendonitis/Bursitis
This injury occurs where the tendon inserts into the heel bone instead of above it. Chronic irritationcan, at times, cause a spur to develop within the tendon itself. This condition can also result in an inflammation of a small fluid-filled sac in the area called the retrocalcaneal bursa.
Evaluate the area
Push the area on the back of the heel. You may notice a thickening in this area as well as
tenderness. There is a similar problem to the achilles insertional spur which also causes an
enlargement on the back of the heel called a haglund’s deformity or “pump bump”. This can only be differentiated from insertional Achilles tendon spur by x-rays and careful examination. The
conservative treatment for the haglund’s deformity is similar to a Achilles insertional spur so, for the sake of length this article, we won’t go into a lot of specifics on how these problems differ.
Self – Treatment
Be sure the back of your current running shoes are not so worn that there is a hole in the area behind your heel. Next, find something to cushion the back of the heel (such as adhesive felt or foam) and cut a doughnut or U-shaped pad so that the area of irritation sits inside the “doughnut hole” or “U”. Place this in the back of the shoe so the pressure is off the irritated area. You can also try multiple layers of moleskin or cut a “U” in the back of a heel cup.

Ladies, stay away from “pumps” and high-heeled shoes that may aggravate the area. Try clogs or
sandals whose strap does not come across this area.
Possible Medical Options
Be sure your current running shoes are not too worn out and you are using the correct type for
your running biomechanics. Treatment is very similar to that of standard Achilles tendonitis so review that area again. I’ll frequently use different custom forms of padding and be sure my patients are not just performing the standard “calf” stretch but also the “soleus” stretch in which the back leg has the knee bent instead of straight to localize the area of pain more effectively. Once again, surgery should only be considered as a last option. A new option that may be available in the future is shock wave therapy or ESWT (extracoporeal shock wave therapy). This technology uses deep shock waves to break up scar tissue and allow new vessels to flow into the area to help the Achilles tendon insertion heal itself. This is still in the investigational stages with pending FDA approval for insertional Achilles tendonitis, but it does show promise. This is the same technology being used in chronic plantar fasciitis.
C. “Tennis Leg”
This injury occurs at the junction of the calf muscle and the Achilles tendon or just below this area.

Evaluate the area
As mentioned in the last article, you may have the sensation of being hit in the back of the calf and possible bruising. Pain and swelling may even extend into the ankle area. This usually occurs as a result of more ballistic movement such as reaching for a tennis shot (hence the name “tennis leg”) or from trauma. My two incidents with this injury occurred while playing basketball and doing intervals on the track. Pushing at the junction of the bottom of the calf muscle and thinner Achilles tendon will illicit symptoms as noted above.

Self – Treatment
Initially includes RICE: rest, ice, compression and elevation. Your sports medicine physician should
evaluate this problem to ascertain if the Achilles tendon has been torn. Do not run until the injury has been evaluated.
Possible Medical Options
Usually this requires no running for at least two to three weeks. Physical therapy, message therapy
and gradual stretching can speed the healing process. Once again, heel lifts in both shoes will likely
be of benefit and anti-inflammatories may be prescribed. Also, no speedwork or hillwork is allowed; typically at least six weeks or until pain has subsided.
D. Achilles Tendon Ruptures
Rupture of the Achilles tendon, although not common, is a very serious injury and should be treated as such. As mentioned in last months article, the Achilles loses its elasticity from age 35 on and so it is more frequent in those of us in this group.
This is not a time to attempt self-treatment. Immediate evaluation by a sports medicine physician is essential, not only to help you return to running, but also to prevent further damage. Partial ruptures can usually be treated successfully with some type of immobilization such as a cast. Complete ruptures may require surgery.
The easiest way to treat Achilles tendon injuries is to prevent them in the first place. These injuries can take several months to totally resolve and may result in the formation of scar issue and permanent limited mobility. With that in mind, it makes sense to take strides to prevent them. Keys to prevention include warming up sufficiently, maintaining appropriate flexibility, sensible running and wearing appropriate shoes.
Warming up includes starting all your runs at an easy pace. I always run the first 1-2 miles slowly,
usually 30 seconds to a minute slower than my normal training pace. This is especially true when
doing speedwork or hillwork. To help maintain flexibility, I feel stretching is in order. I know all you running gurus who read the
running literature these days will say the jury is still out on stretching and its proposed benefits. But from my own personal experience, I must say stretching has helped keep me on the roads, and my periodic bouts with Achilles injuries have usually been at times when I have not been stretching. If I do no other stretching, regardless of injury or not, I always try to stretch the Achilles. The simple straight leg and bent knee Achilles wall stretch performed gently for two repetitions each of 15-20 seconds has been my bread and butter. Also, I prefer to stretch after I’ve taken my one to two mile warm up so that I am not stressing an already tight region.
Sensible training includes allowing the muscles and tendons to adapt to increasing amounts of stress loads placed upon then. In regard to overall mileage and long run mileage, don’t increase more than 10% per week. In regard to speedwork or hillwork increase the speed, repetitions and distance gradually. And when increasing overall mileage per week or speedwork, only change one variable or the other at one time. Don’t increase both at the same time.
Wearing appropriate shoes is important. “Appropriate” refers not only to the correct type for your
running biomechanics, but also appropriate heel height. Many running specialty stores can evaluate
you and put you in the right shoe for your mechanics. Also, be aware that shoes having a lower heel, such as most racing flats or spikes, may put additional stress on the area because of the lower heel height. I have given up true racing flats and use lightweight training shoes with my orthotics to give me additional support, only using these for speedwork and races.
As outlined in the previous paragraphs, the best way to treat Achilles tendonitis, or any injury for that matter, is to prevent it from happening. But as they say, “Even the best laid plans of mice and men sometimes go awry.”
When mild injuries occur, self treatment can be of benefit and keep you out of my office. But in the cases where the injury has not improved in a week despite the outlined measures or an Achilles tear or rupture is suspected, you need to seek the attention of the sports medicine physician.
See you on the roads!

Managing Achilles Tendon Disorders- Part I

Posted in Achilles Tendon

I half joking tell my patients and friends when they ask why I became a podiatrist (no I
don’t have a foot fetish) that it became cheaper to become one than keep going to see
one. Of the many injuries over the past 25 plus years of running, one the most frustrating
and recurrent ones has been to the Achilles tendon. Over the years I’ve become better at
“managing” the problem and keeping it at bay.
The Achilles is the strongest tendon in the body, yet, because of the great amount stress
applied to it, is very prone to injury. Combine this with the fact that the Achilles tendon
loses a large amount of elasticity once one is past the age of 35 and you have a recipe that
can end in sports injury related disaster.
This article will look at an overview of the anatomy of the Achilles, different forms of
this problem. Next month I’ll outline in more detail things to try yourself if you have the
problem and some alternative treatment techniques a sports medicine specialist may

ANATOMY (see diagram) 

The Achilles tendon connects the two big muscles of the calf – the gastrocnemius and the
soleus- and attaches them into the back of the heel bone.
The myotendinous junction is the area where the calf muscle attaches to the tendon. This
area is relatively strong but may be susceptible to quick or “ballistic” movement where
extreme amounts of pressure are incurred at one time such as sprinting all at once. (See
Tennis Leg below.)
The watershed area is the portion of the Achilles about two inches above the attachment
into the heel bone. This is the most commonly injured area due to two factors. First, the
tendon narrows and is therefore less strong. Secondly, probably more importantly, is the
fact that this is an area of relatively poor blood flow. This poor blood flow also accounts
for these injuries taking a long time to heal.
The final crucial portion of the anatomy is the area where the Achilles attaches into the
heel bone itself call the insertion.
This is an inflammation of the sheath around the tendon itself. It most commonly
occurs in the previously mentioned watershed region about two inches above the
insertion into the heel bone. Symptoms generally include tenderness, stiffness, or burning pain. There may be
swelling or nodules also present when comparing it to the other leg. The nodules
usually develop in more chronic cases as a result of small tears in the tendon or a
tendinosis which may or may not disappear in time. Frequently symptoms disappear
after running a bit but reappear afterward.
There are many causes for Achilles tendonitis but it frequently results from training
errors, excessive tightness and biomechanical problems.
Training errors can include increasing mileage too fast (more than 10% per week),
hill work, changing from the roads or track to cross country or trails and adding speed
Excessive calf tightness can also be a problem. There is a current controversy about
the role of stretching in injury prevention. My opinion is to stretch in moderation
which I’ll cover in more detail in next months article.
Biomechanical factors may include over pronation but can in also be seen in the high
arched foot due to increased tightness of the calf. In addition leg length discrepancies
may be present.
Here the problem is located where the tendon attaches into the heel bone itself.
Patients with this problem often have other associated problems.
a. Haglund’s Deformity – a prominence of the back of the heel bone just below the
Achilles attachment. This area may be irritated by the heel counter of the shoe and
has the affectionate term of “pump bump”. (Don’t look at me guys, if the shoe
fits…). This area may become red and swollen.
b. Bursitis – the bursa is a small fluid filled sac just in front of the Achilles insertion
and behind the heel bone itself.
This form occurs where the calf muscle and tendon join together or at the previously
mentioned myotendenous junction. I don’t usually see this in my long distance
runners unless they are doing speed work or running on trails, etc. and strain the area
all at one time. It can occur when reaching for a tennis shot, thus the name “tennis
leg”. There is some question whether the plantaris, a small muscle behind the calf,
may also be affected or ruptured in these cases but MRI results have not shown this.
Most patients relate the sensation of being hit at the back of the leg with an object.
Immediate pain and swelling occur and it is difficult to walk. Bruising many times
may occur although this may be delayed. Walking is usually difficult and it is hard to
push off.

A rupture is a partial or complete tear of the Achilles tendon. This most commonly
occurs at the watershed area about two inches above the heel bone. This usually
results from an acute or sudden movement in the calf area from activities such as
basketball, tennis, football, etc. Chronic ruptures can also occur. These are usually
the result of previously untreated ruptures that were just treated as a strain and later
result in weakening and scar tissue of the tendon.
Many acute partial ruptures can be treated conservatively with immobilization such as
a cast but a total rupture or chronic rupture may require surgery.
Two take home messages I would recommend from this article. First, Achilles
tendon injuries are difficult to heal and require patience and care during the healing
process. Attempting too rapid return to running will not only prolong recovery but
will make you more susceptible to future injury. Second, any injury in this area
lasting more than seven consecutive days should be evaluated by a sports medicine
physician, preferably one who treats runners. Also, if you have severe pain, seek
immediate attention since you may be dealing with a rupture which requires
immediate treatment.
Next month, as mentioned previously, I’ll outline some things that you can try
yourself for these problems and outline some of the treatment options yours sports
medicine specialist may recommend.
Until then, see you on the roads!