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!

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