Achilles Tendon problems, including Achilles Tendonitis, are frequently encountered by elite and amateur athletes alike. Problems range from mild irritation through to debilitating and even career threatening injuries. This article will explain why runners get these problems, how to prevent them from happening to you if you are running The British Airways Run Gatwick Half Marathon or 5k race Sussex. Also, it explains what interventions are sometimes required to get you back on your feet.
The Achilles Tendon is essentially a piece of bungee cord that connects the powerful calf muscles and the Calcaneum or Heel Bone. Just like a bungee cord the Tendon is made up of thousands of individual fibres, the cord has some elasticity and is incredibly strong. In fact whilst running the force in the tendon is thought to exceed 9000N which is 920Kg!
In order to manage this incredible feat the tendon can’t have too many flimsy nerves or blood vessels in it. The low nerve count means damage can build up before you notice a problem and poor blood supply can make tendon healing a frustratingly slow process.
Achilles Tendon Problems
If some of the tendon fibres become damaged the tendon tries to repair itself. New blood vessels grow into the tendon, it surrounds itself with fluid and swells. Initially running is painful, then simply walking and rest pain develops. The tendon can be damaged either in the fibrous part, usually between 2 and 6cm from the heel bone, or where the tendon attaches to the bone.
The fibrous part of the tendon repairs itself by laying down new fibres. Initially the goal is to avoid a rupture so the body lays down a lot of fibres but not necessarily in the correct orientation. When there is a large area of damage to repair these mattered fibres can be felt as a painful swelling or nodule within the tendon. Over time the body will remodel the nodule by removing fibres that aren’t in the correct orientation. This may take months to years to return to normal. If the damage occurs where the tendon joins the bone, the body can also lay down calcium and bone which is seen on an x-ray as a bone spur.
The Achilles is usually able to repair itself and hardly ever progresses from Achilles Tendonitis to a rupture. More commonly the tendon ruptures because of a combination of a rapidly applied and high load, such as falling off a step, together with the strong calf muscles contracting. An Achilles rupture is usually pretty obvious, most people get a sudden pain at the back of the ankle and a feeling that they’ve been kicked and sometimes a popping or snapping sound. A ruptured tendon releases a lot of healing cells and chemicals (blood) which can join the tendon ends over about 12 to 18 weeks. After this the remodelling process as described above continues to strengthen the tendon over several years.
“Why does the tendon get damaged?”
Too much load applied too quickly
Thinking of the tendon as a bungee cord explains how the tendon can get injured. If too much load goes through the cord, or if the load is applied too quickly some of the internal fibres will snap.
Too much tension
If the tendon is too tight and is always under tension then the fibres are more likely to be damaged and it’s more difficult for the tendon to repair itself. An elastic band that is floppy doesn’t snap, one that is taught does. This is why stretching the tendon is so important in managing Achilles conditions, a tendon at the correct tension has some reserve before it snaps.
Training too hard too fast
The tendon can respond to an increase in load by getting stronger, but because of the poor blood supply this can be quite a slow process. If you try and load the tendon too much too soon the amount of damage to fibres exceeds the amount of new fibres being created. This is the road to Achilles Tendonitis.
How do I prevent Achilles Tendonitis?
Listen to your body
If you are starting to get Achilles pain it’s your tendon telling you that some damage has occurred and it needs a rest to repair itself and then a slow increase in load so it can strengthen up.
Change your training program
You might need to reduce the frequency or duration of training but often a change of activity to one where the load is applied more slowly works just as well and maintains cardiovascular fitness. Running applies a high load to the tendon, an exercise bike or cross-trainer are equally good at keeping fit but significantly reduce the load on the tendon.
The earth is flat! This might not be true from space but our daily lives are spent walking on billiard-table flat surfaces at home, at work and on the road. The days of lifting the front of your foot to avoid tripping over a tree root or mammoth trunk are long gone. The result is a calf muscle that gets a daily work-out but a shin muscle that doesn’t have to do much, just compare the size! This muscle imbalance, where the calf is so much stronger, leads us all to tend towards tightness in the Achilles system. Ironically if you run the imbalance can be even worse as that calf gets stronger as you run.
The solution is to stretch the calf muscle and the Achilles; this should be a regular stretch even on non-training days. On training days the stretch performs a slightly different but equally important job of warming the tendon up and preparing it for loading.
Maximise your healing
If you have Achilles Tendonitis your body needs all the help it can get to heal up. It needs fuel in terms of energy and protein to turn into tendon fibres. Maintain a healthy diet and if you smoke, stop. In fact the new blood vessels are extremely susceptible to cigarette smoke and even nicotine from vapour and patches can inhibit new blood vessel formation.
If these simple measures haven’t helped our dedicated team of Physiotherapists are able to help with stretching and strengthening programs. If things still haven’t improved there are a range of surgical options most of which are minimally invasive that can improve your symptoms and speed up the healing process.
MB BS, BSc, MSc, FRCS (Tr. & Orth.)
Consultant Orthopaedic Surgeon
Specialising in Foot & Ankle and Trauma Surgery