Achilles' Heel Revisited
Just mention Achilles tendon to a runner or a tennis player and you'll see him or her squirm. Once injured, the Achilles tendon can take a long time to heal because it is the most important tendon in pulling a person up on his or her toes and has minimal blood supply. The tendon comes from two calf muscles: the gastrocnemious and soleus muscles. The Achilles tendon is the heel cord that attaches to the heel bone and runs two-thirds down your leg. There are a myriad of injuries associated with this tendon. As a physician, I see about 150 cases of Achilles-related pain a year.
Achilles tendon tears or ruptures are fairly common in middle-aged males, particularly those involved in ballistic sports such as basketball and racquet sports. When the tendon tears or ruptures, a patient generally feels a "pop," as if he or she was hit in the back of the leg and can't stand on his or her toes. People who don't stretch their calves much, who have chronic Achilles pain or who have taken steroids (particularly injections for tendonitis and bursitis) are more susceptible to rupture. Athletic patients should have the ruptured Achilles tendon surgically repaired to ensure they have as close to normal strength as possible.
Achilles tendonitis and tendinosis (a chronic case of tendon swelling) are by far the most common ailments I treat. The tendon feels bruised, stiff or sore, especially in the morning and the early part of a run. However, the Achilles tendon generally does not hurt for the majority of the run or activity; the patient may think the injury can't be too bad and has a false sense of security. As the condition worsens, a burning sensation may develop, and, at this point, sports activity should stop. Unfortunately, patients continue and scar tissue develops within the tendon. There is often a partial tearing, resulting in the chronic swelling of tendinosis. Typical initial treatment includes rest, heel lifts, anti-inflammatory, ice, physical and massage therapy, and sometimes orthoses. Surgery is usually reserved for Achilles tendon injuries that are resistant to healing.
Achilles paratendinosis is inflammation of the fatty covering of the Achilles tendon, which often results in diffuse swelling of the tendon, and, in contrast to tendonitis, usually gets worse with activity. Directly massaging the tendon, performing heel lifts and icing the area all seem to make paratendinosis worse. Calf (not tendon) massage, physical therapy, and complete rest are the best remedies. Chronic cases of Achilles paratendinosis heal well with surgery. It is important to note that a patient can have both tendinosis and paratendinosis, particularly runners who have ignored symptoms for more than a year.
Other common conditions of the Achilles tendon is a heel spur (tendo-calcinosis), "pump bump" and bursitis. Any tendon or ligament can calcify when stressed. Surgery may be recommended if the typical remedies for tendonitis don't relieve symptoms. This is more likely if the calcification is fragmented and standing on one's toes causes pain. These functional ruptures can happen with any Achilles problem when patients ignore the symptoms.
Pump bumps and bursitis in the back of the heel are due to bony prominences on the heel bone itself. High-heeled shoes ("pumps") were once thought to cause the problem, but in fact anyone who has an irregularly shaped heel bone that "rocks and rolls" (pronates or supinates excessively) and who wears a hard contoured heel cup in their shoe is susceptible. Bursitis is an inflammation of the sack or cushion that protects the bone from pressure. Conservative measures mentioned above are helpful, as is accommodative padding. Surgery is less likely for bursitis than other Achilles-related conditions. I usually don't recommend surgery for chronic Achilles conditions unless patients have tried six months or more of conservative treatment. When surgery is indicated, I've found it to be 95 percent successful; the remaining 5 percent may still have some discomfort, decreased activity level or need additional surgery.
Patients must rule out that Achilles-related conditions are really stress fractures of the heel bone, nerve problems or a deep ankle injuries, all of which may transfer pain to the Achilles tendon region. As with any health problem, the treatment is more successful with an accurate diagnosis.
The problems mentioned in this article can be prevented by doing the wall stretch (held for 30 seconds with the knee straight and then bent), icing the area when sore for five to 10 minutes and wearing appropriate shoes. You don't have to be plagued by Achilles tendon problems. Don't fool yourself thinking you're not seriously injured if it doesn't hurt while you exercise. Early treatment will minimize downtime and potential complications.
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