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Advice from Dr. Greenapple:
Achilles Tendinitis - A Real Pain in the Heel
By Dr. Scott Greenapple
With spring time here and race season starting we are seeing an increase in all running related injuries. More than usual, we are seeing an increase in heel pain, both acute and chronic. When the pain is at the posterior (back of the heel) where the large tendon meets the heel bone, including the area 2-6 centimeters above it, that is what is commonly referred to as Achilles tendinitis. However, right where it attaches to that bone (calcaneus) there is a bursa and that is called Achilles bursitis.
Achilles Tendon & Bursa
The Achilles tendon is the largest and strongest tendon in the body. It is where the calf muscles (gastrocnemius and soleus) form the tendon which attaches to the calcaneus, heel bone. It has been reported as high as 18% of runners will experience this malady some time in their career. Studies have also shown that the forces can be 10-12 times the body weight within the Achilles tendon during sprinting. Runners will typically present with pain above the heel, localized to the tendon itself, or typically more on the inside of the tendon.
The Achilles tendon does not have a good blood supply therefore has a tendency for prolonged healing. This is where the theories of tendonosis vs. tendonitis come into play. An area with poor blood supply and chronic repetitive injury has a tendency to develop micro tears and scarring. This is called tendonosis, a non-acute injury that will not respond well to anti-inflammatories due to the absence of acute inflammation. This is in contrast still to most that treat these conditions without proper sports injury training.
The tendon can become sore, hot, and swollen, this is an acute injury. When the patient presents with a thickened tendon or "bump" we know this is more of chronic inflamed area that has progressed over time. Also this is a common area to get what is called a "pump bump" from the shoe or high heels chronically rubbing on the area. The patient will usually come in complaining of stiffness in the tendon area when going from a seated to standing position after sitting for prolonged periods, or stiffness and pain with the first few steps in the morning. The area feels better after walking or light running when it gets warmed up due to increase in blood but will return to a painful area after the activity.
There are many theories as to why a runner will get the condition. It usually presents with an insidious onset after the athlete starts to change their training schedule: increased mileage, increase speed, hill repeats, new or different style shoes, and the tendency to pronate or supinate. I also have seen an increase with Achilles problems due to all the "new" theories on shoes and "proper" form running. The minimalist style shoe with a low heel can cause havoc in the calf and Achilles if the athlete has not trained their body to run in this style of shoe. Methods like Pose and Chi running can cause this as they have you lean and go midfoot to forefoot. If the ankle is not flexible enough or has a lack of proper motion, the calf has to elongate too much and pulls on the Achilles. Shoes with a very cushioned heel cause the heel to sink too low and pull on the Achilles. A very stiff forefoot shoe can cause a longer lever and increase tension in the Achilles as the calf has to work harder. From a biomechanics stand point tight hamstrings can impact the ankle joint and cause issues with the calf muscles resulting in Achilles issues.
Treatments can be effective and good results have been shown with ART, Graston, Acupuncture, Dry Needling, Ultra Sound, and laser. The jury is out on stretching and my belief is stretching will make this worse. If you do want to try stretching, lean against the wall and lean into it with your knee first straight, then bend the knee. I do not recommend going farther than neutral on the stretch meaning do not go below ground level like off of a stair or curb. The most problematic and serious issue is from ignoring the pain at first and continuing with the activity causing the problem to become chronic and leading to the dreaded tear. You do not have to stop if there is no swelling, but be cautious. No hills and no speed work. Increase cross training and lower your volume. Try a ¼ inch heel lift to minimize the dropping of the heel.
See the attached video on how to strengthen and prevent calf and Achilles injuries using eccentric strengthen by elongating the calf and making the muscles strong and long, vs. concentric calf lifts which will shorten and produce tight calves. Good luck and stay healthy this coming season.
ECCENTRIC ACHILLES/CALF EXERCISE
Dr Greenapple (DC, CCSP, FIAMA) has been practicing for the past 25 years. His specialty is sports injuries with heavy emphasis on running, triathlons, gait and performance enhancement. He was the first to bring to ART, Graston, Kinesio Tape, and Laser treatments to the athletes in Charlotte. Dr. G also incorporates Acupuncture in his practice and uses traditional eastern philosophies as well as specific sports and orthopedic Acupuncture. To learn more, check out his website
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