Achilles Tendon

Bad Heel Day – The Achilles Tendon

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A bad heel day ended the career of Achilles during the Trojan War when Paris launched an arrow into that vulnerable spot at the back of the ankle. Achilles was a strapping young buck of epic stature, the Greek army’s mightiest warrior. Today’s aging weekend warriors are a lot less mighty and a lot more vulnerable, and we’re suffering bad heel days in epic numbers thanks to Achilles’ namesake Achilles Tendon.

Inflammation in and around the Achilles tendon, which connects the calf and heel and is basic to walking, running and jumping, is one of the more common overuse syndromes seen in sports medicine clinics.

“That’s definitely on the rise with the kinds of training people are doing now,” says  Dr. Nicholas DiNubile, an orthopedic surgeon and best-selling author of the “Framework” series. “Tendonitis can also come from deterioration with age, where the tendon begins to change from very strong collagen into fatty tissue, or scar tissue.”

Tendonitis is what they call more acute inflammation, more common in the younger, healthier person. Tendonosis, or tendonopathy, is more the chronic problem: an athlete who has been running for many years, for example, where the inside of the tendon has a long history of getting beaten up. It’s a chronic, degenerative change, often age-related, where there’s not a lot of circulation, it deteriorates, weakens internally and is more likely to rupture.

Attitude can be as much a problem as age. “My biggest problem is with baby boomers with tendonitis,” says Dr. DiNubile. “They think, ‘Oh, it’s not that bad. They get out there with the endorphins, and the adrenalin’s high, and you can’t get these people to stop.”

Taking care of the Achilles tendon is important to preventing tendonitis and, horror of horrors, that SNAP!!!, the tendon’s sudden and catastrophic rupture, or complete tear. While the Achilles is the thickest and most powerful tendon in the body, aging, repeated injuries and overuse cause micro-trauma, micro-tearing and cellular degeneration (tendonosis) that can accumulate even without any warning signs of tendonitis pain. And then? Some trainers allow their athletes to “play through” some injuries or stresses, but with the Achilles tendon, that’s just asking for big trouble in the form of a rupture.

“You’re coming down from a rebound, turning the bases on the ball field or stepping back to the baseline in a tennis game, there’s a sudden stretch to the Achilles and snap, it goes,” says Dr. Stephen Simons, of St. Joseph Medical Center in South Bend, Indiana.

New Orleans Saints head trainer Dean Kleinschimdt gave one of the best descriptions of what happens in a rupture, during the 1998 NFL season, after quarterback Billy Joe Hobert dropped back to pass and planted his right foot behind him. “He just crumpled down into a ball,” Kleinschmidt said. “Typically they go down like somebody’s shot them in the leg, and there can be an audible pop, like the sound of a small-gauge weapon being discharged. There’s nothing pretty about it. The tendon is composed of fibers, and when it ruptures it looks like a plate of spaghetti that just exploded, a wet mop, a plate of worms, ends and tissues going everywhere.”

Pro athletes’ Achilles tendons have typically taken a pounding over many years, but that’s not the case for most of us. For most people, says one athletic trainer, “it’s from sitting on the sofa doing absolutely nothing and then going out and trying to be an athlete.”

In the population at large, Achilles injuries happen most often in men, and age-wise they happen most often in the 30-49 age range. They are more common among men who, despite infrequent athletic activity, poor conditioning and age issues, still try to prove they are stud athletes. According to Kleinschmidt, now Coordinator of Athletic Medicine for the Detroit Lions, “The problem is that most people stay at the office late, change clothes and rush to the softball field or basketball court, and there’s nine other guys waiting for them. Their shoes aren’t tied, they jump out of the car and run into the gym and say, ‘Let’s start!’ And they don’t even warm up.”

Running is the most common cause of chronic tendonitis because it gives you a strong calf as well as a tight one, one of the physical characteristics that make you prone to tendonitis. The signs are hard to miss. First, running becomes painful, with a feeling of sluggishness in the lower leg. Later, there may be more pain along the tendon during and for a few hours after running. The next morning, the Achilles tendon may be tender about an inch and a half above the connection to the heel bone – This is the snapping point, where the tendon is thinnest and the blood supply is weakest.

Surprisingly, people whose Achilles tendons snap often don’t realize what has happened. Tennis players have reported thinking a ball had hit them. Some think it’s just a bad sprain, and the injury is often missed, even by emergency-room doctors. But if you feel a pop or sudden pain back there, if there’s any swelling or limpness, consult a sports-medicine or orthopedic specialist.

“If you see them right away, before it swells, you can stick your finger in there,” says Dr. DiNubile. “There’s a gap of about an inch. Most active patients or athletes with a rupture need to have surgery right away, within 10 days. I’ve had some people come in six months later, and the tendon shortens. It just rolls up into the leg like a window shade, and to restore that is really tricky. There are times where, for certain patients, especially those less active, Achilles tears can be treated non-operatively with a long periods of immobilization.”

Surgery can have its complications as well. Among the most notorious of Achilles snaps in pro sports in recent years, Philadelphia Phillies first baseman Ryan Howard tore his during a National League division series game in October 2011 and has never been quite the same since. Surgery repaired the tendon, but recovery was long and complicated. In February 2012 another surgery was needed for an infection.

No Achilles injury, even rupture, is completely preventable, but the experts say that warm-up and stretching activities are a necessary precaution: a brief warm-up, and then stretching. You don’t want to stretch cold muscles or tendons, says Dr. DiNubile. “A warm-up can include a light aerobic type activity like jumping jacks, running in place or stationary cycling. It brings blood flow to muscle and tendon areas but also increases their temperature, all of which can make the tendon and surrounding tissues behave more elastically. And make them less likely to snap.”

Dr. DiNubile compares it to brittle hard candy, which easily cracks or shatters with impact or pressure, while when that same candy is warmed enough it becomes more elastic like taffy.

Less severe Achilles injuries may be treated with measures short of surgery. Stress on the tendon can be relieved temporarily by heel pads, and minimized by shoes that break at the ball of the toe, instead of shoes with stiff soles. If you have tendon pain, rest from the activity, at least temporarily, is the experts’ recommendation, along with cross-training in other activities such as swimming.

Among today’s conventional treatments is ultrasound iontophoresis, an ultrasound massage combined with steroid cream. While steroid injections are used for rotator-cuff or tennis-elbow problems, they are not advised for the Achilles because they actually increase the risk of rupture. But ultrasound is an alternative way to drive the steroid into the deeper tissues to relieve tendonitis.

Newer technologies continue to make a difference. Diagnostically, MRI imaging has made it easier to see inside the Achilles tendon and reveal the state of degeneration, see if they are starting to develop age-related tendonopathy. And of course, now popular among athletes and most often used for chronic tendon issues, is platelet-rich plasma (PRP) therapy, aimed at regenerating health tissue to replace degenerated tissue. PRP is still controversial in medical science and more research is needed to validate it, but some athletes and trainers swear by it.

When all that’s not enough, says Dr. Simons, he may equip his patients with a “cam walker,” a removable cast that allows the foot to rock over a central pivot. “Then, after that, you think about surgery,” he says, “but you wouldn’t operate for tendonitis until after four to six months of more conservative treatment.”

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