In an interview with the Los Angeles Times, Dan Marino said, “Sometimes you do take it for granted. You go out there and play every Sunday and nothing happens. Then all of a sudden when something does, it’s a shock.” So was the case in October 1993 in a game against the Cleveland Browns. Marino stepped back in the pocket and planted his right foot to pass, when he felt as though he’d been kicked in the back of the leg. In reality, he’d ruptured his Achilles tendon.
Structure and Function:
The Achilles tendon is the thickest and strongest tendon in the human body. It is composed of bundles of collagen fibers stretching longitudinally from two muscles— the gastrocnemius and soleus–to the back of the calcaneus. It is responsible for allowing your body to rise up on your toes, or propel you forward when walking or running. The Achilles begins to fire as your forefoot loads and moves your body forward through mid-stance until your foot lifts from the ground.
The repetitive demands on the Achilles during athletic activity will typically require adequate conditioning and flexibility. Without proper conditioning, stress will occur beyond the tendon’s ability to recover. As with any load bearing apparatus, excessive stress beyond its yield point will undoubtedly lead to structural failure. Likewise, diminished flexibility will contribute to micro-trauma within the substance of the tendon, or surrounding tissues. This may lead to longitudinal tears between the collagen fibers; calcification in the back of the heel or within the body of the tendon; and can even predispose the tendon to rupture.
Extrinsic Factors–An intensive running schedule with rapid increases in speed or mileage always poses a threat to injury. Also, changes in running surfaces can trigger injury, such as moving from a soft track to hard roads; or running on banked running surfaces. Also, something as simple as worn out running shoes can be a predispose injury. This risk increases after age 30.
Intrinsic factors—There are systemic causes that can lead to early tendinous degeneration as well. Systemic illnesses such inflammatory arthritides, (rheumatoid arthritis, gout, etc.), diabetes mellitus, or a history of sedentary lifestyle. A prior medical history using certain antibiotics, or treatment involving injectable steroids near the Achilles tendon, should be considered as well. You should check with your physician with any such concerns.
The onset of symptoms is usually gradual. Pain usually occurs with activity and there may be swelling or redness over the injured area of the tendon. As the injury progresses, a “creaking” sensation may be felt when the ankle is bent upward and downward. Many times the first step in the morning (or after several minutes of resting) is the worst, with relief experienced after 5 minutes of “walking-it-off.” Over time, there will continue to be a dull ache, with intermittent sharp sensations accompanying certain movements or excessive activity. Eventually, the tendon, or tendon insertion in the back of the heel, may change shape and become more prominent. These areas of prominence are usually most painful if squeezed from side to side.
Types of Injuries:
Injuries to the Achilles complex can occur as follows:
- Peritendonitis is inflammation to the soft tissue surrounding the tendon.
- Tendonosis is a pure degenerative process within the tendon. There is usually a lack of symptoms, because the surrounding tissues are not inflamed. This degeneration however could be a precursor to spontaneous rupture with increased activity.
- Tendonitis involves an inflammatory process within the tendon itself, and is usually accompanied by peritendonitis. This may also be accompanied by longitudinal tears and thickening within the tendon. Given time, this could eventually lead to the formation of calcium at the tendon’s insertion or within the tendon itself as the body attempts to strengthen the injured area. Even with successful conservative treatment, surgical intervention could be needed to “debulk” the tendon of the calcified areas.
- Rupture usually occurs after months or years of events that have led to weakening of the tendon complex. This process can be accelerated with any underlying systemic illness.
What you can do:
- Maintain flexibility, particularly in the posterior leg. If you’ve read my previous articles, you know that a tight Achilles complex is the root source behind many foot disorders. It’s important to do the “Runner’s Stretch” before and after running. The benefit gained after running is significant, as your tendon has increased blood flow and elasticity from your workout.
- Avoid training errors. Start with a plan to slowly progress in mileage, resistance training, or any cross-fit program. If you’re beginning a new fitness program, remember that you are in shape primarily for those activities that you’ve been doing. For example, strong swimmers can’t usually assume they will be strong runners (and vise versa). Also, if workouts are missed, don’t try to make-up for time lost with your next workout. Pick up cautiously where you left off, or slow things down if you’ve been out for a while.
- Footwear is important. Our area has several retail shoe outlets that have personnel able to help you find the right shoe to accompany your individual biomechanics. Be sure to replace your shoes every 6 months.
- Don’t be afraid to slow down or even rest. If your body is telling you that the demands are too great, it’s tempting to silence the symptoms with analgesics or anti-inflammatories. However, masking the symptoms will only perpetuate the injury.
What your physician can do:
- If there is any underlying illness, consult your physician prior to engaging in intensive physical exercise.
- In spite of advances in athletic footwear, you may also need arch supports or custom orthotics in your shoes. Your podiatrist would be best qualified to help determine the right choice for you. He or she will also be able to evaluate the mechanics placing strain on your ankles, knees and hips and help prevent future injury as you progress in your training. This may also involve the use of home stretching or physical therapy to prepare you for increased demands on your body.
- If injury has occurred, your physician can help you understand the nature and severity of your injury. This may involve use of x-ray, CT or MRI to determine such severity. If surgery is among the choices in treatment, the risk verses benefit, should be considered carefully. If surgery is warranted, give yourself permission to take time off to heal properly and follow your surgeon’s plan for your recovery.
Keep in mind that as we grow older, injury will be the greatest obstacle to our continued athletic endeavors. Early intervention may prevent severe injury with extended time off work and doing those things that we enjoy. As the weather is about to change for the better, train wisely my friends!
Dr. Randall Kline is a board-certified podiatrist specializing in injury, wound and diseases of the foot and lower leg. Contact Allied Bone and Joint at (574) 367-2795 or visit AlliedBoneandJoint.com for more information.
This article was originally published in RacePlayMichiana. RacePlayMichiana is the premier local source for all news regarding sports and fitness in the Michiana area. RPM is produced in print and online on a bi-monthly basis.