According to Greek mythology, when Achilles was born his mother tried to make him immortal by dipping him in the river Styx. However, when she dipped him in, she forgot the spot on the heel she held him by, which left one small area unprotected. In the end, Achilles was struck by an arrow in his vulnerable heel and was killed. Achilles shares his vulnerability with the rest of us entirely mortal runners, and that is why the tendon which connects the calf muscles to the heel bone bears his name today. The Achilles tendon is the largest tendon in the entire human body and is very strong, but it is also the tendon we rupture the most often. Anyone who is active can suffer from Achilles tendonitis, a common overuse injury and inflammation of the tendon.
If you are out running hills and feel a sharp pain or dull ache in the back of the leg down near the heel, this could be Achilles tendonitis. That said, not all pain in the back of the leg or heel is Achilles tendonitis. If you have a tender swollen knot at the back of the heel where the tendon attaches it might not be Achilles tendonitis.
There is a condition called Haglund’s disease (commonly known as “pump bumps”) which is really bursitis and inflammation of the soft tissues near the attachment of your Achilles tendon. In some cases there may be an underlying bony enlargement as well. In most cases the tender bump is red, painful and more irritated by a stiff heel counter (the back of the shoe). If you have no pain doing toe raises and most of the pain is related to shoes rubbing on the area, it is more likely just bursitis. Bursitis is inflammation of the fluid filled sac that eases friction between tendons and bones. This will usually calm down with icing and shoes that don’t press on the area.
If you feel along the course of the tendon (where it is mobile just above your heel bone) and you have tenderness, this is most likely Achilles tendonitis. Don’t ignore this. Ice the area and decrease your activity level. Avoid hills or speedwork until it subsides. If it doesn’t quickly get better, see your podiatrist. Otherwise you might end up sidelined for four to six weeks.
The best way to prevent Achilles tendonitis is to stretch and warm up before intense workouts. As mentioned earlier in this injury prevention series, a little self-restraint, the right pair of running shoes, and a good training program (such as the ones on the San Francisco Marathon training website) can help you stay injury free. Always stretch before speed workouts, hill repeats and long runs. Stretching helps to keep the tendon pliable, preventing micro-tears. In addition, stretching can improve blood flow, enabling a speedy recovery if you do become injured. Stretching is most effective after a short warm-up; never stretch aggressively when you muscles are cold. This can increase your risk of problems. Include these stretches in your workout routine s follows:
Stand upright about one large pace away from the wall with your feet parallel and about hip width apart. Keep your feet in line as shown. Place your hands against the wall, at shoulder height. Move your right leg half a pace forward. Lunge forward on your right leg so that the knee is brought directly above the ankle. Stretch your left leg back as far as is comfortable with the foot and heel remaining flat on the floor. Slowly lean forward to stretch the left leg calf muscles and tendon. Hold the stretch for 10 seconds, relax, and repeat on the other leg. This is for prevent…do not stretch as illustrated if you have pain. You can also view demonstration videos of these stretches at MyRunningDoc.com.
Symptoms of Achilles tendonitis can include mild pain after exercise or running that gradually worsens, a noticeable sense of sluggishness in your leg, and episodes of diffuse or localized pain, sometimes severe, along the tendon during or within a few hours after running. Other symptoms can be swelling, morning tenderness in the Achilles tendon, or stiffness at the back of the leg that generally diminishes as the tendon warms up with use.
Treatment depends on the degree of injury to the tendon, but normally includes rest. It may even mean a total withdrawal from running or exercise for a week, or simply cross-training with another exercise, such as swimming, that does not stress the Achilles tendon. Treatment can also include non-steroidal anti-inflammatory medication or orthoses, which are devices designed to help support the muscle and relieve stress on the tendon, such as a heel pad or shoe insert.
Other treatments are bandages specifically designed to restrict motion of the tendon, stretching, physical therapy, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors that work against the Achilles tendon. If the tendonitis is mild, simple modifications of activities may help. Decreasing mileage, running on flats instead of hills, and backing off the activity level until there is no pain with exercise can allow the tendon to heal. In general ice is much better than heat for tendonitis.
Some medications can increase the risk of Achilles tendon ruptures (complete tear). If you are taking steroids (prednisone) or flouroquinalone antibiotics (Cipro, Levaquin, etc.) you should not exercise unless you have discussed this with your treating doctor. You may have seen in the news where the FDA recently posted a strong “Black Box” warning about these antibiotics and the associated risk of tendon ruptures.
A torn Achilles tendon is serious. Interestingly, it is not always painful. However, there is usually significant weakness and difficulty standing up on the toes if this has occurred. Any suspected torn tendon can be serious and should be evaluated by a podiatrist. In rare cases surgery may be needed to repair the tendon.
If you happen to be a marathon or half marathon runner in training for battle; warm up, stretch, and stick to your training program. Do not run through the pain if you think you have Achilles tendonitis. If you are a Trojan War hero in battle, and you see any arrows coming your way, stay low and keep moving!
Dr. Christopher Segler is a multiple Ironman finisher and marathon runner. When not busy seeing athletes during podiatry house call appointments, you will find him riding the Alpine Dam Loop, cycling through Nicassio Valley, or running in Golden Gate Park. If you think you have Achilles tendonitis, but are just too busy to sit in a doctor's office, he will come right to your Bay Area home or San Francisco office to help get you back on the road to recovery as quickly as possible. (415) 308-0833