The Achilles tendon has 2 major functions during running. The calf muscles (1) lower the forefoot to the ground after heelstrike; and (2) raise the heel during "toeing off". Achilles tendinitis is caused by a force on the tendon greater than its inherent strength.
Most runners land on their heels with their forefoot still 2 in from the ground. Running fast and up and down hills places extra force on the Achilles tendon. During downhill running, the forefoot strikes the ground with greater force than on level ground, since it drops further and has more distance to accelerate. During uphill running, the heel is much lower than the forefoot, so it takes a much greater force by the calf muscles to raise the heel before toeing off.
A soft heel counter allows excessive movement of the heel in the shoe. The rearfoot is not as stable and the Achilles tendon has to pull on a wobbly insertion. This places unever force on the tendon and increases its chance of being torn. Stiff-soled shoes that do not bend just behind the first metatarsophalangeal joint place great stress on the Achilles tendon just before toeing off.
The tendon can be strained, or suffer a minor tear, at or close to its point of insertion on the heel. Or the bursa between the tendon and the upper part of the bone may become inflamed. The condition may be complicated by small bony outgrowths (spurs) forming on the heel-bone. The spur sometimes becomes detached, formed a focal point of pain.
The pain usually comes on gradually, but it can be sudden. You feel it tiptoeing or running, and the tendon feels tender over the heel when you press on it. The cause is usually excessive use of the calf in extreme ranges of movement, as, for instance, when you run fast up a steep hill. Rough, protruding linings in your shoes can also be a cause, producing bruising and tenderness over the heel.
Specialist treatment may consist of an injection, or physiotherapy treatment. Your podiatrist may have X-rays taken, to make sure that there is no damage to the heel-bone, or spur formation. It may be necessary to line the backs of your shoes with felt or padding, to create a smooth surface. This injury is slow to heal, so you must rest it.
The tendon may become sore, thickened, and tender to touch at any point up to about five centimetres above the top of the heel-bone. Some of its fibres may be torn or degenerated, while the tendon's covering becomes thickened. The tendon feels stiff first thing in the morning, and on starting exercise. When you stand on your toes barefoot, the tendon hurts at first, but then eases. However, it remains very sore to touch.
The cause is almost invariably friction from shoes with high backs, or heel-tabs. The first priority is to remove the cause: cut down the heel-tabs with two vertical slits on either side of where the tendon lies, to the level of the back of your ankle, usually about five centimetres above the upper edge of the sole. If there is no spasm causing pain higher up where the tendon joins the calf muscle, you can safely resume running and sports provided you warm-up and warm-down thoroughly. The tendon may remain thickened and sore to touch for months, possibly years, but provided you feel no pain during exercise, it is safe for you to continue your sport.
This may happen at any level in the tendon. A sudden severe pain occurs, which often feels like a violent blow to the calf. Swelling and bruising may appear, and the two broken ends of the tendon often leave a visible gap. Usually, you fall at the moment of injury, and walking is then too painful to try.
The cause can be a blow to the muscle or tendon when they are tensed. More often, the injury is caused by strenuous activity involving the calf, such as sprinting or playing squash. The injury may occur at the beginning of the activity, when the muscles are 'cold' and tight.
At the moment of injury, it may not be clear whether the tendon is completely torn. One test for this is to lie on your stomach, and have someone squeeze the calf muscle bulk gently: if the tendon is partly intact the foot will move to point downwards, but if the tear is complete, the foot will remain still.
This injury requires specialist treatment, which may consist of surgery, to stitch the two tendon ends together, or immobilization in a plaster cast, allowing the tendon to heal naturally. After surgery, you can usually resume sport within three to four months. If your leg is immobilized, the plaster will be on for eight to twelve weeks, so, after rehabilitation, you will probably resume sport about six months after the injury.
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