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The Achilles tendon - patience is necessary...

The Achilles tendon, the strongest tendon in the human body, was considered to be the weak point of the otherwise invincible Achilles (Achilles heel) in Greek mythology. Ambitious runners will also have a story to tell about this tendon.

The function of the Achilles tendon is to bend the ankle, i.e. the forefoot is pulled downwards forcefully. This movement is crucial for pushing off the foot when walking and running.

Overexertion of the Achilles tendon during running and inflammations resulting from this (achillodynia) are, unfortunately, common - and often also very prolonged. Either the Achilles tendon directly at the area of attachment to the calcaneus or the tendon and the surrounding paratenon several centimetres above the attachment are affected. In the case of chronic achillodynia, a spindle-like thickening of the Achilles tendon occurs, together with persistent pain that is sometimes stronger and sometimes weaker.

Acute achillodynia (paratendinitis)

 

The reason for acute pain and irritations of the Achilles tendon lie in the anatomy: The Achilles tendon is surrounded by a thin layer of tissue and glides by moving in a type of tube (tendon sheath) consisting of six to eight membranes. To protect against friction, there are gelatinous connections, mucopolysaccharides, between the layers of tissue. The resilience of the tendon depends on the consistency of the mucopolysaccharides: the more able to glide the membranes are, the lower the risk of injuries.

The function of the Achilles tendon is to bend the ankle, i.e. the forefoot is pulled downwards forcefully. This movement is crucial for pushing off the foot when walking and running and is performed many hundreds of times during a normal training run with weight-bearing of several times the person’s body weight. If there is overexertion, the consistency of the mucopolysaccharides changes and the pain commences (you are therefore more susceptible to Achilles problems in winter, in low temperatures, because the consistency of the lubricating substance becomes markedly more viscous).

Typical symptoms include pain, swelling and overheating of the Achilles tendon. A runner typically feels an uncomfortable pulling in the region of the tendon, as well as severe tenderness of the affected region. The tendon and the surrounding tissue can swell and the thickening is often also palpable and hot to the touch. For keen runners, the day often begins with a feeling of frustration, as the pain is usually particularly severe in the mornings. Even when running, the first few minutes are especially uncomfortable, then the pain disappears and often only a pulling sensation can be felt. More severe pain can then occur again after running and at night.

Image: MRI of chronic achillodynia

Chronic achillodynia:

 

The tendon is usually thickened in the chronic stage. The chronic inflammation causes lasting pain (often this involves deep dull pain) and leads to a weakening of the Achilles tendon. The cause of this lies in the fact that the type 1 collagen that makes up 95% of the collagen in a healthy Achilles tendon is replaced by the significantly weaker type 3 collagen. This also happens in the context of injuries to the Achilles tendon, as the fibroblasts (that migrate from the blood vessels as a reaction to the injury) primarily produce type 3 collagen. A tear of the Achilles tendon can occur later as a result.

As we know from new studies, there is an additional problem in that the growing blood vessels, which should serve to heal the Achilles tendon, also pick up small nerve endings, which can react to a pulling load with severe pain.

Inflammation of the area of attachment of the Achilles tendon (insertion tendinitis) and Haglund's deformity:

 

Some runners complain of an osseous thickening (Haglund's deformity) directly at the attachment of the Achilles tendon and severe pain. This concerns insertion tendinitis (i.e. an inflammation of the tendon at the area of attachment) as a result of overexertion.

The osseous thickening can further intensify these symptoms, and as there is also a bursa in the region that becomes inflamed easily, the symptoms can be increased again as a result.

Image: Pes planovalgus (flat valgus foot)

The causes of irritation of the Achilles tendon including Haglund's deformity are frequently errors in training, such as inconsistent stretching, insufficient warming up, etc. Injuries, however, (often small ruptures of the Achilles tendon that are not taken seriously in the beginning) can also lead to long-lasting problems in the Achilles tendon. Many runners with Achilles problems have shortened calf musculature due to inadequate stretching.

Leg axis problems can lead to symptoms. Unsuitable running shoes are also responsible: above all, overpronators develop problems with the Achilles tendon if they complete quicker training sessions with unsuitable running shoes. It is common for a combination of causes to then lead to problems with the Achilles tendon.

TIP

 

Many runners have a tendency towards overpronation (in which the inner edge of the foot lowers excessively and the foot bends inwards) in the supporting phase and to oversupination (in which the outer edge of the foot lowers excessively and the foot bends outwards) in the push-off phase. This leads to asymmetrical weight-bearing and pain in the Achilles tendon. Treadmill analysis and correct running shoes, possibly together with leg axis training carried out by a sports physiotherapist, can work wonders.

TREATMENT TIPS IN THE ACUTE STAGE

 

  • Stop training (if possible, change to another type of endurance training such as cycling, swimming or aqua jogging, until the symptoms have disappeared).
  • Ice pack – in the acute pain stage, if you have nothing else at home, however do not apply for longer than ten minutes – and never place it on bare skin).
  • Cold compresses – help a lot because they alleviate the inflammation
  • Sports plaster: I think particularly highly of the Flector EP Plaster. This plaster releases an anti-inflammatory active ingredient (Diclofenac) consistently over 12-14 hours – it therefore very often leads to a rapid improvement in the symptoms. (it should obviously not be used in the case of a Diclofenac intolerance, as it can cause skin irritations –fortunately, this is extremely rare)
  • Sports ointments: also help, however they have the disadvantage that the majority of the active substance is not absorbed by the skin but rather by the patient's sports socks
  • REPULS depth-radiator: this concerns a new, especially gentle fast-acting method of promoting healing processes. The pulsed, cold red light penetrates deeper into the tissue than the traditional UV light and therefore stimulates its metabolism even in the case of low-lying diseases and injuries. The REPULS depth-radiator influences organic molecules in diseased or injured tissue, which serve as messenger substances, the type that create cleavage products and these are removed via the circulatory system. My results with this pulsed red light are extremely positive, as the REPULS depth-radiator significantly accelerates the regression of inflammation.
  • Increase in heel height (is only useful in the initial stage and in the short term - it is counter-productive later!)
  • Examination of the running shoes in a specialised running shop (most preferably by means of a treadmill analysis)
  • Some runners swear by the positive effect of magnesium.
  • If, after a run, you notice that the Achilles tendon is causing problems for the first time, it is worth trying to scrub the Achilles tendon vigorously in a full bath for five minutes using a hand brush for a period of several days – this leads to a strong improvement in the perfusion and therefore often to an immediate improvement in the symptoms.


When free from pain, training can be recommenced. Heat therapy immediately before training is recommended in the initial weeks (e.g. with essential thermal ointments) in combination with consistent warm-up exercises. After training, stretching should be carried out consistently (even though articles are unfortunately very frequently being published at the moment showing that stretching exercises are useless), preferably in the form of a dynamic stretching programme and with eccentric exercises for the Achilles tendon. Moreover, after each training session, the sore tendon should be cooled with ice packs or cold compresses.

In the chronic stage, the treatment looks quite different:

 

The best results are achieved in this stage using a combination of daily eccentric muscle exercises, podological inserts (that should primarily be worn during day-to-day life) and physiotherapy - in combination with the Repuls depth-radiator (see above).

Eccentric muscle exercises: A Swedish study showed that patients with chronic Achilles tendon symptoms were able to achieve a full recovery within 12 weeks if they carried out eccentric exercises consistently. It was astounding that all these athletes had already had treatment-resistant symptoms for two years.

The exercise involves standing on a step on the ball of the foot and lifting the heel slowly upwards (to help you rest you can also do it with the other foot) – then slowly lowering the heel and pressing it down as far as possible (the Achilles tendon is stretched significantly during this – the authors also recommended that a heavy rucksack be worn so that you can add more weight to the stretch – I feel, however, that this is somewhat excessive… the stretching is the important part, not lifting the heel – therefore also an eccentric muscle exercise).

The eccentric muscle exercises cause small vessels to necrotise on the one hand (and therefore also the painful nerve endings), and on the other, the exercises produce increased type 1 collagen, which heals and strengthens the tendon.

It often takes months, however, until an actual improvement in the symptoms occurs, and that is obviously very detrimental to any keen runner, as running is only permitted to a limited extent during this time.

See also - Video

Concomitant treatment for athletes:

  • Ice pack for a maximum of 10 minutes prior to and after training
  • Eccentric stretching immediately after training
  • Reduced running training up to a pain intensity of VAS 5 (on a scale of 0-10)
  • Nitrolingual spray 2 x 2 puffs locally on the Achilles tendon for 6 months as off-label use
  • Balance training in the context of physiotherapy 

The following treatment measures can also be carried out in the case of persistent symptoms:

  • Mesotherapy (3-5 sessions)
  • Shock wave therapy (3-5 sessions)

 

Cortisone

 

Injections with cortisone are only indicated in the event of truly treatment-resistant cases, although improvement with cortisone is often immediate and lasting.

Cortisone leads to excellent inhibition of the inflammatory reaction (and can therefore be used to treat specific symptoms) and to necrotising of the small vessels and therefore also the painful nerve endings - leading to rapid freedom from pain.

It can, however, also lead to a deterioration in the perfusion situation in the tendon if the cortisone is injected too close to the tendon or into the tendon itself, and therefore to the necrotisation of microscopically small sections of tendons, which significantly increases the likelihood of a later Achilles tendon tear. The non-critical and often incorrect infiltration directly into the Achilles tendon has, as a result of its high complication rate, led to the fact that some doctors completely refuse to administer cortisone (this attitude is also incorrect: the administration of cortisone (as with every other medication too) must be considered carefully.) Infiltration with cortisone should therefore not be carried out more frequently than twice (within a short amount of time) as it is probably more sensible to carry out a small operation to remove the inflamed sections of tissue in a minimally invasive procedure.

ACP infiltrations

 

ACP (autologous conditioned plasma) is an autologous blood product for which the patient has blood removed from an arm vein and it is centrifuged in a special manner. Thrombocytes (blood platelets) are therefore activated, which, in turn release proliferative substances (such as Platelet Derived Growth Factor, PDGF) and morphogenic proteins (Transforming Growth Factor, TGF), which are important for muscle, tendon, cartilage and bone healing. New scientific studies show that the application of ACP can significantly accelerate and improve the healing of muscle injuries, as well as tendon and cartilage problems.

Patient film about ACP therapy

>> Watch video

Operation methods:

 

CHRONIC ACHILLODYNIA

 

In the event of chronic symptoms, an operation may be indicated should the conservative (= non-surgical) treatment fail.

Image: endoscopic Achilles tendon operation

Endoscopic Achilles tendon decompression is a minimally-invasive operation method, which often leads to very good treatment success in the case of chronic achillodynia and Haglund’s deformity. This involves removing the layers that have changed as a result of inflammation and milling off the ossifications. Following the operation, immobilisation in a cast for 2-4 weeks is required.

In very severe cases, a larger skin incision is necessary. The Achilles tendon is split lengthways and the necrotic centrally-located sections of the tendon are removed. The tendon can then be resutured.

Image: open Achilles tendon operation
Image: removal of necroses (= dead tissue) from the middle section of the Achilles tendon

Haglund’s deformities are particularly easily removed using this method. A disadvantage of it, of course, is the somewhat larger skin incision.

 

Additional treatment options:

 

Extracorporeal shock wave therapy in the case of achillodynia:

Extracorporeal shock wave therapy is a newer method of pain relief. It is suspected that the pain alleviating effect is not based on the fragmentation but rather the shock waves appear to activate the self-healing of a cell. Moreover, shock wave therapy improves the cell metabolism and deactivates the pain fibres. Following multiple treatments, 60-80% of patients achieved alleviation of pain or even complete improvement in the symptoms. The success rate appears to be too low to me personally (in comparison with the good results with eccentric muscle exercises, consistent physiotherapy and podological inserts), however it is a non-surgical method that can be attempted in treatment-resistant cases.

ACP - autologous conditioned plasma:

Treatment with autologous conditioned plasma (ACP) represents a new type of treatment procedure for the treatment of chronic achillodynia and insertion tendinopathy. It has been known for a long time that the growth factors contained in human blood can positively affect different healing processes. ACP therapy works on the basis of this knowledge. Healing and construction processes in damaged or tendon tissue changed as a result of inflammation can be stimulated using concentrated growth factors.

What happens during ACP therapy?

A small amount of blood is taken from the arm vein for a blood test. Using a special separation process, the portion of the blood containing the autologous regenerative and arthrosis-inhibiting components is obtained. The autologous solution obtained in this manner is injected into the affected tissue using a specially developed double syringe (Arthrex Double Syringe). This newly developed double chamber system ensures that the growth factors are obtained and injected in sterile form and therefore offers the highest possible level of safety. Note: There is still no scientific proof that this treatment helps or to what percentage healing success can be achieved, however patients suffering from arthrosis are familiar with the positive effect and there have been positive reports regarding application in the meantime.

ACHILLES TENDON TEAR

 

With sudden movement (such as the start of a sprint or a jump when playing tennis), patients can suffer an Achilles tendon tear as a result of sudden contraction of the tendon. Runners with chronic pre-damaged tendons are particularly frequently affected here, incomplete tears of the Achilles tendon can also occur here.

Another typical injury mechanism is a direct kick to the tendon, which can occur, for example, during a football match as a result of a rough opponent. A clear “crack” is often heard in this injury.

Typical symptoms include pain and restriction of movement, a definite indentation in the Achilles tendon can often also be palpated. The injured person is no longer able to stand on tip toes. A typical diagnostic indication is a positive Thompson test: Compression of the calf whilst the patient is kneeling does not lead to plantar flexion (= flexion of the foot or the toes towards the sole of the foot), when compared to the other uninjured side. If the diagnosis cannot be made with absolute certainty, an ultrasound examination or magnetic resonance imaging (MRI) should be carried out.

The treatment involves an operation which involves the direct suturing of both tendon stumps, possibly strengthened using an autologous tendon (plantaris tendon). Conservative (= non-surgical) treatment is only then useful if you are able to verify in an X-ray that both tendon stumps are well apposed in plantar flexion.

Several weeks of treatment in a cast is then required. A “walker”, a boot-like support that protects the surgical result is more comfortable than a plaster dressing.

 

Please note that medical indications and treatments change constantly. Sometimes these changes occur more rapidly than I am able to update on my homepage. Some information regarding dosage, prescription and compositions of medications may have changed in the meantime. Reading an internet page cannot replace visiting a doctor - it may be that during an examination and subsequent discussion with your doctor, other information is also communicated as a result of new scientific knowledge.