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Achilles Tendonitis

Kangaroos have amazing Achilles tendons. On a medium-sized kangaroo the tendons are over 35 cm long! Our human Achilles tendons are less than half that at 15 centimetres. Do Kangaroos get Achilles tendonitis? Not really as their lifespan in the wild is only 8 to 12 years. Kangaroos are of course famous for their hop. The most comfortable hopping speed for a red kangaroo is about 20–25 km/h. During a hop, their powerful gastrocnemius or main calf muscles lift the body off the ground whilst their smaller plantaris muscle; which is very small in us, that attaches near the large fourth toe, is used for push-off. Seventy percent of that potential energy is pre-stored in these highly elastic tendons. At its most efficient hopping speed (15 km/h) a kangaroo uses even less energy than a similarly-sized four-legged mammal running at the same speed. Hopping, in kangaroos at least, is a very efficient means of travel.

Why do we get Achilles tendonitis? Well not so long ago when we hunted woolly mammoths rather than Parkrun on a Saturday morning, we’d mostly be dead by age 35. So we live much longer now and as anyone who pulls up the loose skin on the back of their hand knows, as we age it stops snapping back as fast. Eventually it stops snapping back at all, hand sculpture anyone? Having said that, old age is a luxury denied to much of the world’s population. So what’s happened? Well it’s a loss of elastic tissue not just in your skin but also in the rest of the tissues of your body that causes the problem.

It commonly affects middle-aged runners who have suddenly increased the duration or intensity of their (lockdown) runs and those who only play sports such as tennis and squash at the weekends. A preference for hill reps in the cold also doesn’t help. There are other risk factors such as psoriasis, high blood pressure, tight calf muscles, male sex, obesity and feet at the flatter end of the spectrum. What certainly also doesn’t help is running in old worn out training shoes. Prevention is always better than cure of course. Increase your level of activity gradually and don’t start hill reps early in a training cycle. Get a new pair of running shoes every six months or about 500 miles whichever is sooner. Hoka, Asics and Mizuno are all good makes to run in. There is good evidence that the most expensive shoes do not protect you from injury but they do have to be fit for running. Stretch up regularly, strengthen your calves, swim, cross-train and work on your upper body a bit! There are many basic to advanced training programs on-line from Asics, Nike and BUPA.

What to do when you get those first twinges? Well back off for a start and certainly don’t try to push through it. Get an ice cube and rub up and down both sides of the tendon until the cube melts. Then eccentrically stretch. What’s that you say? Well this works best when you are stable with a handhold on your front porch or non-slippy first step on a flight of stairs. Under tension slowly lower your affected heel down below the step until it is angled down about 20 degrees, or maximally, below the step. This stretches the calf and tendon and you will feel it in the upper part of the calf. Repeat ten times morning and evening. Also move onto upper body or core work for a few days. Swimming is of course always a good way of maintaining aerobic fitness whilst not over-irritating the tendon.

Medically, if the irritation has come on n within the last few days, consider applying a smear of 5-10% Ibuprofen or 1-2% Diclofenac gel along the sides of the sore area of the tendon. This will help settle most mild cases within 5-7 days. You could try, if you don’t suffer from stomach ulcers/gastritis and/or asthma, 200mg of Ibuprofen with food three times a day for 3 to 5 days. This is also a good time to remember when you last bought some new trainers! What if it doesn’t settle within about four weeks? Well, a little help from your friendly neighbourhood physiotherapist is the next step. They can get you ‘back on your feet’ and also assess any biomechanical issues that you might have. Recovery from Achilles tendon problems can take some time and you need to be patient. If the problem has lasted for more than 3 months sometimes imaging the tendon helps and an orthopaedic surgeon can often arrange an ultrasound scan (USS) or magnetic resonance scan (MRI) for you within a few days. This can tell us how long recovery is likely to take. You get your GP to refer or in some instances, self-refer. These tests can also rule out; heel stress fractures, wear and tear osteo-arthritis, heel spurs, plantar fasciitis, and the like. It can also tell us whether it’s an insertional, mid-substance or musculotendinous problem. Sometimes the lubricated sheath that the tendon runs in called the paratenon can become constricted and inflamed. This condition termed paratendonitis can be helped quite neatly by an ultrasound guided injection of anti-inflammatory into this sheath when a more conservative approach outlined above has failed to produce improvement.

People will often say that there is most pain and stiffness first thing in the morning. This is part of the ‘tear & repair’ cycle. Whilst you are asleep and curled up your feet naturally point down. Your body enters the repair cycle and like any scar or wound on your hand this involves little cells called fibroblasts. They naturally pull skin wounds closed and minimise scars. They do the same in any inflamed tendon so that the tendon heals overnight but slightly shorter than before. When you take that first step, it’s often excruciatingly sore but then may get a little better. The key intervention here for this more advanced tendinitis is to hold the foot overnight at 90 degrees. The tendon then heals over a few weeks but at the correct length. It no longer needs to re-tear for you to walk every morning. There are special socks called Strasburg socks available online for just a few pounds to help with this. If you are a bit more muscular the for about £15 on Amazon, other suppliers are of course available, you can get a 90 degree night resting splint. It’s not very romantic but it really does the job.

If this doesn’t work then you may require something more interventional! For more severe paratendonitis, a surgeon can strip or release constrictions surgically. Focal areas of inflamed tendon, especially if there has been calcium deposition, think speckled gritty tendons, often do well with ‘dry needling’. This is where, with appropriate local anaesthesia, one can pass a needle through the tendon multiple times to jump start a clean-up and repair process. Sometime a more open approach is required to remove specific scar or more ‘bone-like’ calcium depositions.

Good luck and keep on running!

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