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25 Questions about the Achilles’ tendon injury
Warning: Achilles tendon injuries which one runs out during the exercise can become chronic. Reducing training volume and change is necessary.

25 Questions about the Achilles’ tendon injury

Most injuries caused by overtraining, more than half of them, are suffered from by people who train no more than 30 kilometers a week. People spending many more hours on their exercises are probably more experienced; their body can take much more. Because they are more experienced, they will most probably look after their body far better as well. They are more likely to have multiple sets of shoes, allowing themselves to change shoes regularly. So much different is our starting runner: with less training hours and less experience in training correctly, they can take only a fragment of their well-trained co-runners. Should every runner enjoy the same sophisticated starters programme and learn to listen to their own body signals, there would be far less suffering from training injuries, say seventy percent or so. The Achilles’ tendon injury is very common to runners. Following training injuries to knees, feet, shinbone and low back is our Achilles’ tendon injury claiming an “honourful” fifth place.

1. What function does the Achilles’ tendon have in our body?
The Achilles’ tendon is an extension of the calf muscle and connects the calf muscle to the heel bone. You could see it as a cable, transmitting the forces from the calf muscle to the heel bone. Because the calf muscles contract and relax while you are running, the heel bone moves, thus the foot moves, thus you are able to walk.

2. How could I get injured on my Achilles’ tendon?
See the Achilles’ tendon as one going through a tube. With every move of the calf muscle, this tendon glides on and back through this little tube. In the tube is some fluid that works like a kind of lubricant. If, which tends to happen very often while running, the position of the foot is not perfect - the Achilles’ tendon angle should be 180 degrees, more ore less - the tendon will cause friction to the inside of the tube. It is also possible that the Achilles’ tendon gets pulled on from above. Remember our calf muscle is connected to this tendon: if the calf muscle is stiffened or shortened, it will of course try to gain length by pulling on the Achilles’ tendon. The calf muscle can develop great strength. If it does so, it will pull unhealthily hard on the Achilles’ tendon. Another cause of an injured Achilles’ tendon is that one asks too much of his body, by suddenly changing the training programme into a much heavier one, or changing from soft grounds to hard ones, e.g. from forest floor to street surface. These three circumstances: wrong foot position, stiffened, shorter muscles and an overload all bear with them that the body will produce extra fluid on the spot to make it recover again. The tube will get too narrow. And moving the Achilles’ tendon will begin to hurt. This could lead to an infection.

3. What places near the Achilles’ tendon will be most likely to hurt?
The heel bone, till its edge (about five centimetres from the ground) will probably start to hurt. The cause of this pain is mostly the use of wrong shoes. Then there is the pain around the Achilles’ tendon itself, between five and ten centimetres from the ground. This is the more persistent injury. The pain spot could be a bit higher though, where tendon and muscle connect (about twenty cm. from the ground). This pain is a signal; the real Achilles’ tendon injury will be there soon. But, at this point, there’s still something you can do about it.

4. What is the classical Achilles’ tendon injury spot?
Starting from the connection point of the tendon on the heel bone some five centimetres upwards. If you run your fingers across the Achilles’ tendon, that’s the spot that might feel swollen up. It is of course but a small spot, only 2 or 3 centimetres across. Move your foot and ankle, you might detect some rustling sounds. In that case, you hear the Achilles’ tendon, crying for help.

5. What is the Achilles’ tendon angle?
Every time you land your feet on the ground, they suffer from strong blows. The forces of these blows are the equivalent of two to three times the weight of your own body. Every decent sports shoe should absorb an important part of this shock. But it is also very important the Achilles’ tendon is kept straight, so as to enable the tendon to slide through the tendons tube smoothly. As you might understand, the shoe should not change form on the blow: your foot should not be allowed to sink into the shoe. If the Achilles’ tendon remains straight on putting your foot to the ground and the further unrolling of your foot, the tendon will have an angle of a 180 degrees. If the foot will sink in, the angle will be either larger or smaller and the chances of getting an injury will be increased.

6. Of course, it is hard to tell if the tendons angle is exactly 180 degrees: how would you find out?
Strong differences of the Achilles’ tendon angle are not too hard to discover. Ask another runner to walk for some time behind you. Hold your shoes next to those of the other runner and see if the heel caps are still straight.
Or run for a while on one of these conveyer-belts with a camera behind and a monitor in front of you. Smaller differences are indeed somewhat hard to spot, but they won’t hurt you all that much, as long as you keep walking on good, specific running shoes. Sports shoes that fit your personal walking pattern.

7. What could I do to keep the Achilles’ tendons angle at a 180 degrees?
One important step into the right direction would be to wear appropriate shoes. This would be the shoe with a solid heel cap that fits your heel bone neatly. The shoe has to have the right balance, which is very personal, between stability and shock absorption. Someone weighing a hundred kilograms would need different shoes than someone weighing only sixty kilograms. The shoe has to provide support at the right places, which again differs from individual to individual. If the foot tends to slide to one side within the shoe, the shoe has to prevent that. There are quite enough people around whose feet are uneven, there is nothing much to be done about that, but the shoes they wear, have to provide as much support as possible on the places where it is needed most to keep the tendons angle at an approximate 180 degrees. And by that preventing a serious tendons injury. Walking with an incorrect Achilles’ tendons angle can cause even more injuries still; shinbone trouble, hurting knees, foot injuries, hip injuries, pain in the lower back, even a pain in your neck. All of these are injuries that could have been prevented by wearing the right kind of shoes.

8. Do bad shoes really increase chances of an Achilles’ tendon injury all that much?
Yes, indeed, depending on how bad they really are. In badly worn-off shoes the Achilles’ tendons angle will never be 180 degrees. This is also the case with heel caps of low quality. If the shoes edges are too low at the backside, the calf muscles as well as the Achilles’ tendons will experience much tension from above. It is also possible the shoe provides too little absorption, leaving the foot, and so the Achilles’ tendon, to suffer from heavy blows. The tendon will of course get tired of all this stamping; it will get irritated.
New shoes could also lead to a tendons injury. This is because the feet get pushed in a different position. By switching old and new shoes every once in a while, you give your feet the chance to get used to their new position. So, never get rid of your old shoes before your new shoes fit your feet. Wearing the right shoes will decrease the chances of getting a training injury considerably.

9. What more could I do to prevent an Achilles’ tendons injury?
Besides all that has already been said, varied training is always of importance. On top of that, it is highly recommended you use different pairs of shoes in alternation. That way, the tendon will never be put too much pressure on in the same way for too long a period of time. A good walking technique is also rather important. The more you roll your feet while walking, the less pressure your feet and Achilles’ tendons have to endure. Also of influence is to be able to relax your leg during the swing phase. Concentrate on your swinging leg: is everything completely relaxed? For the rest, the stronger feet and leg muscles are, the smaller the chances of getting problems on your Achilles’ tendon. Regularly taking exercises, like written in the Runners’ Paper, will accomplish that. And of course regular stretching exercises for your calf muscles, hamstrings and Achilles’ tendon will help you a lot. The more flexible your muscles are, the less tension there will be from above the Achilles’ tendon.

10. Do these precautions really work for everyone?
Unfortunately not. Some people just do not have the feet to run for miles on end. Or they have inherited shorter tendons. But they still like to run. If you were one of these people, you would most certainly benefit from orthopaedic adaptations to your sports shoes. With changes on the spots where you need them. Also, many people suffer from a difference in length concerning their legs. You can let the length of your legs get tested during a medical inspection. If your legs differ more than one centimetre in length, ask your doctor if you have to do something about it. An insole in your sports shoe for example. Or an orthopaedic sports shoemaker could adapt the shoe to measure by means of an extra layer.

11. Is there more in store to prevent an Achilles’ tendon injury?
When the insole has become too old, the foot will not be supported enough anymore. A new, fresh and firm insole can work miracles. The foot will return to enjoying support, so the Achilles’ tendons angle will approach the 180 degrees once more. You could also find correcting insoles. Insoles that, for example, have been thickened at the outside so our feet are pushed inside, towards the 180 degrees. There is also the shock-absorbing insole, which adds extra absorption to the shoe. Another thing you find in the market is the inheel, by which the heel of your foot is raised a little, so the calf muscle and the Achilles’ tendon will suffer less stress. Last product to mention is the calf muscle compression bandage. This is meant to be used when you are already starting to experience a small amount of pain. You should strap them around your leg just beneath and above the pain spot. One of the advantages of these bandages is that they keep the body heat inside at that area, thus causing an increased blood circulation, by which the healing process will be accelerated.

12. How could I know I have got an Achilles’ tendon injury? We all feel some pain any time, don’t we?
A good first indication is the pain you feel right when you get up in the morning. If your Achilles’ tendon hurts during the first steps you set unto the floor, that is a sign. This pain will fade away quite fast, especially once you put on your shoes. But the next day, it will stay a little longer, and the day after and in the next days it will increase even more. Then you will start feeling pain at the start of your training-sessions, which again will disappear once you have warmed up. The next time this pain will stay longer as well and in the end, it will not go away at all; by then, you have got yourself a fine, hard-to-cure, Achilles’ tendon injury.

13. How should I train if I feel pain or stiffness in my Achilles’ tendon in the morning?
To start with, submit your sports shoes to a thorough inspection at once. Are they worn-off, not straight, or sloppy? If so, you should pay a visit to the sports shop as soon as possible, to find yourself new and better ones. To continue: lessen your training-load at once. From now on, it is all not too long, easy walks, on an even, soft floor and absolutely no more sprinting, hill walks or competitions. Put two heel raisers in your sports shoes as well as in your daily shoes. And spend much time every training session on stretching exercises for your calf muscles. And of course, never forget a decent warm-up and cool-down.

14. Why are warm-up and cool-down so beneficial to my Achilles’ tendon?
A good warm-up will cause your blood to run faster, the calf muscles will get enough blood. Everything will become smooth. In short words: the biological mechanism will get started up. Stretching exercises are of course part of it all. And at the end of a training session/match, there will be many waste products in your body, and that way in the calf muscles. By spending time on a cool-down, you will reach the goal of getting rid of four of these waste products. Taking a hot shower is also a good means of reaching that goal. The smoother the calf muscles are, the smaller amount of pressure the Achilles’ tendon will have to endure.

15. Is there more I can do to get rid of the pain after a training session?
At the end of your training, put ice on the Achilles’ tendon. A cold pack would be quite fit for the job. But first, place a piece of cloth on your skin, after that you can put the ice pack on it. Leave it there for about fifteen minutes. Try to leave your Achilles’ tendon completely relaxed. In addition, provided you have got the time to, you could take further actions during the day to stimulate blood circulation in the Achilles’ tendon and especially in the calf muscle. Which will speed up the healing process.

16. Could you give me some examples of how to stimulate blood circulation in the Achilles’ tendon and the calf muscle?
For example by taking alternating hot and cold baths: keep your foot and lower leg in hot water for about two minutes, and thirty seconds in cold water. Or you could try ice massage. If you want to do ice massage, put a cup of water with a little stick in it in the freezer. Once the water has frozen up, take it out. Using the stick as a handle, massage the stressed Achilles’ tendon for six or seven minutes (leave out the piece of cloth). Please take care to keep the ice moving, by describing small circles with it. You will soon find the skin will turn red, because of a strongly increased blood circulation. The effect will stay on for another few minutes. You could use ice massage up to ten times a day. You can also put a heating bandage on it at night. You wrap a wet piece of cloth, a towel for example, around your leg. To finish it off, you will have to put a plastic bag or a peace of dense silk around it and keep it all in place by means of a smaller bandage. Leave it like this for the rest of the night. This kind of water bandage will start to get heated, so the blood circulation will increase. The red lamp method, which will not be discussed here, is known to many older people. And practice stretching exercises of the Achilles’ tendons, calf muscles and hamstrings up to the pain threshold, as much as you like.

17. So, what stretching exercises should I do?
You can find loads of exercises in sports literature, or you can find posters displaying several exercises. If the calf muscles are seriously shorter, stand on a sloping plank; put a book on the ground at about thirty or thirty five centimetres away from the wall. Now, put the plank on top of this, one end touching the wall. Now, stand on the plank with your heels and back against the wall for a few moments. Once the calf muscles get stretched a bit more, you can try increasing the angle of the plank, by putting more books under it, or by moving the existing pile closer to the wall. Repeat this exercise for several days in a row. If you feel standing still all the time becomes boring, try reading a book or listening some music during your exercises.

18. What should I do if my Achilles’ tendon gets genuinely inflamed?
Give yourself a box on the ears. It really is not that hard to find out, if your Achilles’ tendon is inflamed. The area around the Achilles’ tendon is not only swollen and red, but also the temperature is raised locally. You can detect that by putting the back of your hand on the swollen area. Besides, you have felt it already, long before. In the morning, you would hardly have been able to get up from your bed. The only way to move around the house would have been by wearing slippers or shoes. You will have to quit running for about two or three weeks. There are now only two things left you can do: on your doctor’s referral, visit a physiotherapist, or start using self-treatment. Choosing the latter, put a cold pack on the pain spot for twenty minutes, several times a day (but do not forget the towel in between). If you do not suffer from stomach problems, take the maximum amount of aspirin each day. In addition, take a grain of Arnica D6 and three grains of Ruta D6, once every two hours, to slow down the inflammation. These homeopathic medicines are available at your local chemist’s or from your pharmacist. In succession, you place a tape bandage, which will cause pressure on the area of inflammation, and less pressure on the areas around it. It will probably hurt quite a lot for the first fifteen minutes, but after that, the pain will slowly fade away. This tape bandage tries to push the surplus on fluid somewhere else, away from the inflammation, where it can get cleared away. All this you will keep doing for just two days, from the moment you have ascertained your Achilles’ tendon is inflamed.

19. So when these two days have passed I would have to switch to a different treatment?
Yes indeed. These first two days, all you do is to stop the inflammation. If you have succeeded, you still need to recover the damaged tissue. Although the tendon is not inflamed anymore, it is still damaged. And rest assured, there is a lot of work to be done in healing the affected tissue. From now on, you should take care to stimulate local blood circulation as much as possible. This is essential to enable the body to recover well. Next step is placing tape strips over and below the formerly inflamed area. The fluids have been cleared away by now, and by placing these tape strips, you will create a kind of reservoir of blood. So there will be more blood locally available, which will stimulate blood circulation. By now, the ice-pack treatments will be exchanged for ice massages. You should also give up taking aspirin. From this moment on, you will only take three grains of Arnica D6 a day, and two times three grains of Ruta D6 a day. You can start using the heating bandage treatments (if necessary using alcohol instead of water) as well as the alternating hot and cold baths, and the red lamp method. Stretching exercises are always beneficial, provided you never cross the pain threshold. You should keep heel-raising insoles in your shoes until you can walk painlessly without them. Do not start training all too soon. If the Achilles’ tendon is not allowed to fully recover, it could get stuck. It would be ‘glued’ to the edge of the tube, as it were. And that of course will cause a terrible pain.

20. Can injections be used as a cure to an inflamed Achilles’ tendon?
Generally spoken: no, they cannot. A well-known phenomenon is the practise of cortisone injections. From experience can be learned: never let yourself get treated by a cortisone injection aiming to cure an Achilles’ tendons injury. To the surgeon, it will be very hard to determine whether the needle is indeed between the tendon and the tube. Because if the cortisones get in the Achilles’ tendon, the hard tissues can become soft. The tendon will simply dissolve, in a manner of speaking. This is certainly the case with several injections. A surgery is also an extreme solution and is only practised in a few percent of all cases. And that would still be with people who did not pay attention to the first signs, because “no training could be missed”.

21. Are there more ways to get an Achilles’ tendon injury?
Yes, indeed. You could also get a ruptured tendon by putting a spurt or running up/down hill without having done the necessary warm-up exercises. The Achilles’ tendon has little blood circulation and cannot take the pressure. People who do not do sports training have the same experience when they try to catch the bus or train... These are no training injuries, but caused by an evident event. Of course, you would immediately visit a doctor or a First Aid post.

22. Would sports massage help in preventing an Achilles’ tendon injury?
Yes, it most certainly would. The sports masseur is probably treating you every once in a while, so he could easily notice if your Achilles’ tendon is not as slender as it used to be. That it is thickened, that it makes rustling sounds when you move your foot. He could give you training advice, which you naturally comply with immediately... In addition, the chances on getting a sports injury will decline if you pay a visit to your sports masseur for regular maintenance. He or she will remove all possible waste matter from your calf muscles.

23. How exactly should I put these inheels in my sports shoes?
There are heel-raising products on the market that are made of shock absorbing materials. This material also has the property of staying in place; it is kind of sticky, so to say. You should put this inheel beneath your insole of your shoe. It is always recommendable to keep these inheels in your shoes until the pain in your Achilles’ tendon and calf muscle has decreased considerably. When that moment has come, you can start wearing them less and less. For example, put them in twice in four days, before you leave them out completely. You should not leave the inheels in permanently, because the calf muscles would get used to them and get shorter. Or you would have to keep doing stretching exercises very consequently.

24. Sports shoes sometimes have a notch at the heels and sometimes the opposite, why would that be?
Who knows? If the shoe is cut in at level with the Achilles’ tendon, the tendon will be able to move freely, it will not get irritated. While a shoe with a higher edge will keep the tendon warm and give it a little more protection. Just follow your heart.

25. Is the Achilles’ tendon more vulnerable during winter than in the summer period?
Yes, it is. There usually is little blood in the Achilles’ tendon and it has much trouble getting to temperature and getting a good blood circulation. In winter, it is even more difficult, because the blood is needed elsewhere in the body to keep it warm, especially the torso. There will be less blood available to (for example) the hands and the Achilles’ tendon. Extended warm-up exercises and good sports socks are indispensable during the cold winter months in sports injury prevention.



This article has been adapted and translated from an article from “De Hardloopkrant” by Hans van Holland and Tom Laan.