Jewish World Review May 1, 2003 / 29 Nisan, 5763

True vulnerability: Don't ignore pain in the achilles tendon

By Marlene Cimons | There are a lot of "don'ts'' to keep in mind when coping with Achilles tendonitis. Don't ignore it. Don't try to exercise through it. And don't ever let a doctor talk you into using cortisone to treat it.

As bad as Achilles tendinitis is, it is far worse to rupture the tendon. A tear in the tendon could mean surgery, a cast and a recovery period that can last months. And you are courting rupture when you ignore the above advice.

"If your Achilles tendon is getting sore, it is time to pay attention to it immediately,'' says Dr. Stephen M. Pribut, a sports podiatrist in Washington, D.C. "You should not allow this to turn into a chronic and troubling malady.''

The tendon connects the heel to three powerful muscles: the two heads of the gastrocnemius and the soleus. It is named for Achilles, who (as students of Greek mythology will recall) was submerged as a baby by his mother into magical waters with the hope of making him immortal. Unfortunately, she held him by the heels while she dipped him, and that was the one spot the water never touched. Henceforth, he was vulnerable in the heel, a trait inherited by many athletes (and one that has come to symbolize nonphysical weaknesses, as well.)

It's the largest tendon in the body and can withstand forces of a thousand pounds or more, according to the American Academy of Orthopedic Surgeons. But it also is the most frequently ruptured tendon, and the one that seems most prone to inflammation. Many athletes -- from the elite to the recreational -- suffer from Achilles tendinitis, a common overuse injury. It is also a common injury among ballet dancers who may spend hours training en pointe or who sustain extreme stress to their leg muscles (the force exerted on a dancer's ankle joint, for example, can be up to 10 times the dancer's weight).

The condition is best treated with rest, ice, nonsteroidal anti-inflammatory medications, physical therapy and therapeutic massage to the calf muscle -- although not directly over the Achilles if it is inflamed.

Calf massage will loosen up and improve the flexibility of the muscle fibers that attach to bone via the Achilles, according to Carol Frey, M.D., an orthopedic surgeon in Manhattan Beach, Calif.

If you're an athlete and have frequent bouts of Achilles tendinitis, taping the lower leg will support the Achilles during those first critical days when you return to your sport.

Often, custom orthotics or a heel lift inserted in the shoe can reduce stress on the tendon. "In the most severe cases or ones that do not respond to conservative treatment,'' says Frey, "we will get an MRI (magnetic resonance imaging) to look to see if there is some necrosis (death) of the tendon, or even a partial tear. This may require casting, or surgery in some cases.''

Some doctors put their patients in an over-the-counter closed-heel elastic ankle brace to provide constant compression on the Achilles. This helps reduce swelling.

Whatever you do, never allow your physician to inject cortisone directly into the Achilles tendon. It can seriously weaken the tendons' taut bands of tissue, making them prone to rupture, says Frey.

Three years ago the U.S. Food and Drug Administration approved a medical device that uses shock waves to relieve chronic heel pain -- based on the same technology that breaks up kidney stones without surgery. The machine is licensed only to treat plantar fasciitis (an inflammation of the tissues around the heel), but some doctors are using it "off-label'' for Achilles tendinitis.

There are multiple factors that contribute to a tender Achilles. Check your athletic shoes, first of all. Neglected running or other sports shoes -- or shoes that aren't right for you -- can be a big cause of Achilles tendinitis. For example, shoes that are worn more on one side than on the other can contribute to this condition because "the Achilles will windshield-wiper back and forth and put stress on the tendon,'' Frey says.

Shoes that are worn too much at the heel also are bad for the Achilles tendon. "You need at least 15 mm. of heel lift to decrease the stress on the Achilles while running,'' Frey says.

It's good to avoid shoes that become worn down in the Achilles "notch'' area, or shoes that do not have one. This is the area that pads the Achilles tendon and cups it so that it does not move side to side too much, or put direct shoe pressure on the tendon.

Some experts recommend avoiding sports shoes with air-filled heels. "Supposedly they are now more resistant to deformation and leaks, but they are not good for a sore Achilles tendon,'' Pribut says. "The reason is because the heel continues to sink lower while the body is absorbing the shock, and this further stretches the Achilles tendon at a time when the leg and body are moving forward over the foot.''

Poor flexibility also can lead to Achilles problems, so it is a good idea to engage in regular but gentle stretching exercises. It is really important, however, to stretch in moderation. Don't overdo it, since excessive stretching can exacerbate Achilles problems.

If you are a runner, do not increase your mileage rapidly, or your speed, and don't suddenly add hills or stair climbing into your routine. Everything should be added gradually. Don't start up again too quickly after a layoff. And don't train on unforgiving surfaces that either are too hard (like cement) or too soft (like grass or sand). Try a synthetic track instead.

"Many runners assume that running on a soft surface is ideal, but this is not always so,'' says Dr. Richard Braver, a sports podiatrist in Englewood, N.J. "A surface such as a grassy field causes excessive motion of the heels. The sinking effect of running on sand causes the Achilles tendon to be stretched beyond its normal range, and the soft surface makes push off more difficult.''

Beware of trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort, such as in a final sprint. Even "one large event, such as a marathon, puts more stress on all structures,'' including the Achilles, Frey says.

Also, try to think about your running technique, hard as that may be. For example, "landing during foot strike toward the toes causes strain to the Achilles tendon as the heel decelerates to the ground,'' Braver says.

Achilles tendinitis symptoms usually include pain and swelling after exercise that gradually worsens, and a noticeable sense of sluggishness in your leg, according to the American Academy of Orthopedic Surgeons.

Often there is morning tenderness about an inch and a half above the site where the Achilles attaches to the heel bone, and/or stiffness that usually improves after the tendon warms with use.

Finally, don't try to diagnose this yourself. It is important to have a professional take a look, because other conditions, including a partial tendon tear and heel bursitis, have similar symptoms.

If your Achilles acts up, rest is the best thing you can do. This doesn't mean stopping. But it does mean cutting back. If you must work out every day, try swimming.

Judi Sheppard Missett is CEO of Jazzercise Inc., an international aerobic-dance instruction company. Comment by clicking here.


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