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Runner Therapy: Confusing Medical Words Describing Achilles Pain

Posted Jul 28 2010 8:55am

Question: I have a friend who is in good shape and stays in shape by playing in a soccer league.  A few weeks back he was playing in a game and with no contact from another player ended up rupturing his achilles.  The doctor said that there was really nothing he could do.  My question is how common are ruptured achilles for runners and what can you do to prevent such a catastrophic injury?

Runner Therapy says: Legend has it that Achilles was dipped into the river Styx by his mother Thetis in order to make him invulnerable. Because, presumably she held him upside down when dipping, his heel wasn’t covered by the water. Some time later, as the story goes, he was killed by an arrow wound to his heel. I vote for plain old bad luck.

We all have an achilles heel…that injury that always looms. But what happens when the injury IS the achilles?

First, the achilles is a tendon which is basically a tough group of collagen fibers that does just what every good tendon should. It connects muscle to bone. In this case, it connects the strong and large gastrocnemius (calf) group to the calcaneus (heel bone). Because tendons do not have the ability to contract (collagen has no ability to make a contraction), it is ruled by the large gastrocnemius which has a strong capacity for contraction and for maintaining that contraction over time.

For most runners, we abuse our gastrocnemius on a daily basis when we practice our sport. The constant contraction of this muscle group pulls through the achilles tendon and at the level of the calcaneus where it causes our foot to flex. The faster we run, and the more hill running we do, the more the gastroc and achilles tendon move….and the tighter we get. Add to this any amount of walking, stair climbing, and dare I say it, flip-flop wearing we do will fatigue the already overworked gastroc even more.

Gastrocnemius tightness sets us up for tons of running injuries. (Try not to use your calves in a run and see how that goes for you!). Sometimes, this includes achilles tendonitis. Sometimes there are reasons why you will get injured at the achilles instead of the gastroc itself, or the ankle or plantar fascia. These reasons include your foot structure (flat or arched feet) and type of running (downhill vs. uphill). But it is unmistakable. The pain is usually right on the tendon or either side, and increases with push-off and landing.

Most of the time runners get achilles tendonitis. They generally do not rupture the tendon completely (what we would call a ‘complete tear’). A complete tear may or may not be what this runners’ friend has experienced. Because the tear completely dislodges the tendon from the bone, it must be repaired surgically or there will be no calf contraction and plenty of pain. These occur more with quicker more spontaneous movement, such as with tennis, racquetball or football. You may remember ages ago when quarterback Dan Marino took a season off to surgically reattach his tendon. Much like Achilles being hit by an arrow in the tendon, an achilles tear is unmistakable. When it happens, it feels like a gunshot, and sounds like one too. There is immediate pain and swelling, and the athlete cannot walk let alone keep playing.

So in the friends’ case, I’m uncertain why a doctor would tell him there is nothing he could do. Surgical repair is the only option. However, the doctor may have used the term ‘ruptured’ to mean a partial tear or a tendonitis. But in this case he would still be incorrect. There is always something we can do about pain. That’s what physical therapy is for!

Sometimes the word choice is the problem. “Ruptured” may mean something different to different health professionals. It is sometimes good to stick with the clinical terms so we can share information with more clarity. That being said, you will tend to find orthopaedists and doctors that are not used to working with runners tend to be negative in nature. “Just stop running” or “there is nothing we can do” are told all too often to runners, and it drives me insane. What they should be saying is “I don’t know how to fix it, but I will send you to someone who can!”.

For runners, far more common is tendonitis which is inflammation of the tendon and sometimes means there is a partial tear of the tendon or small micro-tears. This is easily fixable with physical therapy, although painful. I once had a male patient write to his doctor to thank him for sending him to me for therapy, and in the note he said, “…my wife and I have 3 children. Although I never went through childbirth, I think now I have some inkling of what that was like!” Well, he was a bit of a drama queen, but you get the point. The cross-friction massage techniques we used to rid this nasty problem and the scar tissue it caused, are not a joy ride. And, do I need to say it again? Use the prostretch ! Stretch the gastroc and achilles!

So, unfortunately your friend must have been dipped upside-down, but luckily his fate should not be nearly as bad! Get him to a therapist who treats runners and isn’t a Debbie Downer!

Run smart. Use your brain, too.

- Marisa

(Marisa, MS PT SCS ATC, is a physical therapist in private practice in midtown NYC.  She one of a dozen or so therapists  in the state of NY to be board certified in sports.)

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