In Greek Mythology Achilles was brought to his knees and defeated by an arrow into a tendon connecting his calf muscles to the heel and hence the foot. Ever since, this tendon has been called the Achilles Tendon and, either consciously, or unconsciously, associated with a weakness, vulnerability and a fatal flaw.
However, this is far from the truth. The Achilles Tendon is a brilliant piece of evolutionary engineering in human beings. It is the strongest tendon in the body and working together with the calf muscles and connective fascia tissue can store up to 12 times bodyweight loading during running, giving us tremendous spring like efficiency to our movement and enabling human beings to be efficient long distance runners. The very best of us can outrun a horse over many tens of kilometres. It is therefore integral to how we developed as team led strategic thinkers and forward planning hunter gatherers, and so part of who we have become today.
So why are so many elite athletes and weekend warriors felled in their prime, just like Achilles, by pain and discomfort in their Achilles tendon ?
The main culprits, apart from genetics and co morbidity factors such as diabetes, are due to our modern lifestyle. Our activities are much more focused and intense today. Professionals athletes practice the same movements over and over again. Amateurs training for a Marathon tend to repeat movements repeatedly, there is little time left in the day for other varied exercises. As a result, one of the most common causes is repetitive strain, overuse and microtrauma, gradually contributing to degeneration of the structural matrix of the tendon and weakening it. On top of this we live a lot longer and we know that tissue changes start to negatively impact us from our third decade onwards. However, in the pursuit of performance we aim to just try harder rather than modify, compromise and improve our technique as we get older. Finally, and especially during this time of pandemic, our routines have changed and a period of inactivity can lead to a loss of muscle strength in the calf. If we then dive back into our usually training routine, we are much more likely to develop an Achilles Tendon Injury.
Treatment for the problem will vary depending on the diagnosis and severity of the problem. In general, we can divided chronic Achilles tendon problems into four categories.
- Paratendonitis. – Irritation, inflammation and swelling in the sheath within which the Achilles Tendon must smoothly slide and glide.
- Insertional tendonitis – Irritation and the point of insertion of the tendon into the heel bone
- Retrocalcaneal Bursitis – Inflammation of the fluid filled sac that acts as an antifriction devise and sits between the tendon and the heel bone.
- Teninosos – Swelling pain and inflammation or degeneration within the mid portion of the Achilles Tendon.
A good Assessment and diagnosis by a Sports Physician or Physiotherapist is essential to identify what the causative factors are behind the injury and the possible treatment options. The main causative factors are overtraining, errors in training technique, psychology ( i.e. to improve performance must try harder rather than improve technique and focus on quality of training rather than quantity ), biomechanical faults, such as collapsing arch of the foot when landing, poor or worn footwear, tightness through calf muscles and fascia, nutritional and hydration issues.
The main treatment techniques are Physiotherapy to improve strength, length, flexibility and to correct biomechanical and training faults as far as possible. Failing this we have options from the Sports Physician such as Shockwave therapy to promote a tissue healing response, Platelet Rich Plasma Injections to improve structural integrity of the tendon and Sclerosing Therapy to address vascular and over sensitive pain receptors in the tendon.
In conclusion, a multi-disciplinary approach with sports physician, physiotherapists and strength and condition coaches all working and communicating together gives our patients an excellent chance of rising from the Achillean Ashes and getting back to enjoying all the activities that they took for granted for so long, in a safe way. Perhaps, They may even improve their targets and goals in ways that seemed unimaginable during the days when every step hurt first thing in the morning when they got out of bed.
SOHO Physiotherapy in collaboration with Dr Lorenzo Masci from the One Wellbeck Hospital and the coaches at Fitness Lab are here to help you on that journey.
In Greek Mythology Achilles was brought to his knees and defeated by an arrow into a tendon connecting his calf muscles to the heel and hence the foot. Ever since, this tendon is called the Achilles and, either consciously, or unconsciously, associated with a weakness, vulnerability and a fatal flaw. Injury to the tendon is called Achilles tendonitis.
What is the Achilles tendon?
The Achilles Tendon is a brilliant piece of evolutionary engineering. It is the strongest tendon in the body. Working together with the calf muscles and connective fascia tissue, it can store up to 12 times bodyweight loading during running. It gives us tremendous spring effect to our movement and enables us to be good runners. Surprisingly, the very best humans can outrun a horse over many tens of kilometres. It is therefore integral to how we develop as strategic thinkers and hunter gatherers, so an important part of who we are today.
So why is Achilles pain so common?
Apart from our genes, the main causes are life style factors such as medical disease and activity levels. Our activities are much more focused and intense today. Professionals athletes practice the same movements over and over again. Amateurs training for a Marathon perform movements repeatedly – there is little time left in the day for other exercises. As a result, a common cause is repetitive strain and microtrauma, gradually leading to weakening of collagen proteins. In addition, we live a lot longer, and we know that age after 30 leads to a gradual breakdown of collagen proteins. However, in our pursuit of getting better, we just try harder rather than lower our activity improve our technique. Finally (and especially during the recent pandemic), our routines suddenly change. For example, a period of inactivity can lead to a loss of calf muscle. If we then jump back into our usual routine, we are more likely to develop an Achilles injury.
How do we assess Achilles pain?
In general, we can separate Achilles tendon problems into four categories.
- Paratendonitis: swelling of the tendon sheath surrounding the Achilles tendon
- Insertional Achilles tendonitis: swelling of tendon at the insertion
- Mid-portion tendonitis: swelling of the middle of the tendon
Assessment by a Physiotherapist or Sports Doctor is essential to correctly diagnose the problem. Also, finding the factors that have caused the injury are essential to prevent re-injury. These factors include overtraining, calf weakness tightness of calf muscles and fascia, collapsed arch and nutritional and hydration issues. Sometimes, we perform an ultrasound or MRI to confirm the diagnosis.
What is the treatment of Achilles tendonitis?
Physiotherapy is essential to improve calf strength and flexibility and to correct biomechanical and training faults. Changes take time but most cases will settle with exercise. Working with a strength coach is important to prevent recurrence. Sometimes, we use other options such as Shockwave therapy, GTN patches or Platelet Rich Plasma Injections to improve outcomes from rehab. Surgery should be avoid due to risks such as wound breakdown and infection.
In summary, Achilles pain needs input from a physiotherapist, sports doctor and strength coaches. to get the best results. This approach will give our patients best chance of rising from the Achillean Ashes and getting back to enjoying activities. Perhaps, they may get to a better place, seemingly unimaginable during the days when every walking step was sore.
SOHO Physiotherapy in collaboration with Dr Lorenzo Masci (www.sportdoctorlondon.com) from the One Wellbeck Hospital and the coaches at Fitness Lab are here to help you on that journey.