Know Exactly Where Your Achilles Tendon Hurts

Back view of L calcaneus 

I had right Achilles tendon pain earlier in the year. After doing some Alfredson protocol exercises, wearing the Strassburg sock and getting my colleagues and wife to treat me, I could run pain free. 

Yes, I still ran twice a week even though I had some pain while running. Some of that same pain came back during our recent holiday in Japan. I did not cycle nor run during the trip but did some skipping for the first few days of our trip. 

Then I came across an article (with nice pictures) of what makes up the Achilles tendon and how it attaches on the calcaneus (heel bone), pictured above. While skipping, my gastrocnemius (or calf) muscle, was used more than the soleus. I realized that this was what led to the recurrence of my Achilles pain.

The Achilles tendon is the largest/ longest tendon in the human body and is formed when the medial (inner) and lateral (outer) parts of the gastrocnemius and soleus muscles merges.

The authors dissected 12 fresh frozen leg specimens to find where the Achilles tendon inserts (or finishes) on the calcaneus in relation to their corresponding muscles. They also examined 10 embalmed specimens to confirm an observation on the retrocalcaneal bursa.  A bursa is fluid filled sac/ pouch that acts as a cushion and gliding surface to reduce friction.

The superficial part of where the Achilles tendon finishes is where the medial head of the gastrocnemius muscle attaches (in light blue) on to the lower facet of the calcaneus. The authors (like previous studies) found evidence that tendon of the medial gastrocnemius forming the superficial part of the Achilles tendon is continous with the plantar fascia. Like I written before, in order to get the Achilles tendon better, you need to treat the plantar fascia and vice versa.

The deep part of where the Achilles tendon finishes is where the soleus muscle attaches on the inner part of the middle facet of the calacneus, while the lateral head of the gastrocnemius muscle attaches (in red) on to the outside part of the middle facet of the calacneus.

In the space between the calcaneus and the Achilles tendon, a distinct 2 chamber bursa was present in 15 out of 22 examined specimens (9 out of 12 fresh frozen specimens and 6 of the 10 embalmed). The smaller shallow medial chamber is located in front of the soleus tendon whereas the lateral chamber is in front of the lateral head of gastrocnemius tendon.

Here's what amazes me. From the dissections, the authors found that the Achilles tendon rotates as it goes down the leg. Meaning the fibers from the medial gastrocnemius head forms the back aspect of the tendon while the anterior part of the tendon is formed by the lateral gastrocnemius head and soleus muscles.

This article was helpful as it helped me pinpoint exactly where my problem was and most importantly it helped deepen my understanding of the function of each muscular, connective tissue part of the gastrocnemius, soleus and the Achilles tendon and their clinical relevance in the treatment of Achilles and plantar fascia problems.

So, if you are still having problems with your Achilles tendon and it does not seem to be getting better, show your healthcare practitioner the topmost picture so they know exactly which part to take note of. If they don't you can always come to our clinics.

Reference

Ballal MS, Walker CR and Molloy AP (2014). The Anatomical Footprint Of The Achilles Tendon: A Caderveric Study. Bone Joint J. 96B: 1344-1348. DOI: 10.10=302/0301-620X.96B10.33771

Train Your Tendons

If you are a runner and have had pain in your Achilles tendon, you know it takes a long time for it to get better. Compared to muscles, our tendons and ligaments have much poorer blood supply so they take a longer time to heal. Currently, most healthcare professionals recommend the Alfredson protocol (up to 180 eccentric heel drops a day) to get your Achilles tendon better.

Trained runners have been found to have a thicker Achilles tendon, stiffer and better structure compared to novice runners. A longer, stiffer tendon stores more energy and releases that energy when you push off with each step. It has also been speculated that the dominance of international running races by Kenyan runners are due to their long and springy Achilles tendon (Tawa and Louw, 2018).

Can you then train your tendons? Consider the following study. 40 pairs of identical twins were asked about their physical activity and sports habits to determine how active they were. Researchers then measured the stiffness of their Achilles tendons.

Results show that when one twin is active and the other inactive, the active twins have tendons 28 percent stiffer. Since identical twins start with identical genes, this shows that long term training can change the structure of the Achilles. It also fits in with previous studies that trained runners have thicker and stiffer tendons. These runners were not elite runners so you don't need excessive training levels to change your tendons. But these runners have been running for an average of 15 years, so there's plenty of time for change to occur.

Another point to note from the study. Those who did activities that involve an aerial phase with both feet off the ground (running, basketball or tennis etc) had a stiffer TA compared to those with no aerial phase (cycling, walking and swimming). This suggests that jumping and landing may hold clues to getting your Achilles tendon stiffer and stronger.

Tendons may be slow to heal and adapt to load, but for those of you who run, surely this is an incentive to keep on running. Those who play football, basketball or tennis, please carry on too.

Currently, when you visit your current healthcare provider for treatment, most will just recommend the Alfredson protocol (up to 180 eccentric heel drops a day) to get your Achilles tendon better. That you can do yourself (picture below).

In our clinics, after we assess you thoroughly, we mostly use our hands to treat what we find, no ultrasound, no orthotics, no shockwave (ESWT), no electrotherapy. And we get very good results. We DO NOT get you to do exercises DURING the time you have with us. We do treatment that you cannot do yourself.

Previously, I've written that there is some evidence that gelatin (or jell-o) can help tendons heal. Perhaps that is an area you may also want to explore? And do take note that some antibiotic medications can damage your tendons.

References

Sichting F, Kram NC and Legerlotz K (2022). An Identical Twin Study On Human Achilles Tendon Adaptation: Egular Recreatinal Exercise At Comparatively Low Intensities Can Increase Tendon Stiffness. Front. Physiol. DOI: 10.3389/fphys.2021.777403

Tawa N and Louw Q (2018). Biomechanical Factors Associated With Running Economy And The Performance Of Elite Kentyan Distance Runners: A Systematic Review. J Body Mvt Ther. DOI: 10.1106/j.bmt.2017.11.004

See how closely the Achilles and plantar fascia are related. In order to get the Achilles tendon better, you need to treat the plantar fascia as well.

Never Give Up!

Chapeau to  Ronald Susilo. This guy just keeps on going and going. After suffering many potential badminton career ending injuries while at the top of his game, he has always managed to bounce back.

After winning the Japan Open Grand Prix and then beating World Number One Lin Dan at the 2004 Athens Olympics with a torn shoulder labrum, he went under the knife.

More heartbreak followed after coming back from that when he tore his achilles tendon at the World Badminton Championships in 2005.

Yet he persisted. Tragedy again at the 2007 Sea Games when he tore his right forearm muscles playing against Vietnam. Again he managed to bounce back and we went to our second consecutive Olympics together in Beijing in 2008.

His wife sent him to Sports Solutions in this 

Even after retiring from national duty, he kept playing after he started coaching. And subsequently ruptured his patella tendon while tearing his ACL and medial meniscus at the same time. He needed 2 operations after this. Attaching the patella tendon first before repairing the ACL almost a year later.

And now this right shoulder again .....

Well, Ronald we've done this together too many times before. But I know you'll be back once more. You can do this!! Want to be a champion? Passion for the sport and persistence is what you'll need. Lots of it.

In the picture below, you see me celebrating and more excited than Ronald Susilo himself after he defeated Lin Dan in the 2004 Athens Olympics.

Yes, I used to sit on court with him and his coach every time he played.

Patient With Plantar Fasciitis Who Saw Me 3 Days Ago Won 100 km Race

My patient who had been having plantar fasciitis came to see me 3 days ago in the clinic just won the 100  km Cameron Ultra-Trail race.

It was quite a last minute request and I could only fit her in for a 30 minute session during my lunch break (new cases usually have an hour's appointment in our clinic).

Have a look at our WhatsApp exchange.

Not bad for half an hour's work. Now at least I get a full hour to sort it out properly next week. What did I do to treat her? Let me review her case when I next see her and I'll do a follow up post if I find something interesting.

Young Athletes Are Not Small Adults

I've had a few worried parents message or call me on the past two weekends saying that their child has had sharp pain suddenly without any falls or accident. A common area of complaint is in the knee or heel.

After a few short questions and answers I am usually able to reassure the parent that their child is fine and nothing is really serious about the painful episode.

Often these young children/ athletes have growing pain. The long bones grow quite quickly (especially if they are having a growth spurt) and the muscles don't lengthen quite as quickly. When the child is active, this shorter muscle(s) often pull on the bony attachments and cause pain.

Their muscles usually will not have developed enough strength to compensate for the sudden increase in lever lengths.

My older boy who is eight plays football once a week. Other days he's at the playground running, jumping and climbing etc. He's growing taller and  his muscles are not always strong enough to generate the forces required to move his longer and now heavier legs. As a result, he often has this "growing pain" in the night especially after he'e been particularly active.

I just taped my older boy's leg last night

From treating all the young and teenage athletes in our clinics, we observe that it may take up to about nine months for the muscles to develop length and strength after a growth spurt in their bones.
This form the basis of injuries that these young athletes get. If the bones grow longer and the muscles don't quite catch up in length, the muscle will be relatively shorter and hence tighter.

The area most prone to overload is where the muscle attaches via the tendons to the bones. Hence these pain and injuries we see are growth related.  Common areas are where the Achilles tendon inserts in the heel bone (usually known as Severs disease, although it is definitely not a disease), and the patella tendon on the shin bone (Osgood Schlatters disease).

Other areas include the quadriceps tendon into the knee cap (Sindling Larsen disease) and the attachment of the hip flexors onto the pelvis.

It is usually due to overload of the tendon attachment to the bone from doing too much too soon (without rest) that causes these pain or injuries.

Majority of the time, most of these cases get better when the muscles "catch up" with the bone growth by lengthening and getting stronger.

Stretching the muscle may be worse sometimes as static stretching can place more traction forces on the tendon insertion on the bone. We tend to teach our young patients and their parents to use the trigger ball instead.

Correct strength training that is pain free often helps the muscle take load off the tendon attachment. Don't use a load that is too heavy.

Come see us in our clinics if your young or teenage child athlete needs help.

Achilles Tendon Length And Running Performance

My patient's L Achilles

Two years ago, after my marathon running patient tore his left Achilles tendon (AT) and had it repaired. About six weeks after the surgery, his surgical site got infected. The surgeon had to remove the repaired tendon. After the infection was cleared, the surgeon grafted the lateral gastrocnemius (calf) muscle to repair the tendon. 

Needless to say, he couldn't really run let alone think of finishing another marathon. After trying traditional Chinese medicine (TCM) and seeing another physiotherapist for over two years with not much improvement, a fellow runner I've treated before suggested he come and see me.

For runners, the hips, knee and ankle joints generate large amounts of forces during running. The ankle joint (via the Achilles tendon ) contributes remarkably to supply the power required while running.  

R calcaneus bone, where the Achilles inserts

The AT plays an important role in storing and returning elastic potential energy during the stance (foot flat on the ground) phase in walking and running. 

L Achilles inserting on calcaneus

I was wondering how else to help my patient when I came across a research paper investigating AT length and running performance on male Japanese 5000 meter runners (between 20-23 years of age). Their personal best times range from 13:54 minutes to just under 16 mins.

Their running economy was tested by calculating energy costs with three 4 minute runs at running speeds of 14, 16 and 18 km/h on a treadmill with a 4 minute active rest at 6 km/h.

Ready for the results? The researchers found that absolute length of the medial (inner) gastrocnemius (or calf), but not lateral gastrocnemius and soleus muscle correlated with a faster 5000 meter race time and lower energy cost during the submaximal treadmill tests at all 3 speeds tested.

This is after normalizing medial gastrocnemius muscle length with the subject's leg length. That is, the longer the medial gastrocnemius muscle, the better the running performance in endurance runners.

For the medically inclined, note that each AT length was calculated as the distance from the calcaneal tuberosity to the muscle tendon junction of the soleus, medial and lateral gastrocnemius respectively.

Possible reasons to achieving superior running performance may be that the longer medial gastrocnemius and AT store and return more elastic energy (and potentially reduces energy cost) from the ground reaction force compared to a shorter AT.

Have to treat both R and L leg

Reading that paper definitely gave me more clues to treat my patient (and other patients with Achilles tendon and plantar fascia problems). I am happy to say that my patient has since progressed to running up to 12 km.

He is now definitely looking forward to running his next marathon.

Reference

Ueno H, Suga T et al (2017). Relationship Between Achilles Tendon Length And Running Performance In Well-trained Male Endurance Runners. Scand J Med Sci in Sp. 28(2): 446-451. DOI: 10.1111/sms.12940.

Gotta Love Hills

Now those were some hills we ran in Hong Kong during the Trailwalker

I love the hills when running cross country as a kid in school. Probably because I didn't weigh that much then, so I could often accelerate up the slopes at Macritchie reservoir (yes during my time, all the schools cross country races were all held there and not Bedok reservoir). That means I could either break up the pack of runners in our group or hang in there when the going got tough.

Well, now it looks like you (the runner) should run more hills since correct practise makes perfect.

What's more, recent published evidence suggest that both up and downhill running does not seem to harm your Achilles tendon as some believe. It was previously assumed that the forces exerted on your Achilles tendon during downhill running could stretch it further leading to possible long term injury.

The Achilles tendon stretches naturally on every run. It stores elastic energy to reduce the load on your calf muscles especially. It is believed that this constant stretching leads to micro damage in the tendon, especially running downhill.

This was proved wrong after researchers (who used high speed cameras and Doppler ultrasound) proved that the Achilles maintained the same thickness during flat, up and downhill runs.
A word of caution before you attack the hills. The study was done on a group of well trained runners and this may be one of the reasons why the Achilles tendons adapted well to the different inclines.

If you are a fairly new runner and have not done many miles, do add hill running gradually to give your Achilles tendon time to adapt.

Reference

Neves KA, Johnson AW e al (2014). Does Achilles Tendon Cross Sectional Area Differ After Downhill, Level And Uphill Running In Trained Runners? J Sports Sci Med. 13: 823-828