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.

Tendon Damage Linked To Antibiotics

Picture by Oliver.Dodd from Flickr

I thought my patient was kidding when he mentioned that his ruptured Achilles was due to his antibiotic medication. He had to have surgery repair his ruptured Achilles tendon and came to our clinic for treatment and rehabilitation.

I did a quick search and found that the US Food and Drug Administration (FDA) has (since 2008) made it compulsory for drug companies to put a warning label on the side effects of ingesting fluoroquinolone (FQ).

Now if you have taken antibiotics (especially fluoroquinolone), regardless of whether you're active or not, you might want to read on.

FQ are a popular class of broad spectrum antibiotics. They are able to kill a wide range of harmful bacteria and will often work against infections that are resistant to other drugs.They are commonly prescribed for sinus, chest, stomach, kidney and urinary tract infections.

Levaquin (levofloxacin) and Cipro (ciprofloxaxin) are the more commonly prescribed medications. Basically, beware of any antibiotic medications that end with floxacin.

FQ's are also ideal for joint and bone infections and Achilles tendinopathy (or wear and tear in the tendon) or rupture is among the most serious side effects associated with FQ use.

The average person taking FQ has a 70 percent greater risk of tendinopathy and a 30 percent greater risk for a full blown rupture compared to another person taking a different antibiotic. As the Achilles tendon has very little blood supply, it is more prone to injury. It is also the tendon most affected by FQ. The risk of Achilles tendon rupture is quadrupled with FQ. Other serious side effects include nerve damage, confusion and hallucinations.

I found enough data to suggest that FQ's should be used cautiously in a selected group of patients. Older male runners (> 60 years), people with kidney disease, those taking corticosteroid medications (commonly used to treat asthma) are the most vulnerable.

The higher your dosage and the longer you take the medication the greater the danger. The risk does not go away when you stop taking the medication. Tendon problems linked to FQ can appear weeks, months or even years later.

My take is if you're active and if you have sinusitis, bronchitis or a urinary infection, try and ask your doctor if you can take another class of antibiotics instead. This is another good reason to find a doctor/ physiotherapist who understands athletes and knows about your training. Personally I would avoid these medications if at all possible.

In instances where your infection does not respond to other medication and treatment you may still have to take FQ's. You may then have to adjust your training during and after the medication. You may have to cut back your mileage, hill running, intensity for up to nine months after taking FQ's.

Watch out for new pain in any of your lower limb tendons, especially your Achilles (although quadriceps, peroneal, hamstring and rotator cuff tendons have also been reported).

Remember to rest sufficiently after training to avoid picking up any colds that may lead to sinus and chest infections.


Reference

Kim GK (2010). The Risk Of Fluroquinolone-induced Tendinopathy And Tendon Rupture. What Does The Clinician Need To Know? J Clin Aesthet Dermatol. 3(4): 49-54. PMCID: PMC2921747.

Picture by Thirteen Of Cubs from Flickr