Protect Your Achilles Tendon

published in Trail Walker (NY/NJ Trail Conference) Winter 2014

Achilles, wounded. Depicted by Ernst Herter

By Howard E. Friedman DPM

Problems of the achilles tendon are often associated with runners but hikers are at risk for problems with this tendon too.  Hiking uphill for long periods of time is one risk factor for developing this condition.  And Achilles tendon disorders is one hikers should try hard to avoid. A painful achilles often requires three or more months of rehabilitation to heal enough to allow a hiker to resume hiking free of pain.

The achilles tendon is the largest tendon in the human body. A tendon connects a muscle to bone and the achilles tendon connects the powerful gastrocnemius muscle and smaller soleus muscle located in the calf behind the knee joint  to the back of the calcaneus, or heel bone. The tendon is several inches in length and is critical in lifting the heel   off of the ground when walking or running.

Achilles tendon problems are common among runners and  estimated to occur in 10-30% of male runners and even  5-8% in even well trained elite runners. No statistics exist for how many hikers develop this condition. Nonetheless, problems of the achilles often ail non athletes and often occur in people with one of many risk factors including having very flat feet or very high arch feet, or a diagnosis of obesity, diabetes or hypertension. In addition, a course of antibiotics in the Quinolone family, including Ciprofloxacin and Levaquin, can also cause tendon disorders. Overall achilles tendon issues occur in men more frequently than in women.

Hikers are at particular risk since walking up a steep incline especially with the extra weight of a back pack can cause excessive strain on the tendon. The tendon consists of millions of fibrils of the biochemical molecule collagen in addition to millions of tenocytes, or, tendon producing cells. Unlike other tissues in the human body which react to injury by producing inflammation, an influx of tissue repairing cells,  a damaged tendon degenerates with injury. No robust repair mechanism is programmed into the cells. Thus an injury to a tendon can be devastating.

For years doctors referred to achilles tendon injuries as “tendonitis”, meaning an inflammation. Now however, health professionals treating this injury call it a “tendinopathy” meaning a damaged tendon. This distinction is not very important because it has guided new and more effective treatments. The treatment used for an inflammation, “rest, ice, compression and elevation (RICE)”, can augment the treatment for a damaged achilles tendon but is not sufficient to repair the tendon.

Achilles tendinopathy can include damage to the lining of the tendon, called the paratenon, damage to the tendon itself via stretching or tearing of the tendon fibers, or in the worst case, result in a complete tear, or rupture, of the tendon. A complete rupture is usually the result of a hard landing on one foot, say, jumping down from a rocky ledge and landing on one foot. The injury creates immediate pain, often creates a popping or snapping sound and will result in significant difficulty walking. A complete tear is usually considered a surgical emergency.

But the less serious injuries are the more common types. Repetitive uphill walking and over stretching of the achilles tendon will stretch the fibers and result in a swollen section of tendon which is painful if squeezed in addition to painful when walking uphill or running. This type of injury which has a slow onset can result in a partial tear of the tendon. A partial tear has similar symptoms to a simple over stretching but the degree of swelling and pain are increased. A diagnostic ultrasound or more commonly an MRI can discern the extent of the injury.

May different treatments have been advocated over the years ranging from cortisone injections to general physical therapy to ankle braces and arch supports. But the past few years have validated one treatment as most effective: a program of eccentric stretching. This type of stretching can be done while standing on a step with the heels dangling off the step’s edge and slowly dropping the heels to stretch the tendon, holding that position and repeating. The exercise however is part of a multi week program which includes gradually increasing the force of the stretching. If done incorrectly the can condition can be exacerbated and therefore is best supervised by a health professional knowledgeable in the technique. In addition, using a lift in the heel portion of the shoe is often helpful as well.

What can the hiker or trail runner do to avoid this condition? When traveling uphill, reduce stride length to reduce the strain on the achilles tendon. Take smaller more frequent steps. And, use hiking poles for any sustained climb. And respond to any discomfort in the achilles tendon promptly. Icing the area can help reduce some of the accompanying soft tissue inflammation and local massage may help reduce the pain as well. Most important, however, is to correctly diagnose the extent of the injury and than, if appropriate, begin a program of eccentric stretching.