Achilles Tendon Partial Injuries - A Patient's Guide

You've just completed an excellent session of speed work at the track, doing 10 x 400 repeats, then decide you'll do 2 more - your rationale being "gotta be good for that race coming up in 4 weeks time if I have a faster sprint to the finish line!" The 11th 400m goes well - exact same pace as the previous 6, so on the last 400, a little voice says - "go for it" at the 200m. In the split-second you decide to make this one faster than the last 7, you feel an agonisingly sharp pain in the lower calf area that immediately pulls you up. You hobble to a post just off the track - and stretch out your calf. There's that sharp pain again on the inside of your Achilles tendon. You sit down and try to massage it yourself, very tender! You decide to get home as quickly as possible to get some ice onto it! What have you done?

Most likely you've suffered a partial tear to your Achilles tendon - hopefully not a complete rupture. Why did it happen? Because the load you applied to the tendon over that training session exceeded the ability of the Achilles to withstand that load.

The most common factors predisposing you to Achilles tendon injuries are:

Sudden increase in mileage, speed or gradient
Reduced recovery time between training sessions
Change in running surface
Poor footwear - "worn-out", poor antipronation control if you're an overpronator, stiff in the shoe's forefoot
Changes in footwear e.g. lower heel such as spikes, higher heel-tab shoe
Tight calf (gastroc and soleus) muscles
Poor ankle joint range of motion

See Biomechanics and treatment options for achilles tears here

An Achilles injury is certainly an injury you want to try and avoid at all costs. It is notoriously slow to heal because of its relatively poor blood supply. It also has a slow metabolic rate which is what allows it to carry heavy loads for such long periods but also helps explain why it requires such prolonged rehab to get you back to where you were. But most of the time these injuries are preventable.

Acute tendoachilles "ruptures" aren't uncommon but certainly their risk and frequency increases over the age of 30 in the more ballistic type sports e.g. squash, tennis, netball, basketball, and track. Blood supply to the poorly endowed tendon further decreases with age. Thus it becomes even more important to have a good gradual warm-up, then stretch, before you go onto the court or track as those years tick by.

There will usually be a sudden onset of sharp pain in the tendoachilles, often an audible "snap" and the feeling of "having been kicked or shot in the calf". An Achilles rupture will take you out of running for at least four months. You won't be back to any decent race fitness before considerably longer than that. As indicated however, the scenario presented above in a runner will most likely not be a rupture but a partial tear of the tendon or a paratendonitis (inflammation of the layer surrounding the tendon) due to overload. Even these will necessitate several weeks off running and frequently a lot more time than that depending on whether conservative management (i.e. non-surgical) alone is successful.

The prognosis is much better if treatment is instigated early - if the athlete tries to keep running on it, there is a far greater likelihood of much more severe tendon damage, necessitating more prolonged rehab and often surgery. Why is the Achilles tendon, the thickest and strongest tendon in the body, so frequently injured and slow to heal, and therefore the cause so many chronic problems?Although it averages about 15 cm long, where most of the injuries occur is about 2-6 cm above its insertion into the heel bone, the calcaneus. It is thought the tenuous blood supply to this area of the tendon is partly responsible (most of it comes from above or below). The tendon becomes even less vascular during running, jumping etc. due to the "whipping" motion of the tendon with foot plant and takeoff.


So what should you do with your injured tendon? Yes, "ice" should be started as soon as possible, and rest from anything that hurts it. That will mean stopping doing anything that puts the Achilles on further stretch e.g. avoid shoes with flatter heels. You might want to put a heel raise in the back of your shoe - you can make do with a carpet cut out. Anti-inflammatories may be very beneficial in the early stages to reduce local inflammation, but don't just use them as painkillers to enable you to run "injured" or you'll be setting yourself up for more long-term problems. You should still be able to swim (+/- pullbuoys), and usually stationary biking will also be pain-free so you needn't lose fitness. There'll be a lot of gym work you can also do, though obviously calf raises, squats, and other standing weights with knees bent under load need to be excluded.

If after 4-5 days there's no real improvement, then you should see your sports doctor and physio. If there's a lot of morning stiffness, that indicates a significant inflammatory response to the tendon. Your sports doctor will examine the Achilles and your lower limb including foot mechanics. It may be appropriate for you to see a good sports podiatrist to look at your running gait in your running shoes, e.g. on a treadmill, to better assess what contribution your lower limb mechanics have had in your injury.

After examining your Achilles, your doctor might want to get an ultrasound scan (MRI) of the tendon to help differentiate between the various types of tendon pathology that you might have. This will help determine the best course of treatment and also enable more definitive advice on how long it will take to rehabilitate. You may have a tendonitis, paratendonitis, focal degeneration, partial or complete tear, or more than one of the above going on in the one tendon - each has a different pathology and different treatment. There are also other pathologies that can cause pain down at the attachment of the Achilles to the heel bone, but they are outside the scope of this article.

written by Dr Ruth Highet - Sports Physician (New Zealand)

See Biomechanics and treatment options for achilles tears here

The Medic8® Family Health Guide