New Hope for Chronic Achilles Sufferers

Rob Rinaldi,DPM
Posted January 1st, 2007

Every runner has, at one time or another, experienced tightness and a stiff Achilles tendon.  Proper treatment of these short-term injuries can prevent long-term pain.
Chronic Achilles tendon pain has often stopped short athletes’ goals and enjoyment of their sports. Every runner has, at one time or another, experienced tightness and a stiff Achilles tendon. We know that most Achilles injuries are caused by inadequate warm-up or poor training techniques. Treatment programs have frequently fallen shy of their goals to prevent re-occurrence of Achilles tendon dysfunction. Icing and stretching, though an important treatment regimen, has limited value as a cure for this injury.
Anatomy of an Achilles tendon injury
The Achilles tendon is the strongest and largest tendon in the body and
lacks the elasticity of smaller, more slender tendons. It also differs from
other tendons in that instead of being covered with a tendon sheath, the
Achilles is covered by a blood-rich substance called paratenon. Paratenon is
made of mesothelium, which is a single layer of cells, sort of like a
gossamer veil, that has been the subject of exhaustive studies. A tear in
the paratenon will cause bleeding, which may interfere with the normal
function of the Achilles tendon, resulting in further damage and limitation
of motion. If you feel a very tender, sensitive lump or bump in the injured
Achilles, it may really be a tear in the paratenon.
Because it is so filled with blood, mesothelium heals rapidly and
this was always thought to be a good thing. But now, experts think it may
also be a problem if the Achilles tendon fibers are not completely healed
when an athlete returns to activity, leaving the Achilles prone to
re-injury. And runners often do not allow complete recovery time because
acute symptoms may go away before healing is complete.
Often, an athlete will complain of tightness and pain that will
dissipate in a short time with rest. These episodes of short disability and
rapid recovery may be the cause of chronic Achilles tenopathy; if complete
healing has not taken place, the paratenon will still be preventing normal
expansion and contraction of the tendon during the gait cycle.
After repeated incidences of injury and short-term recovery, blood
will pool within tendon fibers and cause chronic pain. If the blood prevents
the tendon fibers from moving properly, the athlete will suffer from
Achilles tendon pain almost constantly, or anytime he or she increases
stress with mileage or speed.
Modifying the Achilles tendon stretch
I prefer the lunge-type Achilles stretch, modified to accommodate
hyperpronation, because the athlete has more control of the pressure. The
modification makes sense because most people hyperpronate to some degree.
Here’s a description:
Standing with one leg about 18 inches in front of the other, in an
easy lunge position, bend the forward knee slightly. As you increase this
forward knee bend, the rear knee will follow with a slight bend itself, and
you will begin to feel a mild stretch in the Achilles tendon of the rear
leg. Lunging further forward can increase the stretch. The modification is
simple. With the rear leg, rotate your knee slightly inward. You will feel
the stretch on the Achilles go from directly behind to the outside of the
tendon. This modification emulates the function of the Achilles with
New surgery for chronic Achilles sufferers
Coblation, minimally invasive radio frequency treatment, is a surgical
procedure similar to ultra sound that has been shown to be effective in
chronic cases of Achilles tendonitis. It’s becoming more widely used and
available. Though the procedure is simple and fast, post-surgical
recuperation will keep a patient out of athletic activities for several
On the horizon
Injection therapy, utilizing the assistance of ultra sound imaging, has been
used in Europe with very good results. It deals with the small pools of
blood from injured fibers that can prevent the Achilles from expanding or
contracting smoothly. Utilizing ultra sound images to determine exact
placement, medications are injected to cause absorption of the pools of
blood. The injections will also sclerose (harden) small bleeders within the
mesotheluim paratenon sheath.
Mechanical cures
If you suffer recurring problems with your Achilles tendon, the first
diagnostic tool you should seek is a simple weight-bearing x-ray. This
inexpensive test will give a clear view of the calcaneous and how its form
may be causing trauma to the Achilles tendon. Surgical correction can then
be planned from these images. The surgery is outpatient but you
will find yourself in a short leg cast for several weeks.

Rob Rinaldi DPM

Robert Rinaldi is a board-certified podiatrist and podiatric surgeon at the Gifford Medical Center in Randolph, VT. He is a fellow and a founding member of the American Academy of Podiatric Sports Medicine, and a podiatric consultant to the Dartmouth College track and cross-country teams. He is a former nationally ranked long-distance runner, having competed in 25 world-class marathons. You can reach him at Gifford Sports Medicine and Surgery Clinics in Randolph, VT, or at the Sharon Health Clinic in Sharon, VT, 802-728-2490 or 802-763-8000 or at