Achillodynia The carrot and stick of the shoe
If before it was the knee, today it’s the Achilles tendon – for many runners, the pain has moved downwards. Excessive strain, an unhealthy diet but also unsuitable footwear are some of the reasons for this problem.
In one of his poems, the German author Joachim Ringelnatz wrote “…but cursing their feet in a Belgian street…” Based loosely on Ringelnatz’s poem, this could refer to a patient with Achilles tendon pain by the name of Lutz Wendler. His physician, Dr. Med. Henning Vollbrecht , an orthopedic specialist , has a practice located on the famous Hamburg Elbchaussee street by the river. Time for a check-up appointment. One glance at the patient’s medical file confirms: Lutz Wendler’s began suffering from symptoms at the turn of the year 2013/14. “I remember it exactly as I had just started a new job and unfortunately I was limping.” Lutz Wendler works as the city editor of a Hamburg daily paper. A stressful job, says the sixty-year-old. Exercise is therefore all the more important for Lutz, it helps him find the balance between work and private life: Tennis, swimming, running (including marathons), but most of all he enjoys playing football. The pain in his Achilles tendon suddenly made him aware that he could lose all of this without warning. Although “without warning” is not entirely correct in this case: “It was an incorrect movement whilst playing football , banging my tendon on the shopping cart , sprinting to catch the train”, he recalls.
By a thread
“Lots of micro-tears. Sometimes more, sometimes less. These add up over the years and leave their mark.” Dr. Vollbrecht sits with the ultrasound image in front of him and points to the bright areas. “Here, this is all scarring”, he explains. The physician is pleased nevertheless. “The tendon is eight millimeters thick. That is good for a sportsman. The normal value would be between six and seven millimeters. At the start of treatment it was twelve millimeters due to the traumatization.” At that point Lutz Wendler’s swollen Achilles tendon was hanging by a thread. 80% of it was already ruptured. Constant irritation of the Achilles tendon, including irritation below the human perception threshold, had led to this. Finally, because of the pain, Lutz had to go and see a physician.
Severe side effects caused by antibiotics
Dr. Vollbrecht has some good news. “Nobody runs perfectly. Many cases of achillodynia can be cured,” he says. And some bad news: “This can sometimes take a long time.” We should add that problems with the Achilles tendon are complex to treat. This is due to the numerous factors that influence the condition: Excessive strain – this mainly affects runners between 40 and 60 years old. Stress and incorrect positioning of the foot or the pelvis. The wrong diet , a lack of vitamin D or an acid-base imbalance also play their part , as does unsuitable footwear. Apparently, heavily cushioned running shoes with a soft sole, for instance, can trigger an increased “whiplash motion” of the Achilles tendon which leads to additional mechanical strain.1 This kind of running shoe, soft like candy floss, was promoted particularly in the 1990’s as a means of preventing knee problems. In Lutz Wendler’s case another factor played a major role: Ciprofloxacin. This antibiotic belongs to a group of drugs called fluoroquinolones. Lutz Wendler was prescribed the antibiotic because of an infectious illness. The antibiotic can lead to inflammation and rupturing of the tendon even weeks after the patient has taken the drug.
Foot orthoses to reduce shearing forces on the Achilles tendon
Dr. Vollbrecht treats the multifactorial process that is achillodynia with an impressive range of measures. In his view, basic treatment involves a multimodal concept of prescribing physiotherapy, foot orthoses and supports. Prior to this it is necessary to check for possible structure or alignment defects, particularly for uneven pelvis, hip misalignment and leg length differences. In order to “facilitate natural processes”, hyaluronan can be administered to reduce tendon adhesions as well as platelet-rich plasma from the patient’s own blood containing growth factors and micronutrients. The physician regards diet as important: “Unfortunately there is often a tendency towards being acidic. Vegetables, fruit and the Mediterranean diet balance this out.” Can one therapy measure be emphasized in particular? “Foot orthoses and supports are useful tools”, according to Dr. Vollbrecht. Lutz Wendler pulls a TRIactive soft foam foot orthosis out from his shoe. “The product’s different cushioning zones ensure that the foot is guided in a controlled manner,” the physician explains, “as shearing forces can be damaging to the Achilles tendon.”
Independent exercises using the AchilloTrain
In addition to the foot orthoses, the orthopedic specialist had prescribed his patient the AchilloTrain. The active support relieves strain on the Achilles tendon with a pad that surrounds the tendon. The pad provides guidance during movement and the support also features an integral heel wedge which minimizes strain on the calf muscles. The physician recommends the AchilloTrain Pro to be used as part of the ongoing healing process and to prevent further injury. Its winged pad stretches up to the area where the muscle meets the tendon and its frictional nubs massage the area parallel to the Achilles tendon. “This stimulates proprioception and establishes preliminary muscular tension,” says the physician. “Both supports are suitable for use in everyday life and also for home exercises”, the physician notes. Lutz Wendler has worn the supports at work and sometimes whilst playing tennis. “All of the steps I have taken within the last six months with the help of Dr. Vollbrecht have ultimately proved successful. Today I hardly experience any symptoms when running.” Lutz Wendler now runs with harder, more stable shoes. The only thing missing now is playing in a real football match. But maybe he will stick to the lines of Ringelnatz:…. where, according to the poem, the man wisely decided to cut his journey short in the end.
1 Alt W, Reule C, Hochwald H Achilles tendon overuse injuries: risk factors and biomechanics British Journal of Sports Medicine 2011;45:e2.
Images: Stefan Volk