(at least until the pain is gone). Sadly, 1 of 4 patients is forced to receive medical care of some form for their pain.
If the injury occurs higher mid calf, this is the product of repetitive contractive forces on the myo-tendon junction. At the point where the tendon and muscle join a fail zone resides where most true athletes notice a problem. Muscle is strong and tendon is stronger, but the junction where the two tissue types fuse is the weakest part of the whole system as it contains both contractile muscle-like tissue and fibrous non-contractile tissue. Pain in this location is a tip that a long term issue has been going on and is about to move down the tendon to create a long-term tendonitis type case (without treatment).
Often a patient wants to strengthen it thinking that pain equals weakness. However, this is absolutely the opposite of what truly needs to happen.
With this said, it seems that calf pain is one of those frequently misunderstood symptoms. Most patients believe that if their calf hurts, then it is injured, and if it does NOT hurt then it therefore is in perfect condition.
Usually tendon pain is secondary to another pre-existing condition such as muscle contracture from past strains or a lifestyle or job factor. It is important that one know that pain is the last symptom that occurs to indicate that there is the risk of a major injury. Treatment needs to encompass all these factors.
Taking time off rarely heals these things as they tend to collect with playtime on the road or court. My patients tell me its old age, I tell them its a collection of too much fun. The goal is to return the muscle and tendon tissues as closely back to normal as possible, removing all inflammation, stretching the tissues back out to their normal length, and then strengthening them back up to where they should be and finding out what in the heck caused the injury in the first place (technique, bike fit, overuse, jumping into the season too quickly, training load, etc).
Progression of Calf Pain:
Often a little tear leads to a contracture which then leads to a tendonitis type case. If this tendonitis goes to long, then it turns into tenonosis which is the reinforcement of the tendon sheath after it is irritated by all the friction and inflammation of the previous problem. I have seen hundreds of tendonitis type cases recover well with sports medicine type care, tendinosis is a difficult beast; however, because the body actually creates more friction by its reinforcement of this sheath. In a runner or triathlete, this could mean the end in reality of their sport because I have seen this calcification saw through these tendons and cause a complete rupture. This is why taking care of these injuries is so important, this one can get out of hand. With this said, these injuries are all preventable.
Yes a tear can form at anytime from playing in cold weather, exerting yourself beyond your normal bounds, or just training while dehydrated for a day. Taking care of that tear, and all the tears that occur after it will allow you to keep your abuse from adding up to a lifestyle-ending disaster. I run the medical for tennis tournaments and it is one of my favorite loves. Why? Most injuries are at the final stage of ending the player's fun for good as most do not realize that bodies can be molded back towards normal. These compensations (including tendonitis, biomechanical gait abnormalities from sprains and old memories of injuries, etc) and contractures (tears and the resulting shortening of the muscle and teathering in that shortened position by something called scar tissue or adhesions) that have occurred with years of fun and sweat can be conservatively and effectively returned towards normal. Its not pretty but the warning does ring true...Achilles tendonitis is a nasty beast. The longer you let it go and train with it anyway, the more long term damage may be done.
Keeping these small tears from becoming
a major issue is the goal.
If we know what symptoms to look for and what stage of progression we find ourselves at, then we can begin returning ourselves (and our tendons) to health. As a doctor, the questions I get are often related to age or why the injury hasn't healed since it has been a week (or two!!)...this brings us back to the topic of mechanics and design.
Yes, technique is everything when it comes to overload or using the body in a way for which it was not designed. With improper technique or bad biomechanics, you are setting yourself up for disaster. (On this note, see my other blogs on this subject)
Looking at the triathlete to the right, do you see any major issues that can give him achilles tendonitis?
The answer is yes.
First off, there is the problem of over striding. If you look at this athlete's heel, it is about to contact the ground in the landing phase called heel strike. Landing with the heel in front of the body acts as a brake and is not recommended.
We don't see any skateboarders doing this!
...or we'd see or at least hear more crashes.
This landing phase should be occurring directly under the body. The amount of impact going into the pre-stretched achilles tendon is amplified with this bad habbit.
Secondarily, this patient's hand is always over the foot when he is running, if he brings his hand's in front of the body, his foot is also going to be there as well. Looking above, see how his wrist is directly over his foot and both are in front of his body? If he were to keep that wrist closer to midline with the footstrike, he would be correcting this fault easily with a little mantra repetition (such as "hands by waist with footstrike") or just practicing this drill whenever he feels that he is starting to fatigue.
Technique is everything. Tennis players do the same drills over and over for racquet positioning during a volley and the light mistake could equal the end of their match or season. Swimmers do the same drills over and over for how their hand enters the water and how their elbows are kept high which keeps them from injury and eliminates drag. Runners need to learn from such discipline.
Most notably occurring with fatigue, this runner probably has excellent form when he isn't tired and straight off the bike. If he were to shorten his stride and land with his
foot right under his sternum (breastbone) he would not only exert less energy (as he doesn't have to overcome this breaking motion with each step) but he would be putting more effort into the push-off phase instead of the pulling-phase (which shouldn't really be there anyhow).
Structure defines function.
Each muscle of the body anchors to the bone via a tendon. If we were to use the analogy of a man pulling on an anchor. The muscle is the man, the tendon is the rope, and the tendon-bone insertion is the anchor. The only contractile part of this mechanism is the muscle (man). If the muscle is pulling to hard or too often, the load on the tendon and bone is higher than normal yielding either a tendon reaction (tendonitis or the rope fraying) or a bone reaction (periostitis or the anchor pulling up the sea floor).
Because each structure is designed for an exact function, if the function changes, the structure is either damaged (sometimes past repair) or it modifies itself as much as possible to this new use in an attempt to compensate for this new design.
A perfect example of this is a bunion, which forms because the inside of the big toe joint is blown out medially, because the joint is no longer being used correctly but at an angle...(Will write an article on this some time in the near future).
How far you can push it before it fails?
That is something most athletes and all scientists would love to know!
We have graphed it out on creep curve charts but the answer is different for each athlete. Each structure of the human body is designed for a particular use, the muscle shortens maximally to an exact length, the tendon is an exact thickness, the tubercle (or bump) at the heel is an exact size and shape to allow the exact connection by the tendon...
Any usage for which these materials were not designed means failure.
The photo above is of the muscle tendon junction. The pink to the left is the tendon and the white to the right is the muscle fibers, see how they are weaker in the center because of the quick transition from one to the other? No wonder why most injuries occur in this zone.
Overuse is quite common in achilles tendon problems, it is not that the tendon just tears under the pressure (which is more common in a tear at the heel) but it fails after elongated periods of tugging by the muscle...which becomes SO contracted that it tugs while the patient is sleeping, in the shower, and at work (not asking it to do any work). These issues create a chronic overuse syndrome as that tendon never has a chance to heal. In this case (which is more common than not here in Boulder), if we were to take the pressure off the tendon, it will heal quickly.
Ever heard of the saying "if you don't use it you lose it?" Well the sports med world has our own saying to use in conjunction with that little pearl of wisdom..."If you abuse it you lose it." Enough said.
In school we always argued the question of which comes first...Does design dictate function or does function dictate design?
Both are true to a point.
The exact design comes first and then the structure is modified based on needs or compensations. The tendon is made of a specific material to bear the weight at the achilles.
This structure is specific for your weight, what surface you run on...it becomes thick if constantly tugged on and shrinks after a season off. Your training (i.e. high reps with low weight or low reps with high weight, if you just came from an off-season, etc) all plays into this specific design.
Most injuries I see are on a tendon/muscle that has been asked too much at once. You ride your bike 70 miles a week and then you hit the pavement on foot for a 12 mile run. Well, that stress free tendon just had major pounding added to it with each footstep (at the rate of 10,000 per mile on average with over 1,000 lbs of force per square inch of bone on your heel per contact with the ground...thats a LOT of force and a LOT of repetition).
How do we reverse the effects of this damage?
The load that the muscle puts onto the tendon and its attachment at the heel is the main factor in tendonitis type cases. If the tendon frays near the heel, its most likely caused by a quick return to sport (running and tennis newbies come to mind).
If the weight can be taken off of this zone it stands a chance of healing. I use a two pronged approach by working on the cause (the muscle) and the current situation (the tendon injury) at the same time. The tape job to the left is designed to take the weight off the tendon as it actually acts as the tendon and unweights the area in doing so.
Throw ice into your mix (with any injury) to decrease inflammation and add a nice tight acewrap while icing to compress the swelling from this region.
The special sauce for fixing this area is to not spend your time rehabing the area with calf raises but to spend it doing the opposite in addition to fixing what is causing the injury. If you don't remove the cause of the injury, this problem will continue to recur over and over again thus making you think that you are getting old or that you need to discontinue your favorite sport. It could be technique changes, muscular weaknesses, biomechanical faults that need to be modified, or just a build up of scar tissue. In any case, consultation with a doctor who specializes in these areas is a great idea. DPT, DC, and ATCs all work well in addition to your sports-specific general practitioner. I am a firm believer in acupuncture and sports massage in addition to these providers. Pick a doctor you feel is confident with this issue and has a track record of specializing in it. Here in Boulder we have no problem with that as there are many many many talented and brilliant minds that care only about living the life through their patients.
Often a patient wants to strengthen it thinking that pain equals weakness. However, this is absolutely the opposite of what truly needs to happen. In the cases I have had walk or limp into my office (or to my court-side medical tent) the calf is already overly contracted, overly shortened and needs to be stretched, lengthened and given a rest. The use of deep tissue muscle work such as (active) myofascial release technique to break up the knots, elongate the contractile tissue that forms around old tears. Graston or GuaSha also helps to decrease the friction along the tendon by working to clean up the tendon and break up any un-needed fibrous material that the body uses to reinforce what it believes is about to fail.
Rest assured that most pain can be aided with self care including proper icing, use the foam roller, and the much needed rest for healing to begin. Tucking in your sheets too tightly, sleeping on your belly, and sitting at your desk without a foot stool can all cause achilles contracture. I have had a patient with each situation and often it is only working through the givens to find lifestyle issues that directly effect health. Bracing, taping or a heel wedge will decrease the weight on this tendon while muscle work above it to reduce scar tissue will help to decrease the load on the tendon so it can heal.
Disclaimer: All information contained above is for patient education and not intended for self-diagnosis or care. I have had many many patients come in with incorrect self-diagnosis and the results can be severe. If you have any questions, please feel free to contact your local sports-specific doctor to have help with your specific situation. Evaluation usually takes more than an email or a website blog posting as each body (and injury history) is completely different.
