Protect Your Achilles Tendon

By Howard E. Friedman, DPM

Tendons connect muscle to bone, and the Achilles tendon, which connects the powerful gastrocnemius muscle in the calf to the back of the calcaneus, or heel bone, is the largest tendon in the human body. An injury to the Achilles tendon, which is several inches in length and flexes the foot downward, can sideline a hiker for a season and require three or more months of rehabilitation.  

While often associated with runners, hikers are at particular risk since walking up a steep incline, especially with the extra weight of a backpack, can cause excessive strain on the tendon. Unlike other tissues in the human body that 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 tendon cells. Thus an injury to a tendon can be devastating.

A Range of Injuries

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 indeed 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 it is not sufficient to repair the tendon.

Achilles tendinopathy can include damage to the surrounding covering of the tendon or stretching and tearing of some of the tendon fibers themselves. In the worst case, the injury is a complete tear, or rupture, of the tendon. A complete rupture is usually the result of a hard landing on one foot, for example, jumping down from a rocky ledge and generating a sudden and large force on the Achilles. A rupture causes 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 straining the Achilles tendon will stretch its fibers and result in a swollen section of tendon that is painful when walking or running uphill or when squeezed. This type of injury, which has a slow onset, can develop into a partial tear of the tendon. A partial tear of the tendon exhibits more swelling and pain than does a strain. A diagnostic ultrasound or an MRI can help discern the extent of the injury.

Risk Factors?

Risk factors include having very flat feet or very high-arch feet, being obese,or having diabetes or hypertension. In addition, use of oral steroids or a course of antibiotics in the quinolone family, including ciprofloxacin and levofloxicin, can also cause tendon disorders. Overall, Achilles tendon issues are more prevalent in men than in women. 

Best Treatment Option

Many different treatments have been advocated for Achilles tendon injuries over the years, ranging from cortisone injections to general physical therapy to ankle braces and arch support.  But in the past few years, one treatment has been validated 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 that includes gradually increasing the force of the stretching. If done incorrectly the condition can in fact be worsened. It 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.

How to Avoid Achilles Tendon Injuries

What can the hiker do to avoid this condition?

• When hiking uphill, shorten your stride length to reduce the strain placed on the Achilles tendon.
• Take smaller, more frequent steps.
• Use hiking poles for any sustained climb.
• 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 then, if appropriate, begin a program of eccentric stretching. 

Howard E. Friedman, DPM, is an avid hiker, a podiatrist in Suffern, NY, and a frequent contributor to Trail Walker.