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Achilles tendonitis...it's back...!!

post #1 of 24
Thread Starter 
Acutally it never went away. I posted on this last year so excuse me if I repeat myself. I've been carrying a small bump on the tendon directly behind my anklebone all summer form a partial tear. Now it is ski season and after the first 2 days the are is again irritated and inflamed. It doesn't hurt at all during activities but if I rub the area it is definetly tender.

Now, before you feel too sorry for me, I have only been doing the suggested PT sporadically. This consists of simple heel lifts off a stairstep. I have to say that I have a bit of a hard time thinking this will actually work but mostly I just have a very hard time remembering to do it. One thing I am doing is dumping the Sallie CrossMAx (XWave) 10s I bought last year. I am convinced that these play a role in the injury. But this doesn't address the issue that the tendon never seemed to get any better *at all* all summer. I thought it had, but I guess that was just wishful thinking. Anyway, a few questions.

1) Isn't there *anything* else I can do to help repair this thing? It is so friustrating that it just won't get any better. Can it even get better? My PT said the big problem was that there is very little blood flow to that area so it is very difficult for the body to repair it. Hell, I'd even try acupuncutre if I thought it would work. It's been suggested that Yoga with down-dog etc. might help, Lisa-Marie's antipathy notwithstanding.

2) How do you guys remember to do your therapy on a regular basis?

3) What are the chances that this will turn into a full blown snap? My docs seem somewhat concerned but then I have heard from people (runners esp.)who say that they have lived with this for many years without significant problems except for occasional tenderness. It is certainly not incapicitating, usually I don't even feel it.

thanks all!
post #2 of 24
Time is the healing factor in a partial tear, as I understand it. I had a complete rupture requiring surgical reattachment. My repaired tissue was forced to "rest" and heal because they kept me in casts and a walker boot for six months. It's been 10 years now and the injured tendon remains half again as thick as the other one, which the surgeon told me would be the case forever. So I don't see how your "bump" is going to disappear.

If I don't do my daily routine of heel raises (I use a floor transition in a doorway where I have about 1.5 inches of level difference, but a piece of 2X4or a thick telephone book would do the same) and stretching on a 30 degree ramp, my tendon tightens up in a couple days. After a week or so of ignoring the routine, my tendon begins to hurt. So I start every day with this half hour of attention to my legs. It's a part of life like brushing your teeth or taking any medications you require.

My routine is two sets of sixty rises. At the same time I'm stretching my short, stiff neck by turning my head back and forth to each side for a count of ten rises. This helps prevent stiff necks, which I also used to get when skiing. Between sets I do some edging routines standing in a corner in the kitchen countertop so I can support myself with my hands. Then I go stand on my ramp for 15 minutes.

Regarding the potential for a complete tear after you've experienced a partial, I'd guess you're in a weakened position and really should be paying attention to keeping the tendons loose. My tendon rupture occurred when I had tight tendons that would get sore with just a bit of activity. I was an avid Nordic Tracker previously for several years, and I think the way you stop foot movement back and reverse direction abruptly when really going at it on a Nordic Track made my tendons tight. I'd never had sore tendons until using the Nordic Track vigorously for a year or so.
post #3 of 24
Lodro,
Like Kneales suggestion, view the exercises like you do personal hygiene. And stretch often.
For me, the achilles injury was over 20 years ago. At the time I ran 6-8 miles every day. During the winter I got in the habit of stretching in the shower immediately after the run. To this day my morning shower includes stretching of achilles,calf,and quads. (For years the hamstrings were included, but eventually the soap dish fell off the wall and my hamstrings have been tight ever since.) I only do each stretch for about 30 seconds but it has been effective. Today I can dorsiflex more then most people 25 years younger.
Tendons do take a long time to heal. Most of my sprains have taken 3-4 years before they stopped bothering me and some closer to 10 years. My guess is that if you attend to the therapy dilligently, risk of further injury is greatly reduced. If you don't do the therapy it will come back to bite you hard.
Good luck.
post #4 of 24
Thread Starter 
Quote:
Originally Posted by Kneale Brownson
So I don't see how your "bump" is going to disappear.
Actually, in a funny way that makes me feel a lot better. I was thinking that my somewhat lacidaisical approach had doomed me -- that if only I had listened to my docs I'd be all bettter. But the thing is that my achilles is actually pretty flexible, and I have never had any real pain or even tightness except at that contact point itself, and there was no swelling or tenderness all summer. I don't run but I do do a *lot* of hiking.


I do know that the present condition is not sustainable. And honestly I'm still not completely convinced that any amount of strength and flexibility training will hold that back. Not that it won't help, but I feel like it will get worse and worse regardless. I have absolutly no medical advice to back this up, but I really think that the problem is coming from the rubbing of the inside of my boot against the existing tear area. So my hope is that changing to a boot with a different shaped ankle pocket and that is more upright and stiffer will help significantly, and that that *combined* with conditioning will keep things from getting worse, but perhaps that is just wishful thinking.

Re: keeping at it...thanks for the good advice guys. I was thinking that I had to do it throughout the day, like other PT excercises I've been given. And I just don't rememebr to do it then. It sounds like the best idea is to pick a good time to do it and do it everyday. I like the toothbrush anaology, it really doesn't take much time to get into that kind of habit. I don't have a problem rememebering to stretch often during activites, it is when I am sitting around the house/office that I forget.
post #5 of 24
I've got a bunch of those lumps! And I can't do heel raises, or I'm in agony for days and can't walk in the mornings. Heel raises on the flat floor are OK-ish, but the ones where you drop your heel off a step are a complete no-go. So there you go, it could be worse.
One caution: don't stretch to pain levels. = damage. Loooong, very gentle stretches will actually stretch your tissue, not tear it.
post #6 of 24
Lodro -

Get the foot/ankle into a boot, now. Couple of things to keep in mind:
  • inflamed / damaged tendons are much more prone to rupture
  • immobilizing the tendon is about the only thing that would take the stress off and allow some healing. Immobilizing = day/walking boot and a sleeping splint at night (which keeps the tendon stretched, so when you wake up you don't have the stretching of a contracted tendon). Immobilizing means 23.5 hours per day of booting & splinting
  • PT, pt, pt....
  • Avoid steroids and avoid cipro (the antibiotic) - both will possibly weaken things further.
Like you I had a partial tear that refused to heal. Even with the booting/spliting, and extensive PT, I eventually had the tendon debrided and reattached. It was fine thereafter for three-four years, and began to bother me last year. More PT, strict booting, and monitored weight training seem to have fixed it. (The weight training is what really helped, IMHO, by increasing the blood flow dramatically to the region. But I didn't start this till after booting for 8 weeks and then extensive PT).

Despite the temptation, I would try to not ride it out. It'll likely get worse, and the surgery takes a major period of time to heal and sucks big time. And get a good orthopaed.
Good luck
David
post #7 of 24
Thread Starter 
Quote:
Originally Posted by tetsuma
LThe weight training is what really helped, IMHO, by increasing the blood flow dramatically to the region. But I didn't start this till after booting for 8 weeks and then extensive PT).
Thanks David. Eeeshh. I am assuming that you didn't mean 'ski boot'. That I could do.

Can you be more specific about the training? Just general lifting or focussed on calfs? What does your pt regimen look like?

Frankly, I am compleltely mistified by the whole thing..they tell you to stretch it and strenthen it, and then to immobolize it?

How far gone was your tear?
post #8 of 24
Immobilise etc is part of the treatment to repair damage. Stretching and building strength is a re-hab or maintenance thing. They won't repair inflammation and physical damage. DIY repair would be strapping into a fixed position during the day and the night, with frequent icing and anti inflamm. use I should imagine.
post #9 of 24
Quote:
Originally Posted by Lodro
Thanks David. Eeeshh. I am assuming that you didn't mean 'ski boot'. That I could do.

Can you be more specific about the training? Just general lifting or focussed on calfs? What does your pt regimen look like?

Frankly, I am compleltely mistified by the whole thing..they tell you to stretch it and strenthen it, and then to immobolize it?

How far gone was your tear?
Yeah, chuckling, not a ski boot. A walking cast boot. Air cast makes a good one (the Foam Walker), here. The night splint I got from the doc, so not sure where to look for those. But, either way, both are important. It's the only way to remove the stress/injury from daily use, and let the thing heal.

Then I started PT, which consisted of a lot of pleasant (not) stretching of the groin, hamstrings, calfs, ankle; followed by balance games, some ultrasound heating, massage/manipulation... all aimed at getting my hip-knee-foot alignment good and straight...

Once things were sorted on the alignment and joint mobility, I started the weight work. Specifically, for the achilles, calf presses -- essentially using a leg press, with the knee straight, and only the ball of foot to toes on the press, and moving up and down (foot flexed toward your head, and then back to more or less a perpendicular to leg position).

So, to get the sequence right, immobilization is the thing. Let the thing calm down, heal a bit. I think there is some disagreement in the medical community about when to start PT, etc... so check with your doc. For me it was immobilization for eight weeks, followed by PT for two months , and then I started the weight training (while still doing PT). As I said earlier, the addition of the weight training has ended all the pain I was experiencing... something about blood and gag (some glyco-something-something protein that lubes things).

My tear was sort of longitudinal -- I had a bunch of necrotic tissue in the center of the tendon, about two inches above cancaneous up for two to three inches. (I tore it due to Cipro use.)

All I can say is try to get it working without blowing it out and having to do the surgery. It might mean staying off skis this season (i know not a nice thought), but it's better than having to have a hamstring or acl transfer to your ankle. Oh yeah, if you smoke... stop. The complication rate in healing for smokers is many times worse than for non smokers -- it's the poor blood flow thing, and smoking cutting down the O2 level going through the bod.

Good luck, I know what you're facing.
David
post #10 of 24
Thread Starter 
Quote:
Originally Posted by tetsuma
Let the thing calm down, heal a bit.
Yea I think I was more or less there. No tenderness at all. I am going to be off skis for the next 2 weeks anyway and will take it easy and see if we can get back to where I was last week. Then see a PT and find out what makes sense.

Quote:
Originally Posted by tetsuma
My tear was sort of longitudinal -- I had a bunch of necrotic tissue in the center of the tendon, about two inches above cancaneous up for two to three inches.
Yikes, mine is off to the side and 1-2cms, so that sounds like a significant difference.

Quote:
Originally Posted by tetsuma
It might mean staying off skis this season (i know not a nice thought), ...
NOOOO!!! Well, we'll see. The doc and PTs who saw me last year didn't tell me to quit, so hopefully we won't even have to go there. : I would be a very sad monkey and a very po'd one as well since noone suggested more radical approaches in the off season.

Quote:
Originally Posted by tetsuma
Oh yeah, if you smoke... stop. The complication rate in healing for smokers is many times worse than for non smokers...
Wow, now that is very good advice. I am a very light smoker but this is as good a reason to stop as any I've heard.
post #11 of 24

contact point

Lodro,
In your second post you mention "contact point". Any chance your problem is right where the achilles attaches to the heel? I ask this because it reminds me of a problem I had a few years ago. The "bump" at the attachement point was getting more and more tendor, to the point where I was afraid I would have to bail part way through an exam. It turned out that my foot beds had been trimmed 1/4" shorter then the stock insole. This resulted in the footbed and my foot shifting fore and aft in the boot as I skiied. As I flexed the heel was driven against the shell and after a while it got really tender. New footbeds solved the problem.
If this rings a bell for you, the problem may be a boot fit issue. Also,any chance you've been really agressive at downsizing your boot to achieve a "performance" fit? Maybe to far?
post #12 of 24
Thread Starter 
I think you are not too far off the mark. In my case it is about 2 12" up from base of foot. But it was definetly caused by a boot issue. In this case I think it was rubbing of the tendon against the liner. This is why I think if I can get a nice tight ankle fit I'll actually be better off. That and less fore aft motion (I tend to get too far forward in my boots). A few other people have said they have had this same issue w/ the Salamon XWave actually.

But my problem was classic. I would never have had a problem except that I was teaching kids and so walking around in the boots all day, skating, bending down, etc.. It started to really hurt and I got the bump. I allowed the swelling to continue -- it was my first year teaching, the school was totally slammed and everyone has some kind of ache or pain. So even though I could barely walk, I soldiered on, not wanting to let them down. Of course, huge mistake.. The problem is that a partial tear apparantly presents just like regular tendonitis, even in MRI, so my doc didn't pick it up right away, just told me to get off it which I did as soon as I could. Funny thing is as soon as I actually asked they put me on the mountain w/ higher level kids so that I wasn't skating and that seemed to work fine.

Anywho, long-winded but I guess lesson is listen to your body, even if it means that you have to stick your neck out. The tenderness is very minimal today so here's hoping. My response has been a) giving up smoking immeddiatly, b) staying off the mountain for another week and a half, c) see a doc or PT at least when I get back d) icing until swelling and tenderness are gone. I also got some glucosmine tabs but I don't htinkt here is much evidence of benefit.
post #13 of 24
One clarification on the smoking bit: I was told by my surgeon that the healing rate following surgery is much more problematic (and lower) for smokers -- to the extent that wounds don't always heal at all. So, not sure if it impacts healing w/o surgery, but it's probably a good guess that it does. That area is so poorly blood/nutrient supplied.

good luck. and good to stop puffing generally.

-D
post #14 of 24
Lodro
I just thought of another possable cause. You said you were teaching kids. Did you by chance unbuckle your boots thinking you'd be more comfortable and didn't need the tight fit and control that you use while skiing? I used to undo the bottom 2 buckles. This also leads to your foot moving for and aft, banging the achilles attachement point against the shell, leading to tenderness.
A possable way to aleviate pressure on the tender area is to make a donut shaped pad that moves the pressure to the area around the tender spot. Dr. Scholls may sell these in the foot care area of stores, or your local ski shop could provide the padding material. Good luck
post #15 of 24
Quote:
Originally Posted by tetsuma
One clarification on the smoking bit: I was told by my surgeon that the healing rate following surgery is much more problematic (and lower) for smokers -- to the extent that wounds don't always heal at all. So, not sure if it impacts healing w/o surgery, but it's probably a good guess that it does. That area is so poorly blood/nutrient supplied.

good luck. and good to stop puffing generally.

-D
yep would think so

wound foundation guys say periphereal blood flow decreased by 50% for 1 hour after each ciggie
post #16 of 24
Thread Starter 
Quote:
Originally Posted by disski
wound foundation guys say periphereal blood flow decreased by 50% for 1 hour after each ciggie
Wow! But I beleive it ecause thtat is how long it takes the kind of low energy feeling to go away. Again, I knew it was bad but had no idea how bad. Afeter Tetsuma's post I read some other things including study that showed that bone breaks took *on average* 70% longer to heal.
post #17 of 24
PT is the wy to start, another treatment worth investigating is shockwave
therapy, check out heelspurs.com ( eswt section)
post #18 of 24
Thread Starter 
Just a followup -- good news! I saw an actual honest to god orthopedic surgeon and he said that there is no evidence of a defect (I assume meaning at tear, etc.) just a pressure tendonitis (good because my sports med GP thought he felt a tear) and that I was good to go..and to follow the standard stuff, e.g. ice, stretch, etc..if I feel any pain come back. But no PT or anything. Meanwhile I have cut out the liner around that area in my salomons -- the evil boots that caused this problem in the first place -- and no pain or tenderness at all. And in my new Atomics where my heels are very solidly anchored, also no issue.

BTW, a couple of interesting things. He said that ruptures are not predicted at all by tendonitis; no relationship between the two. In fact ruptures are typically sudden with no real forewarning. I don't know if that is comfroting or not.
post #19 of 24
Salomon x-waves, by any chance? They are the boots that flared up my on-going achilles problem. To the point where I couldn't walk after a ski season, literally. I could shuffle.

Although now my knees have flared up, the ankles have become quiet (or so it seems).
post #20 of 24

that's no tear

Quote:
Originally Posted by Lodro
Just a followup -- good news! I saw an actual honest to god orthopedic surgeon and he said that there is no evidence of a defect (I assume meaning at tear, etc.) just a pressure tendonitis (good because my sports med GP thought he felt a tear) and that I was good to go..and to follow the standard stuff, e.g. ice, stretch, etc..if I feel any pain come back. But no PT or anything. Meanwhile I have cut out the liner around that area in my salomons -- the evil boots that caused this problem in the first place -- and no pain or tenderness at all. And in my new Atomics where my heels are very solidly anchored, also no issue.

BTW, a couple of interesting things. He said that ruptures are not predicted at all by tendonitis; no relationship between the two. In fact ruptures are typically sudden with no real forewarning. I don't know if that is comfroting or not.
Lodro - I've had two minor achilles tendon tears, they also present as bumps, and also tenderness, but there is some weakness (even with a few fibers of tear) and generalized swelling/thickening of the involved tendon. You don't describe this so I agree with your OS. No tear.
post #21 of 24
I've got weakness, lots of it. I find it very difficult to ski on one ski (very wobbly in the ankle), and jumping is also a challenge. I can do these things, but not as well as pre-ankle-meltdown in 2002.
post #22 of 24
Thread Starter 
Quote:
Originally Posted by ant
Salomon x-waves, by any chance? They are the boots that flared up my on-going achilles problem. To the point where I couldn't walk after a ski season, literally. I could shuffle.

Although now my knees have flared up, the ankles have become quiet (or so it seems).
Yep..one more 'evil X-wave' datapoint. I assume you tossed them. If not the liner cut out has worked reasonably well. But in any case they are packed out and weak now.
post #23 of 24
I ride a road bicycle about 4 to 5 days a week. And I just had an achilles rupture and my ortho said because I'm dying to ride my bike, that'll be a good thing. Low impact, gets blood pumping in the legs, etc. He's just warning me already that there's a lot of stretching and ice in store for me for a long time... It was weird, no real warning at all. No soreness prior to the rupture and we were 45 minutes into a neighborhood football game so it wasn't like I wasn't warmed up. Field wasn't too smooth though.

You feel pain. Ice it for 15 minutes ASAP.
post #24 of 24
you might consider orthotripsy or shockwave treatment
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