Thank you in advance for your help and for reading! I have a question regarding pain in the achilles tendon.
I will give you some background that may help. I am 23, and I have been an active runner since I was about 16. At my university, I ran track and field and cross country. This year, after graduating, I have continued to run daily (between 4 and 7 miles daily) and to do mild speed training workouts. I have never had a major injury, only a few very minor aches and pains now and again like shin splints. For the most part, however, I have been very lucky. I consider myself to be in good health, and remain athletic.
However, about 20 days ago I twisted my left ankle. It hurt very bad in the first moments, but then it felt ok to keep running. By the afternoon, it was swollen near the top part of my ankle and painful to walk. I took some ibuprofen, iced it, and wrapped it. Within about two days, it was feeling fine and no pain at all. I went for a short run, and had no trouble. Even so, at this time I was traveling around a lot so I figured I would lay off of running during that week just in case. I did a lot of walking, but there was no trouble, and no pain.
After returning home at the end of the trip, I went for an easy run, about 50 minutes at a very easy pace. Again with no trouble, no pain, and everything seemed fine. The next day, however, at the start of the run I began to feel a slight pinching/stinging feeling in my achilles tendon on my left foot. I thought it was just my sock or running tights pinching me, but even after readjusting these, the "sting" was still there. It was nothing very painful initially--just a slight stinging and it did not interfere with my running at first. However, throughout the run (about a 50 minute run again), it grew gradually worse. By the end, I could still walk but running was quite painful and I can still best describe the feeling as a "stinging" in the achilles tendon. When I stopped and walked, it still hurt though not as bad as while running. I noticed it was a little inflamed, so I put some ice on it thinking it was something that would go away or soreness from taking a short break from running while on my trip.
The next day, however, I had a lot of trouble going down or up stairs. I had to hobble along by holding the handrail. While walking, my achilles still "stung" and I could not walk smoothly or without pain all day. When I took a look at my achilles, it was definitely swollen compared to my right foot. Furthermore, there was a slight "bump" in the swollen area about 1.5 inches up from the bottom of my foot. Just at the area of the achilles that is usually smooth. The bump was not hard or a knot or anything, but more of inflammation as far as I could tell. I could feel it and see it. I put ice on it again, and took a day off from running because I was nervous, and also because I could no longer bend my foot upwards or downwards without pain. I could also not go up on my toes without the pain intensifying. When I needed to walk places, there would still be twinges of pain and I became very scared that it felt like threads slowly tearing. Not aching pain, but always more of a "sting."
As a runner, my biggest fear is to tear or damage my achilles tendon. I am certain it is not a complete tear or anything like that. I would have felt far more intense pain. It is clearly still connected, and doing a 'Thompson Test' by squeezing the calf muscle, my foot still moves. Furthermore, I went in to see a doctor and he said that it is not torn but only examined it by touch, not with an MRI. I am currently living in Japan, and often in Japan sports related injuries are not taken quite as seriously as they are in the United States. Although I speak decent Japanese, I also cannot be sure if I was able to explain the situation as clearly as I could in English. The doctor was apparently a foot and ankle specialist, but not a specialist in sports injuries or athletes, and not accustomed to running injuries either (mostly just sprains and twisted ankle, etc.) I wanted to try to get an MRI, but in Japan (at least where I am now) because these injuries are not taken as seriously, it will be difficult for me to convince a doctor to okay it, and take at least another week. The doctor was also convinced that my achilles pain was due to twisting my ankle, despite the fact that I had no pain even near my achilles at that time or in the week after. I am sure it is possible that the events are connected to each other, but I cannot be sure. (He also said it may be an achilles "strain" or "sprain." I am not certain, but is this not the same as a small tear?) His only recommendation was rest, ice, and painkillers when necessary.
My worry is that it is a small tear. Based on all the symptoms I've experienced, they match perfectly with many of the descriptions I have read about small or very small tears to the achilles tendon. I participate in a track and field running club here in Japan, and I have taken another full week off from running already because it hurts to go on my toes or to run. And I am still scared to cause more damage or potentially worsen a tear if there is one. During this past week of rest, I have tried to keep off my feet, to do some mild stretching, and to ice as much as possible. This has helped some. The inflammation has gone down some, but tends to increase with activity such as walking or stairs. It still feels different from my right achilles tendon, and not as "smooth" as it should be. The pain is not so bad anymore while walking, but I do have trouble going up on my toes, and this brings the pain back fairly quickly.
This is by far the longest amount of time I have been forced to take a break from running (in total, about 18 days at least if I count all the rest when I twisted my ankle up until now). I take achilles injuries and pain very seriously because of my nervousness about a full tear, and how debilitating achilles problems can become. At the same time, running is a huge part of my life. I am accustomed to running every day, and I feel unhappy and am loosing hard-earned running fitness during this time. If there is a possibility that it is a small tear, than I will remain patient and do my best not to run until it is safe. I do not want to risk a full tear. At the same time, I want to get back to running and have no way of knowing when might be safe to do so.
But I would like to know if anyone thinks it is possibly a small tear, or if anyone has any other opinions? Prior to the onset of this pain, I have never had achilles pain or issues before. It all seemed to start "stinging" over the gradual course of one 50 minute run and now has stuck with me. Furthermore, does anyone have suggestions for how long I should rest and not run? Things I can do? Should I insist on an MRI? I'd like to get back to training, even if it is cautious and light training.
Sorry for the long question, but I wanted to be as specific as I could. I'd greatly appreciated advice or answers.
First, a bit of terminology. A strain is an injury to a muscle and/or tendon. A sprain is an injury to a ligament. These are usually graded I to IV. A grade I is a minor injury, mainly over stretching of the structure. Grade II is a little more significant, with some actually tearing of the fibers, but the overall structure is maintained. A grade III is a significant tear of the tendon or ligament, and can result in laxity of a joint in the case of a sprain. Grade IV is a complete rupture of the tendon (strain) or ligament (sprain). Of course, there is some overlapping of the grades, and it is a "judgment call" by the orthopedic surgeon.
So, an injury to the triceps surae tendon complex (the Achilles tendon) is a strain.
It is possible that your ankle injury has led to the problems with the Achilles. It is not uncommon for a minor injury to cause a change in the way the patient is using the limb, the biomechanics, which can lead to an "overuse" or "improper use" type of problem.
This usually causes some inflammation around the tendon and/or its sheath. Inflammation of the tendon is referred to as tendonitis and inflammation of the tendon and its sheath is called tenosynovitis. If there is not a lot of an inflammatory component, then the problem is referred to as a tendonopathy. (The suffix -itis means "inflammation of".)
Conventional treatment of Achilles tendonitis or tenosynovitis is rest, ice/heat, and the use of some anti-inflammatory medication. To take some stress off of the tendon, sometimes the orthopedic surgeon will recommend a small heel lift. Gentle stretching of the triceps surae tendon complex is very important. You do not want to over stretch to the tendon, causing more injury, but you need to maintain the necessary range of motion in the ankle joint. You have to stretch both the gastrocnemius and soleus tendons. The gastroc is stretched with the knee kept straight (fully extended) and the soleus is stretched with the knee bent (slightly flexed). So, you can do "wall leans" to gently stretch the Achilles complex: with the knee straight for the gastroc and with the knee slightly bent for the soleus.
Physical therapy can also help in recovery from an Achilles problem. Especially if the PT specializes in sports injuries. If you do go to a physical therapy clinic, be sure to select one that emphasizes recovery from athletic injuries. The physical therapist may be able to use some modalities, such as ultrasound, diathermy, hydrocollator packs, electrical stim, deep friction massage, etc, etc to assist in your recovery.
However, some sports medicine physicians feel that the "inflammation" aspect of tendon problems is overemphasized, and as a result, the NSAID medication is overused. These physicians feel that the majority of tendon problems are tendonopathies (not tendonitis or tenosynovitis). They also feel that the body will eventually heal the tendon, but it takes a long time (months). Most of these physicians' studies and opinions have been written up in the British literature.
But, with our society being the way it is nowadays, most patients do not want to take the extended rest it takes to allow the body to heal. Thus, most patients will try to speed things up some. And, that is not unexpected, since patients have invested a lot of time getting into shape and maintaining that physical conditioning.
So, again, the idea behind the NSAID medication is not for its "pain killing" property, but rather to treat the inflammation (the swelling around the tendon). If the inflammation is decreased, then the discomfort will usually decrease also.
In some cases, if the inflammation (or tendonopathy if you believe more in that) can weaken the tendon, resulting in some micro-tears within the substance of the tendon. But, these "tear" are on the microscopic level.
The discomfort in the tendon is telling you that there is something "wrong" with the tendon. It is the body's way to protecting itself. If it hurts to do something, usually, patients will decrease doing that activity (of course runners are a bit crazy). Most of the time, if you listen to your body, it will tell you that there is something wrong, or as the discomfort decreases, that things are getting better.
Of course, you do not want to decondition, while the body is healing. But, you are probably going to have to decrease the amount of running you are doing. If it hurts to run, you need to back off. You will need to do some other type of training, such as cycling or swimming (to keep your aerobic conditioning up). In some swimming pools, they have weighted vests, so that patients can "run" in the deep end of the pool. This is a common way for athletes to maintain conditioning when they have a lower extremity disorder.
Then, as the Achilles gets better, you can gradually return to jogging and running. But, you have to start low and go slow. You cannot just jump right back into running the same distance/intensity as you did before your ankle injury.
A rule of thumb that we tell our athletes, is that for every day they are out of practice, it takes two of rehab to get back to their pre-injury level. Some patients can return a bit faster, but it does take a lot of time and effort to recover from an injury.
As to the MRI, it is a bit early to recommend one. What information will you obtain that you do not already know? By examination, you know that the tendon is in continuity (intact) and that you have some swelling/edema around the tendon. The MRI cannot detect micro-tears. It can infer that there are some, by showing edema around the tendon, but again, you already know that by examination.
So, again, it is going to take some time and effort to recover from this problem. The key is to try to maintain your conditioning (through alternative training techniques), yet allow your body to heal. Rest, ice/heat, gentle stretching, maybe some NSAIDs, possibly a small heel lift, and a very gradual return to activity will usually take care of an Achilles problem. But, again, it takes time to recover from this problem and it can be very frustrating at times.
Remember, you do not want to continue to produce the micro-tears within the tendon by overusing the tendon while it is healing. If it hurts to do something, you need to back off on that activity. Pain is the body's way of telling you that something is not quite right. Listen to your body.
If the usual treatments are just not working (including the physical therapy), you will need to see the orthopedic surgeon once again. You will want to try to see an orthopedic surgeon who has subspeciality training in either foot/ankle surgery or sportsmedicine. It would be at this time, that further imaging studies (such as the MRI) might be necessary (depending upon what the examination revealed).
Thanks so much for your very helpful response! I've been following the doctor's and your suggestion of rest, icing, and gentle stretching for the past few days.
It sure has been hard not to go running, though! The track competition season is just starting here in Japan, and it's been no fun watching from the stands. We unfortunately don't have any facilities here to do the level of cross-training I would prefer (no pools, a bunch of broken stationary bikes) but I've tried to keep doing core and general strength activities that don't involve my left foot. But I'm relieved that the pain has primarily gone away, unless I try to do anything strenuous such as do too many calf lifts. It is also still weaker than my right foot. But I can walk without almost any pain, and no longer with a limp. So something must be healing.
My main worry now is that, instead of pain when I point my foot upwards or downwards, there is a "squeaky" feeling. I can't hear any noise, but I can definitely feel it. I've read that this could be that enough "lubricant" is not being produced and as a result the tendon is rubbing against the sheath? Something along those lines. It is also a warning sign of tendinitis or other tendon problems developing, correct? Even though I think I could probably run on it, I've resisted because of that "squeaky" feeling and my nervousness to do any more damage. I'm hoping that after a few more days of rest, ice, and stretching, that disconcerting feeling will go away.
Thanks again for your help! It was very kind of you to give such a good explanation.
The "squeaky" feeling is called crepitus. It actually is usually caused by the opposite of what you think - it is usually caused by there being more than the usual amount of synovial fluid inside the tendon sheath.
The swelling in the tendon sheath causes there to be extra pressure on the tendon, which can cause friction on the tendon. Of course, the friction can lead to further injury in the tendon.
So, as long as you feel the crepitus, it is probably a good idea to avoid running.
You might see if you can get some anti-inflammatory cream to rub on the Achilles tendon. The medication, along with the massaging of rubbing it in, often helps.
Sorry that you are on the side lines, it is the pits.
If your discomfort is getting better, you can try to do some long brisk walks. If the walking does not cause any discomfort, you might be able to do some walking and jogging. You sort of know the drill. If the walking causes discomfort, you back down. If it does not, go up on your activity. You keep doing this till you are back to running.
Of course, if you had access to the cross training equipment, that would really help (cycles, elliptical trainers, step climbers, swimming pool, etc). Oh well, you have to work with what you have.
Thank you Gaelic and Sousha, this was very helpful. I do not know if I have tendinitis, but my Achilles tendon has frequently bothered me after a long day on my feet. It has gotten better, but I had a lot of trouble with it when I used to dance.
Sousha, I can understand how hard it is to not go running! I had a few injuries where I had to stop dancing for a couple of months and it was miserable! Stay positive, and heal completely before you start running again to avoid being injured again. Good luck!