Runners: when you were younger, did you more often than not have days of running when you felt invincible and strong - like nothing could touch you? In fact, in many aspects you may have felt invincible, like the Greek warrior Achilles. Then, as the years have gone by, every day something new hurts and in general it feels like you body is falling apart. On your last run, the back of your heel began to ache and has been sore ever since. Should you ignore it and chalk it up to old age or pay attention to it? If it is your Achilles tendon that is acting up, runners sit up and take notice- it does not like to be ignored (much like the Greek warrior!) and it can burn you if you do.

The Achilles tendon is the largest tendon in your body and it connects your calf muscles to your heel. The symptoms are felt at the back of your leg, near the heel. The initial signs of inflammation include tenderness, swelling, pain with use, warmth, and possibly a squeaking in the tendon with ankle motion. As the symptoms progress and the condition becomes more chronic, the pain occurs with any activity especially when you rise up on your toes or when walking uphill or climbing stairs. A constant ache and ankle stiffness sets in, in particular the ability to pull your toes up. The last stage is when the tendon begins to thicken and small (often painless) nodules develop.

So, the age old question - why me?? Most Achilles tendon problems are related to overuse injuries and a combination of other factors. It is very common in runners due to the repetitive stretching of the tendon that occurs during running. Unfortunately it is also more common as we age because of degenerative changes that occur in the tendons. However, usually more than one factor is present. Anatomic abnormalities include flat feet, high arches, weak calf muscles, and tight calf muscles and Achilles tendons. Training errors include sudden increases in intensity, duration or frequency of runs, training on hard, banked or sloped surfaces, large amounts of uphill running, and finally poor, worn-out running shoes.

The most important aspect of treatment is to catch and address this early. Problems with the Achilles tendon, almost more than any other tendon, are very difficult to overcome once they have been present for a long time. These injuries certainly have been career ending for some - and none of us want that!! The initial treatment includes rest - at least 2-3 days depending on the severity of pain, ice massage in 20 minute sessions every couple of hours and nonsteroidal anti- inflammatory (ibuprofen) medications as tolerated. A heel lift can relieve tension on the tendon (but wear in both shoes). After the acute pain has subsided, begin a stretching and strengthening program - which may include physical therapy if the pain has been more chronic. While you are recovering, switch to an exercise program that helps maintain your fitness, but does not irritate your tendon (possibly swim or cycle). You may require orthotics, either store bought or custom made, depending on your foot. In severe cases, a cast may be necessary for several weeks to completely rest the Achilles tendon. Cortisone injections are not recommended for this as they may weaken the Achilles tendon and lead to tendon rupture. As with any

injury, it is important to try to discern why it occurred in the first place and make the necessary changes to prevent a recurrence!

I can not stress enough how important it is to catch and treat Achilles injuries early. Typically, the longer symptoms have been present, the longer it will take to get better. Do not return to running until your tendon has recovered and you are pain free. If you return too soon, you could cause permanent damage. So, runners, yes it stinks getting older, but if you follow these guidelines, you can beat the time clock - if only for a while!

Julie Bishop, MD is an orthopedic surgeon, who practices and runs in Columbus, Ohio. She has run multiple marathons, including Boston and NYC. She specializes in sports medicine and shoulder surgery. For more information, please visit: www.orthodoc.aaos.org juliebishop@wowway.com