Figure 1.: The Calcaneal Bursa Sacs, picture from WebMD
The Achilles tendon is a rather avascular (lacking blood) thick tendon that is made up of two of your major back side calf muscles: the gastrocnemius and the soleus. The tendon attaches into a part of your heel bone, the calcaneus, and this part is called the calcaneal tubercle. We have to major bursa sacs (bursa sacs are pockets that only fill with fluid when they are inflamed), the subcutaneous calcaneal bursa and the retrocalcaneal bursa (see figure 1 right). The subcutaneous bursa seldom presents as an issue, but the retrocalcaneal bursa can be a major headache.
Some people who engage in sports that create repetitive use injury of the ankle, such as running, biking and other endurance activities, will overuse the Achilles tendon and this will rub the bone behind it. Rubbing the bone causes it to create more bone to strengthen the area being rubbed. When this occurs, the newly laid down bone (many times called a pump bump) will push into the bursa and irritate it. The bursa then gets swollen as it fills with fluid. If the problem is identified early and the causative agent removed, then the bursa can heal. Sometimes, though, the bursa does not heal and this, too, can calcify and become hard. Should the bursa heal, the issue still remains as what to do with the bony protuberance. Sometimes, it is surgical situation and sometimes it is not. It is a case by case basis. Some people try to train through the Achilles pain by getting therapy, changing shoes, getting orthotics, etc. Although many times this approach helps to reduce irritation of the bursa, still,if the bone is already greatly enlarged, there can still be an issue going forward.
Figure 2.: This is what retrocalcaneal bursa sac inflammation looks like, picture from epainassist.com
Another common problem we see with the Achilles tendon is pain due to abnormal loading as a result of ‘tight’ muscles. Remember, we mentioned that the gastrocnemius and soleus make up the Achilles. Well, if those muscles are too tight, which they usually are, that places additional stress on the Achilles tendon. This additional stress can eventually cause tearing of the tendon. More than just being ‘tight’, the muscles become facilitated. This means that not only are they tight but they also have neurologically forgotten how to stretch. This is a more difficult issue to correct as the brain needs to be involved in the correction and treating the problem only by stretching will not fix it. A properly trained sports rehabilitation doctor knows what to do in regards to implementing the proper techniques necessary to reduce Achilles pain, restore function to the region, and minimize the likelihood of Achilles injury going forward.
As a side note, many people and physical medicine practitioners alike will say that stretching the Achilles will help with plantar fascia (bottom of foot) problems. Well, there isn’t too much to substantiate this. The Achilles attaches onto the calcaneal tubercle and the plantar fascia has its proximal attachment on the medial calcaneal tubercle. Obviously, these are different points. There is fascia that connects these two points but the question arises as to how much effect stretching the Achilles has on the plantar fascia and is stretching the plantar fascia such a good idea in the first place being plantar fasciitis is a stretch injury…eh, we’ll leave that discussion for another blog!
