PDFFriction: a major cause of problems
Shoes or boots which press or rub against the Achilles tendon can cause pain, because the tendon’s blood supply is very poor just above ankle level, about three inches above the base of the heel.
Sports and leisure shoes are the worst offenders. The high heel tab has been modified since its introduction in the early 1970s, but it is still almost impossible to find correctly designed sports shoes. Almost all impinge on the Achilles tendon above the ankle.
Normal shoes for adults and children don’t have such obvious high backs, but they are often higher than they should be. Boots with stiff seams above ankle level can also irritate the tendon. High heeled shoes with high backs are a real killer.
How do you recognize the problem?
There is a specific pattern to the symptoms of Achilles friction syndrome. The tendon feels very stiff, especially first thing in the morning when you get out of bed or after sitting still; it is exquisitely tender if you squeeze the tendon between finger and thumb (this is the “pinch test”); it may become thickened; tellingly, the pain wears off if you walk around in slippers or barefoot; but recurs if you walk or run in shoes which touch any part of the sensitive tendon.
What’s the damage?
Achilles tendon soreness may cause tendinitis, inflammation in the tendon itself, or peritendinitis, inflammation in the paratenon (a tissue which covers the tendon). There may be minor tears or degeneration in the tendon. Swelling in the paratenon can look like a lump, and is usually an accumulation of tissue.
Is it curable?
Yes. The damage to the tendon or paratenon will usually recover with time and treatment. Even if the pain has been severe, it’s not usually necessary to have surgery to mend or clean up the tendon or paratenon. It’s important to identify the cause and any contributory factors. Where shoes are the cause or a factor, you have to modify or discard them. You will have to do exercises for the tendon itself, and to correct any biomechanical imbalances affecting your legs.
Is it really my shoes?
It can be difficult to understand the relevance of shoes to the problem, especially if only one tendon is affected rather than both, or if you’ve worn the same shoes for some time without problems.
When you walk, high shoe backs drive into the Achilles tendons. In sprinting, skipping, hopping or jumping, the pressure on the tendons is more forceful. Mechanical imbalance between the two legs may dictate that only one Achilles tendon suffers from the irritation. The dominant foot may point downwards more, making the heel-tab pressure greater. Either leg may suffer if there is excessive pronation (rolling inwards) or supination (rolling outwards) motion in the foot, bowing inwards or outwards at the knee, or inward or outward rotation in the hip.
New sports shoes can cause problems if the heel-tabs are higher or more rigid than your previous ones. Old, worn-out shoes lose height and shock absorbency in the heel, which may affect the mechanical efficiency of the Achilles tendons, and can bring the heel-tab into contact with the tendons’ most vulnerable area. Shoes which make your heel over-pronate or over-supinate can stress the Achilles.
Non-sporting activities can also lead to the friction syndrome, if your shoes press against the Achilles tendon when your foot points downwards. This can happen when you drive a car, or sit with your legs outstretched and ankles crossed, or in walking or running up stairs on tiptoe.
Who suffers?
Anyone of any age who wears shoes is vulnerable to the Achilles friction syndrome. I have known it happen to children as young as 18 months.
Too many young people nowadays have thickened, sensitive Achilles tendons. Even if they don’t have noticeable pain, it means their tendons are vulnerable, and can easily become painful at any time.
I am often asked why the Achilles friction syndrome does not happen to everyone, if the problem of poorly designed shoes is that widespread. If you wear shoes with high backs, your Achilles tendons are at risk, and it is simply good luck if they never become sore or thickened.
How can we identify the problem?
You need to bring all your shoes with you when you see your practitioner. Make sure you can describe exactly what kind of pain or other symptoms you have. The following functional assessment tests will show if you have the friction syndrome. Other tests will be done if it seems that other factors might be involved. These tests will not be done if it is likely that you have a tear in the Achilles tendon. The practitioner will select the shoes most likely to be troublesome for the tests.
1. The practitioner checks for visible thickening, swelling and tenderness in or around the affected tendon.
2. When you stand still, first in shoes, then barefoot, is there any pain in the affected Achilles tendon(s)?
3. Barefoot, you go up and down on your toes a few times. Is there any pain? If so, is it present as you raise your heels or when you lower them, or both ways? If there is pain in both directions, is it worse going up or down?
4. In shoes, you repeat test 2. If there was pain barefoot, is it worse or better in shoes? Is it painful in shoes but not barefoot?
5. Standing on one leg, barefoot, bend your knee keeping your heel flat, then straighten your knee and go up on your toes; then lower your heel and bend your knee again; repeat this set of movements six times without pausing. Is there pain on any part of the movement?
Treatments
In my experience, gentle massage is the most effective way to ease the tender Achilles tendon and restore its pliability. The area to be massaged may be extended to include the soleus and gastrocnemius muscles if they have become tight. If the patient has developed inco-ordination at the knee through limping, I use electrical muscle stimulation for the vastus medialis obliquus to improve stability and prevent secondary knee problems. Hip mobilizing techniques and remedial exercises may be needed if the hip is stiff.
Shoe correction is crucial to the success of the treatment. The backs of sports shoes can be cut down in various ways to prevent impingement on the Achilles tendons. Vertical slits on either side create a loose flap, or the backs can be cut off entirely. Day shoes and boots may need shock absorbing heel cushions to raise the heels in the shoes. Old shoes or those which cannot be corrected have to be discarded.
Shoes or boots which press or rub against the Achilles tendon can cause pain, because the tendon’s blood supply is very poor just above ankle level, about three inches above the base of the heel.
Sports and leisure shoes are the worst offenders. The high heel tab has been modified since its introduction in the early 1970s, but it is still almost impossible to find correctly designed sports shoes. Almost all impinge on the Achilles tendon above the ankle.
Normal shoes for adults and children don’t have such obvious high backs, but they are often higher than they should be. Boots with stiff seams above ankle level can also irritate the tendon. High heeled shoes with high backs are a real killer.
How do you recognize the problem?
There is a specific pattern to the symptoms of Achilles friction syndrome. The tendon feels very stiff, especially first thing in the morning when you get out of bed or after sitting still; it is exquisitely tender if you squeeze the tendon between finger and thumb (this is the “pinch test”); it may become thickened; tellingly, the pain wears off if you walk around in slippers or barefoot; but recurs if you walk or run in shoes which touch any part of the sensitive tendon.
What’s the damage?
Achilles tendon soreness may cause tendinitis, inflammation in the tendon itself, or peritendinitis, inflammation in the paratenon (a tissue which covers the tendon). There may be minor tears or degeneration in the tendon. Swelling in the paratenon can look like a lump, and is usually an accumulation of tissue.
Is it curable?
Yes. The damage to the tendon or paratenon will usually recover with time and treatment. Even if the pain has been severe, it’s not usually necessary to have surgery to mend or clean up the tendon or paratenon. It’s important to identify the cause and any contributory factors. Where shoes are the cause or a factor, you have to modify or discard them. You will have to do exercises for the tendon itself, and to correct any biomechanical imbalances affecting your legs.
Is it really my shoes?
It can be difficult to understand the relevance of shoes to the problem, especially if only one tendon is affected rather than both, or if you’ve worn the same shoes for some time without problems.
When you walk, high shoe backs drive into the Achilles tendons. In sprinting, skipping, hopping or jumping, the pressure on the tendons is more forceful. Mechanical imbalance between the two legs may dictate that only one Achilles tendon suffers from the irritation. The dominant foot may point downwards more, making the heel-tab pressure greater. Either leg may suffer if there is excessive pronation (rolling inwards) or supination (rolling outwards) motion in the foot, bowing inwards or outwards at the knee, or inward or outward rotation in the hip.
New sports shoes can cause problems if the heel-tabs are higher or more rigid than your previous ones. Old, worn-out shoes lose height and shock absorbency in the heel, which may affect the mechanical efficiency of the Achilles tendons, and can bring the heel-tab into contact with the tendons’ most vulnerable area. Shoes which make your heel over-pronate or over-supinate can stress the Achilles.
Non-sporting activities can also lead to the friction syndrome, if your shoes press against the Achilles tendon when your foot points downwards. This can happen when you drive a car, or sit with your legs outstretched and ankles crossed, or in walking or running up stairs on tiptoe.
Who suffers?
Anyone of any age who wears shoes is vulnerable to the Achilles friction syndrome. I have known it happen to children as young as 18 months.
Too many young people nowadays have thickened, sensitive Achilles tendons. Even if they don’t have noticeable pain, it means their tendons are vulnerable, and can easily become painful at any time.
I am often asked why the Achilles friction syndrome does not happen to everyone, if the problem of poorly designed shoes is that widespread. If you wear shoes with high backs, your Achilles tendons are at risk, and it is simply good luck if they never become sore or thickened.
How can we identify the problem?
You need to bring all your shoes with you when you see your practitioner. Make sure you can describe exactly what kind of pain or other symptoms you have. The following functional assessment tests will show if you have the friction syndrome. Other tests will be done if it seems that other factors might be involved. These tests will not be done if it is likely that you have a tear in the Achilles tendon. The practitioner will select the shoes most likely to be troublesome for the tests.
1. The practitioner checks for visible thickening, swelling and tenderness in or around the affected tendon.
2. When you stand still, first in shoes, then barefoot, is there any pain in the affected Achilles tendon(s)?
3. Barefoot, you go up and down on your toes a few times. Is there any pain? If so, is it present as you raise your heels or when you lower them, or both ways? If there is pain in both directions, is it worse going up or down?
4. In shoes, you repeat test 2. If there was pain barefoot, is it worse or better in shoes? Is it painful in shoes but not barefoot?
5. Standing on one leg, barefoot, bend your knee keeping your heel flat, then straighten your knee and go up on your toes; then lower your heel and bend your knee again; repeat this set of movements six times without pausing. Is there pain on any part of the movement?
Treatments
In my experience, gentle massage is the most effective way to ease the tender Achilles tendon and restore its pliability. The area to be massaged may be extended to include the soleus and gastrocnemius muscles if they have become tight. If the patient has developed inco-ordination at the knee through limping, I use electrical muscle stimulation for the vastus medialis obliquus to improve stability and prevent secondary knee problems. Hip mobilizing techniques and remedial exercises may be needed if the hip is stiff.
Shoe correction is crucial to the success of the treatment. The backs of sports shoes can be cut down in various ways to prevent impingement on the Achilles tendons. Vertical slits on either side create a loose flap, or the backs can be cut off entirely. Day shoes and boots may need shock absorbing heel cushions to raise the heels in the shoes. Old shoes or those which cannot be corrected have to be discarded.
Other commonly used treatments
Electrotherapy modalities such as ultrasound, diadynamic or interferential therapy are often used for symptom relief.
Some doctors inject the paratenon, usually with hydrocortisone. If done inexpertly, injection carries a strong risk of so-called “spontaneous” tendon rupture, which may happen several weeks later.
If the tendon covering has become badly inflamed and thickened, surgery might be recommended to strip the damaged material away. This type of operation is not an instant cure, but may need a long period of rehabilitation.
In all cases, if shoes have been a factor in the problem, treatment will fail if the shoes are not corrected or replaced by more suitable ones.
Recovery
Providing you have corrected your shoes, recovery can be immediate, if the tendon has not been badly irritated. It may take a few weeks if there is severe thickening and soreness. When you have no pain on repeating the assessment tests, you can safely get back to normal activities and sports. There may still be thickening around the tendon, but this need not hinder your activities, if you take care to keep the tendon and calf muscles fully functional.
If the Achilles tendon pain persists, it means that you are still using shoes which are causing irritation, or there are other complicating factors, such as circulatory problems, referred pain from the hip region, inflammation or infection which need to be identified and treated.
Self-help measures
You have to be suspicious of all shoes, correct those which are causing harm, or throw them away.
When you buy new shoes of any kind, always look at the backs and make sure they do not impinge on the tendon above the ankle when you point your foot down. If you buy sports shoes with high backs, choose those which you can cut back easily.
Make sure your shoes are flexible, so that they do not impede your foot movements. Use heel cushions to improve shock absorption and to raise your heels slightly in your shoes. If possible, wear backless shoes or sandals with a properly moulded sole (not flip-flops). If you wear high heels during the day, do stretching exercises and wear flat shoes whenever you can.
You can massage your tendon yourself, but do it gently to avoid further damage. Arnica or heparinoid cream can help the local circulation. Ice massage using an ice cube for about 10 seconds at a time helps to stimulate the blood flow. Remedial exercises are essential to make the tendons pliable and efficient.
After recovery, if you do sport, you must warm up and warm down thoroughly. If you ever notice the warning signs of early-morning stiffness in the Achilles tendon, check the shoes you were wearing the previous day, and modify or discard any which are causing irritation.
Always maintain good posture and circulatory flow, remembering, of course, to drink plenty of water every day.
Preventive help for the young
It is possible to prevent Achilles friction problems from ever happening to a child or young person, if you choose all their shoes with care, making sure any high backs are cut down, and using heel cushions when necessary.
I don’t pretend this is always easy. Sports shoes and school shoes are designed to fit an image rather than feet. Youngsters may protest and rebel against the idea of cutting down their brand-new “high-tech” sports or leisure shoes in defiance of fashion. Making the shoe-cutting fun by creating a little ceremonial ritual for it can help to minimize the perceived pain of the operation.
Remedial exercises for Achilles tendon soreness
Through active stretching and strengthening of the Achilles tendons and calf muscles, you will regain painfree function. You may need to do other leg exercises from the list of core leg exercises as well if you have biomechanical imbalance.
Avoid pain: any exercise which causes a painful reaction is probably harmful. I have not included passive stretching of the calf in this list, because that is mainly for the calf muscles, not their tendons, and it is too easy to over-stretch and cause irritation.
Do the exercises for both legs, with more repetitions on the injured side if only one tendon is affected. If you find any of the exercises difficult to do, start with only a few repetitions, and gradually build up. Quality of movement is much more important than quantity. Always stand close to a support, in case you over-balance. Relax between repetitions, and exercises, or if you feel any strain.
It’s always a good idea to do general exercises for the legs, trunk and arms for overall body condition while you recover from any injury. In the later stages of recovery, you can do sport-related exercises and training, always within pain limits.
These exercises are specific for the Achilles tendons and calf muscles:
1. Stand on one leg and hold your balance. 3-5 times
2. Stand on both legs, go up on your toes and slowly lower your heels to the ground, keeping your knees straight. 5-10 times
3. On two legs, go up on your toes and squat down as far as you comfortably can. 3-10 times
4. On one leg, bend your knee as far as you comfortably can, then straighten it fully. 3-10 times
5. Stand on one leg and go up and down on your toes, keeping your knee slightly bent. 5-10 times
6. Stand on one leg, go up on your toes and slowly lower your heel to the ground, keeping your knee straight. Relax completely and repeat the movement with control 3-10 times
7. Stand with the balls of your feet on the edge of a step, lower your heels to stretch the calf muscles gently. Hold the stretch for a count of three, then go up on your toes. Repeat 5-10 times
8. Stand on one leg, bend your knee, straighten your knee and go up on your toes keeping your knee straight, then bend your knee again and repeat the cycle of movements continuously 3-6 times
9. Stand on one leg on the edge of a step, drop your heel a little way to stretch the calf muscles gently, then lift your heel to go up on to your toes, keeping your knee straight. Repeat 3-5 times
