Wednesday, 2 January 2008

Intro to The Achilles Tendon

Achilles Tendonitis,

The most common tendon injury amongst dancers. The tendon is easily strained and repeated damage causes inflammation of the tendon. The difficulty is that the Achilles tendon affects almost all the foot movements of the dancer and it then becomes hard to stop or reduce further irritation or damage after the tendon becomes inflamed. . Treatment includes rest and raising the heel with a small pad such as the Heel Pop sold by Hullachan. The thicker heel padding in the new Hullachan Jig Shoes acts as a preventative. This shortens the tendon and alleviates some of the pressure. Strapping of the tendon area must be done if you need to continue to dance. This strapping allows the dancer to work but stops the tendon from over stretching in use.

History and the name:

When I speak to dancers that have serious injury, it is usually the Achilles tendon around the back of the heel that seems to be the most common of these. Around 18% of dancers get this painful condition at the back of their heels. It was called the Achilles tendon from the Greek legend of Achilles.

I know we are talking about this part of the body but I thought you would like to hear the background to this myth. It was not always Achilles’ heel that was his weak point.

Thetis was Achilles mother. She wanted him to be immortal so holding him by the heel; she dipped him into the river that runs into the underworld, The Styx. The legend goes; she held him down once and forgot to immerse him a second time holding the other heel so the magical waters of the Styx did not cover the heel. That part then stayed vulnerable and not immortal. Since the 15th century, from writers on medicine such as Ambroise Pare and others, the term, Achilles Heel, referred to a weak point, not only physically, but also mentally.

Writer, Michael Macrone, in his excellent book called, It’s Greek to Me, (Harper Collins, New York, 1991) explained that Achilles did not always have a vulnerable heel. Certainly, he had a weak spot, but according to the original story about Achilles, Homer, in the Iliad, said it was his pride. Later versions indicate his weakness was his love for the Trojan princess Polyxena. In his Metamorphoses, Ovid suggested that Achilles had a vulnerable spot on his body; but the Roman poet, Statius (c. A.D. 45-96), was the first to imply in a poem that it was his heel.

Back to the actual problem.

What is the Achilles Tendon?


The Achilles is connected to one of the strongest groups of muscles in the leg. Huge pressures build up in this area and athletes are very prone to damage in this area. The tendon we are discussing is attached to three muscles. The tendon itself is the end part of that muscle group. These are the gastrocnemius, (gast) which has two ends and the soleus muscles.

The problem is that the gast muscle crosses over three main joints. The knee, the ankle and the subtalar joint. Please let me explain a little anatomy as this really does affect you when you do Irish Dance. The foot is divided into three sections. The forefoot, the back, or hind foot and the mid foot. The back foot is the anklebone or talar joint, and the calcaneus or heel bone. The subtalar (or subtalus) joint is formed by these two main bones and why it is important for you as an Irish dancer is that it is responsible for its amazing flexibility. When you do a rocking side-to-side movement with your ankles, it is the subtalar joint that allows this.

The major part of the Achilles is in the lower part of the leg near the foot and attached to the heel bone or calcaneus. See the drawing.

Unlike other most other tendons, the Achilles is not inside a sheath and does not have a rich blood supply of its own.

Symptoms.

A sharp pain; painful heel up the back of the leg when you start to dance. The pain can subside during dancing and then return before you finish. This is the problem. You are lulled into a sense of false security. Just grin and bear it; work through the pain; deal with it?, I don’t think so!

Causes.

Achilles tendonitis can be caused by a number of factors. These can include simply ignoring any pain at the back of the leg of heel, extra classes preparing for a Championship or show, such as dancing twice a week and suddenly practicing five times a week. Breaking in a new shoe that is far too stiff, and not warming up, or cooling down properly. Fortunately, you are a body and not a machine, however, machines break and so can bodies. Be sensible and warm up correctly.

Shoe pressure at the back of the foot, tying laces around the mid foot which stops the full functionality of the foot joints, getting kicked or damaging the tendon at the heel or just above the heel area.



I was asked about this in November 2005 and the question was that 18% of ballet dancers will suffer an achilles injury at some stage in their dance life. This was my answer:

It depends on the dance discipline. In Highland Dance, around 35% of dancers will get some form of tendonitis injury and Achilles is one of the more common ones. In ballet the damage can be caused by faulty landing and twisting but the cause of achilles in dance is nearly always caused by the tapes or laces being tied too tightly around the ankle, causing compression of the sheath and subsequent damage. In Highland and Irish Dance, the damage is further caused by tying around the arch that can reduce blood flow to the extremities of the foot. The tying around the ankle is secondary here but in tandem with the arch constriction then that sets the dancer up for an Achilles or tendonitis injury. In Irish Dance, there is likelihood of around 30 to 40% chance for an Achilles or arch tendon damage if the dancer ties their laces around the arch.

This was well researched by both me and many leading dance injury specialists including work done by the famous Justin Howse who wrote the book, Dance Technique and Injury Prevention with his associate, Shirley Hancock back in 1988. Mr Howse was the senior consultant and orthopaedic surgeon to the Royal Ballet Schools, The Royal Academy of Dance and the Remedial Dance Clinic, London. Ms. Hancock was the senior physiotherapist to the to the Royal Ballet Schools, The Royal Academy of Dance and the Remedial Dance Clinic, London. I have consulted with them over the years when I was the fitter for over 150 Ballet companies all over the world. My own research in the 35 years of fitting to improve my range of Ballet shoes and to try and reduce injury which is rampant in Ballet, resulted in the creation of the Hullachan range of shoes. None of the ballet shoe manufacturers I spoke to was, at that time, willing to invest in that research to reduce injury and so I started my own company making Highland and Irish Dance shoes. Why? Well I am part Scottish and Irish and I invested everything I had to make that dream happen-at least for Irish and Scottish dancers.

Treatment for Achilles Tendonitis.

R.I.C.E. treatment is, Rest, Ice, Compression and Elevation, so please get that into play immediately to reduce the problem and do it at least three times a day over three or four days.. See a doctor as soon as you can. If your Achilles is getting less painful still continue treatment of R.I.C.E. for the next two to four weeks or until it is healed.

Reduce practice of course to about half of that you normally do. Avoid too much stretching. However saying that use correct stretching and if you do get an attack of Achilles tendonitis from your dancing, do not stretch too enthusiastically, but continue to stretch gently or if attending a doctor, follow their advice. Avoid stair, wall, incline and towel stretches. Try not contract the muscles in the initial period of pain.

If this does not show positive results, use a firm heel support or lift of no more than a quarter inch or half a centimetre. Do not use flat shoes in day-to-day use such as trainers. The idea is to relieve the pressure on the tendon so that it does not stretch too much. A good preventative part of your general warm up should be gentle calf stretches.

Do not use overly cushioned insoles in Jig Shoes or in Pumps that are too soft. Some materials feel great to start with but then collapse and become hard.

I should point out that when I designed the Hullachan Jig Shoe I inserted a special medically approved thin heel cushion covered by a firmer insole. This was not too thick and had the benefit of helping prevent heel strike as well as stopping too much depression following an Achilles tendon problem. Too much cushioning is very bad, as, after contact with the floor, the heel of the foot will sink down lower as the shoe absorbs the shock. That will then further stretch the tendon as the body moves over the foot. Too thick a heel cushion such as a rubber-cushioned insole can have the opposite effect of the preventative measures I incorporated into the Hullachan Jig Shoe. Avoid all trainers when practising if you get Achilles tendonitis.

Other problems in this area.

Heel bump may be diagnosed as Haglund’s Deformity. It can possibly indicate that the tendon is pulling away from the heel bone, or that a bony growth is caused by pressure at the back of the heel. Ascertain if there is any pain while you are barefoot and while you are wearing a shoe. The Achilles Tendon problem will be painful while you are barefoot. Haglund’s is painful while wearing a shoe but, normally, not barefoot. Heel bump, while in some cases, not too serious or indeed even painful can cause shoe fitting problems and this could mean you buying a shoe that is not the right overall fit. Width is probably the answer here. I have an answer for this but will discuss this later on.

Achilles Tendonitis Bursa,

Is where the tendon overstretches, and causes an inflammation of the bursa, or pocket of fluid that allows movement at the joint where the tendon joins the heel bone or calcaneus. Please note that this bursa can also become inflamed if pressured by your dance shoes and creates a similar condition that feels like Achilles tendonitis. The new Hullachan regular pump and Gel Toe has looked at this problem and inserted elasticised side panels to stop the heel being pressured.

Achilles Tendon 2-Growth Pains

A common pain is the severe pain behind the heel, which stems from overusing the foot and ankle in hard competitive preparation. The fibres of the Achilles tendon pull on the growth plate of the heel and create inflammation within the heel bone.

However, growth centre pain which can include Achilles Tendonitis is even more common among children who have flat feet, toe-in or have other foot problems. For these youngsters, an orthotic, a splint or soft cast is usually enough to properly position, strengthens feet and ankles, and prevents future pain and injury in their walking shoes. We can apply a suitable soft orthotic in their Hullachan Pros as well.


With prompt treatment, growth centre pain persists only a few days or weeks and usually without the need for any surgery. However untreated, growth centre injury can require long term treatment.

The notable features of growing pains includes:

1. Intensity - Usually mild, sometimes a few children complain of a lot of pain that makes them cry. The pain can be short or it can last for over an hour.

2. Frequency - Intermittent, Some children get the pains every day or at night, others once a week or so, and some get them every so often. The pains tend to occur after a child has had sports at school or attends a dance class.
When Normally, late afternoon or evening before going to bed. Occasionally the pain will make a child wake up at night.

5. Where - In the muscles but not in the ankles or knee joints. Many children report that the pain is in front of their thighs, in the calves, or behind the knee. Joints can be affected by other more serious diseases and appear swollen, red, tender, and warm. The Osgood Schlatters joint looks normal.

Other symptoms - restlessness, but usually no tenderness, redness, swelling. or fever.

Paediatricians find one symptom useful in making a diagnosis of Osgood Schlatters and that is how the child responds to being handled while in pain. Children who have pain from a serious medical disease do not like to be touched because any movement tends to increase the pain. Children with "growing pains" respond quite differently; in liking to have their legs massaged. That makes them feel better and they like to be held and cuddled.

The child's physician should be notified if any of the following occur with your child's pain: Regular pain, swelling, or redness in the joint or lower limb area, fever, limping, unusual rashes, loss of appetite, weakness, lethargy, or uncharacteristic behaviour. These signs generally do not accompany Osgood Schlatters and may be an indication of a more serious disorder.


Growing pains may seem harmless enough from an adults perspective or even a teachers perspective, but to a child, they are very distressing. Since the child seems better and is free of pain in the morning, parents sometimes suspect that the child is faking the symptom. This is generally not the case ---the pain is quite real and it is at these times that they need their parents reassurance and support more than ever! If you do not believe me, just ask your own parents! I did and it was explained to me that I too suffered this condition. Both my children have been through it as well.

These recommendations must not be relied upon as medical advice and it is not intended to replace the advice of your child's doctor.



Further research:

http://www.hullachanpro.com/achilles.htm

http://www.coretherapy.com/health_news/articles_lower_leg_injuries_in_dancers.html
http://hsc.csu.edu.au/dance/core/performance/dance_technique/prevent_injury/achilles_tendonitis.html
http://www.drnick.com/sports_med/dance_medicine/dancemedicine.asp
http://www.wheelessonline.com/ortho/achilles_tendinitis_in_ballet_dancers
http://www.shape.bc.ca/resources/pdf/MSIDanceInjuries.pdf
http://www.danceart.com/Mechanix/preventinjury.htm

Treatment:
http://www.200.com/tendonitis.htm
http://www.coretherapy.com/health_news/articles_lower_leg_injuries_in_dancers.html


General Information:

I have done research for you and you will find suitable articles here:
General Info on Retro Calcaneus Heel Pain: http://straws.com/a_retroc.htm
Retro Calc Bursa: http://www.shands.org/health/information/article/001073.htm
Surgery of RC Bursitis:
http://www.podiatry.curtin.edu.au/encyclopedia/bursa/
Heel Bone Spur: http://www.merck.com/mrkshared/mmanual/section5/chapter60/60c.jsp

General issues with Heel and Achilles injury or Trauma:
http://www.aafp.org/afp/20020501/1805.html

1 comment:

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