01 January 2010, 8am
There was a time when athletes believed that to achieve their goal, pain was the essence. Since then sport scientists and physiologists have shown that these niggling pains were likely due to microtrauma which, when left unattended, could be catastrophic.
Microtrauma is exactly what it says on the bottle, micro = small; trauma = injury, sometimes known as the “invisible injury” as more often than not there is no initial pain or soreness.
This type of trauma develops when inflammation occurs in the soft tissues due to increased mechanical load placed on them before they’ve had sufficient time to adapt to a previous abnormal load. Or the cause could be friction between the tendon, the tendon sheath and other moving parts. Sport scientists have since shown that although microtrauma is needed for the biomechanical and physiological adaptations necessary to succeed in sports, it can also lead to overuse injuries, in some cases ending in withdrawal from sport.
Sports psychologists agree that inactivity, for some long distance runners, can lead to mental depression and anxiety, especially in someone whose life is based around their training. Injury management during the first 24-48hrs is vitally important, and. research shows that treatment in the first few hours gives the best outcome.
In contrast, the implications of ignoring any sharp twinge in your achilles tendon during a training session can be calamitous. The Achilles tendon is attached to the base of the calf and inserts into the calcaneus (heel bone). It stores and generates the massive forces required to contract the muscle. That twinge or pain you experienced while running may be short and painless enough that it affords you no further irritation during your workout – so you forget about it. You wake up the next morning and as you get out of bed your calf feels a bit stiff but it releases as you walk, so you resume your regular training.
Everything still feels normal when running. Maybe you notice a little tightness in the lower calf but it wears off and still doesn’t interfere with your training schedule.
These symptoms of an underlying injury should not be ignored. With the right treatment in the early stages the problem can easily be resolved. Left unresolved, these underlying issues can lead to a frustrating array of injuries, such as:
Achilles Tendonitis: Inflammation, swelling and irritation of the tendon usually felt at the calf insertion point.
Signs and symptoms: Ache and/or pain or sharp and/or shooting pain in or under the calf muscle where the muscles meet the tendon; inflammation swelling and/or redness; stiffness in the affected area when getting out of bed
Peritendinitis: inflammation of the nourishing tissue surrounding the tendon – the paratendon.
Signs and symptoms: The Achilles tendon feels swollen, tender and painful with a crackling sensation over the area; symptoms present themselves during activity, gradually getting worse and especially after exercise; in chronic cases soft tissue X-ray but may also show thickening in Kagar’s triangle, (area between the front of the tendon and the back of the tibia).
Achillobursitis: Inflammation of the bursa located between the calcaneus and the Achilles, causing it to feel spongy. Usually caused by running on soft surfaces and/or uphill – also by low cut shoes. Any cause of friction between the Achilles and the back of the heels should be immediately removed.
Signs and symptoms: Swelling and redness/heat and tendon insertion at the heel; heel pain, worst at the beginning of exercise; limp may develop.
Tendinosis: This is chronic inflammation of the tendon leading to thickening of the tendon, reducing its mobility – which can lead to complete rupture.
The type and degree of overuse injury depends on the location of the microtrauma and the amount and duration of friction and/or overload placed on the affected tissue – as this dictates the inflammatory response within them.
For the beneficial adaptations of microtrauma to take place, inflammation and its symptoms should be addressed immediately or the opposite is true.
A reduction in training activities alone will reduce the overuse inflammation along with conservative treatment such as the R.I.C.E. technique: Rest, Ice, Compression and Elevation (i.e. putting your feet up).
Intervention and Prevention
Early R.I.C.E intervention increases the chances of a quick return to sports by reducing the effects of the inflammatory response. DO NOT IGNORE THE EARLY WARNING SIGNS. The R.I.C.E. technique is the gold standard treatment when dealing with inflammation. Each component, when applied correctly, reduces the injury time by limiting swelling and decreasing pain. Most effective treatment can be given during a window of opportunity available in the first 24-48 hours, but within the first 20 minutes has been shown to give the best results.
Prevention of overuse injuries is possible by preplanning and preparing for each training session. If your schedule requires running on a different surface, an increase in load, duration, and/or intensity, take the following necessary precautions:
i) the night before fill a disposable plastic cup with water and place it in the freezer as any changes to your training program provides the perfect condition for microtrauma.
ii) After training and a good cool down session examine the Achilles tendon by taking it between your finger and thumb and squeezing it up and down like a tube of toothpaste; any tender spots represent microtrauma.
iii) Use the plastic cup of ice to massage the tendon; concentrate on any tender spots found in your examination; don’t forget the insertion point on the back of the heel.
Massaging with ice forces circulation deep into the tissue structure and breaks down adhesions. This is great for localised microtrauma. A more effective way of treating this trauma however is an ice plunge: fill a bucket with cold water, put ice into the water and plunge each foot into the bucket, if you can take it for more than 8-10mins the water is not cold enough. Plunging flushes out the inflammation mediators and brings fresh nutritious blood to the area. This is important, as the tendon otherwise becomes vulnerable once microtrauma occurs due to its restriction of the blood supply, which reduces the supply of fresh nutrients and makes treatment difficult.