“The Leg Bones Connected to the, Knee Bone…” by Tendons!

October 1, 2010
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Tendons are tough, yet flexible bands of fibrous tissue that connect a muscle to a bone.  Such tendons are responsible for transmitting a muscle contraction to the bone in which it connects, invoking movement.   The most well know tendon in the body is the achilles tendon.  This tendon arises from two muscles in the posterior compartment (calf) of the leg and attaches to the heel bone (calcaneus).  When either of the two muscles from which it arises contract, the achilles tendon pulls on the heel bone and causes plantarflexion of the foot at the ankle joint (movement of the toes in a downward direction).  The tendon itself provides no contraction and ultimately no strength to the movement, but its integrity is important for normal joint functions.  Without the achilles tendon specifically, plantarflexion of the foot would be very challenging, if not impossible!  This would be the case for any joint motion, as without tendons, muscles cannot exert their pull on a bone.

Tendons can rupture (completely tear) at their “watershed” areas, typically as the tendon is bending around another anatomical structure along its path.  These areas are best described as the weakest points of the tendon due to their poor vascularity (blood supply).  Although we are not discussing tendon ruptures today, keeping these areas in mind is helpful when discussing tendonitis, as these same areas are also at a higher risk for development of tendonitis.

Tendonitis is irritation and inflammation of a tendon that is most felt by the injured individual when its corresponding muscle is being contracted.  The presence of inflammation prevents the tendon from “gliding” as it should, when attempting to transfer the muscle contraction to the bone, resulting in pain.  Inflammation within the tendon is usually secondary to over-use, and is most commonly seen in the novice individual, but can also be seen in professional athletes.  It’s the kind of injury, that although attributed to over use, the occurrence in a well-trained athlete is peculiar and has no definitive explanation other than over use!

Whatever the etiology of tendonitis in an athlete, pain and discomfort is a very real thing.  The athlete will most likely suffer from tendonitis in a tendon they use frequently (eg. tendons of the elbow’s in a quarterback; the achilles tendon or lower leg tendons in centers etc), and thus with repeated movement and contraction of the muscles to which that tendon is responsible, pain with motion in eminent.  Pain directly over the tendon and along its course into the bone, in addition to crepitus (a “crunchy” feeling) within the tendon is diagnostic for this condition.  X-rays typically will not show tendonitis, as tendons are not dense enough to show up on x-ray, however and MRI is much more sensitive for detecting the inflammation in and around the tendon.  Is an MRI necessary?  Not always, but will typically be ordered for athletes who fails to improve after several weeks of treatment.

Treatment is much the same as treatment of muscle sprains and turf toe, which we’ve reviewed the past two weeks.  RIICE: Rest, Ice, Immobilization, Compression and Elevation.  Although in this situation, rest is the most important thing.  It will give the tendon a chance to heel and for the inflammation to decrease.  Again, over the counter anti-inflammatory medications and/or tapered systemic steroids will decrease local tendon inflammation, while injections are not typically utilized for tendonitis.  Depending on the location of the tendonitis, steroid injections may be associated with an increased risk of tendon rupture.

Risk of increased pain and even rupture is associated with this type of injury if not treated properly, or if the inflammation isn’t given sufficient time to subside before a return to activity.  Therefore, a slow but important recover, with physical therapy, and most importantly rest cannot be expedited!  It may take several weeks for a return to normal activity.

As old Greek Mythology proclaims, the heel was the most vulnerable part of Achilles’ body, and thus, it was his weakness and ultimately an injury in that area that killed him.  Although this injury will not kill a professional athlete or any athlete for that matter, tendonitis in the achilles and other tendons of the body, can be painful and temporarily debilitating!

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