[LOWER LEG TENDINOPATHY

IN RUNNERS]

[Author: JOHANNA BRISCOE]

 [Achilles Tendonitis, Posterior Tibial Tendonitis, Peroneal Tendonitis]

The most common area of injuries for runners are the lower legs. Due to the high amount of stress that exercise causes and the repetitive motion associated with running, tendonitis can be a very common and unfortunate side effect. Tendonitis is the inflammation of and around a tendon (fibrous thick tissue that moves or stabilizes a part of the body). This essay aims to look at three different types of tendonitis - achilles tendonitis, posterior tibial tendonitis, and peroneal tendonitis - found among runners.

Achilles tendonitis is a very common inflammation that affects the distal portion of the lower leg. The achilles tendon attaches superiorly at the back of the calf (gastrocnemius and soleus) and inferiorly at the calcaneal protuberance. It is the strongest tendon of the body, and allows the foot to push off of the ground. Irritation and inflammation can build up, leading to achilles tendonitis. Common causes are linked to tight calf muscles. When the calf muscles are unable to perform their job due to extreme fatigue, the achilles must pick up the burden of the loading and landing impact forces. Compensation issues from another injury, imbalances in form, unsuited or old shoes, improperly increasing mileages, and intense hill or trail running can also lead to this type of tendonitis.

The achilles tendon is a rather small area with limited blood flow which causes symptoms to persist for prolonged periods of time. This is why it is important to not only address the symptoms, but also the root of the issue. The purpose of a 2019 study about achilles tendonitis was to determine the effectiveness of eccentric calf exercises and heel lifts for reducing pain and rehabbing the tendon. Subjects (n = 91) were randomly divided into two separate groups. The first group inserted heel lifts - orthopedic shoe inserts with a 12 mm lift - and the second group was prescribed barefoot eccentric calf exercises.

Groups performed these exercises for 12 weeks, twice everyday. Measurements were taken in the form of a survey on achilles tendonitis pain levels and improvement, with scores ranging from 0 - 100. Ultrasound tissue characterization (UTC) to measure achilles thickness, calf strength, and pain perception from treatment were also studied. These tests and surveys were conducted at the pre-trials, and then at 2, 6, and 12 weeks (with 12 weeks being the main determiner of the effects of the study) (Rabusin et al., 2019). Both approaches for treatment were found to be helpful, with heel lifts taking strain off of the achilles, and eccentric exercise rehabbing and strengthening the achilles. It was recommended to use both treatment modalities simultaneously for a more rapid recovery.

Another common form of lower leg tendonitis occurs in the posterior tibial tendon. About the diameter of a pencil, this tendon runs medially along the inside of the ankle and then attaches to the tibialis posterior muscle (responsible for plantar flexion). During walking or running, this tendon stabilizes the foot. Posterior tibial tendonitis is easy to diagnose, as the pain is always localized to the inside of the ankle. Causes have often been unclear, so a recent study looked to determine elements that contribute to posterior tibial tendonitis.

The researchers compared biomechanical factors, arch height, and ankle strength (muscles). Because this was simply a comparison study, all subjects (n = 24; 12 athletes with posterior tibial tendonitis and 12 healthy athletes - control) just had measurements taken while standing and walking of the following parameters: “arch height index, maximum voluntary ankle inverter muscle strength, and 3D rearfoot and medial longitudinal arch kinematics.” Strength of the ankle invertors, arch height (during standing), and medial longitudinal arch all had similar results between the posterior tibial tendonitis group and the control. The major finding was that afflicted athletes showed greater pronation (“demonstrated significantly lower seated arch height index (P = 0.02) and greater and prolonged (P = 0.05) peak rearfoot eversion angle during gait”) than healthy athletes. The posterior tibialis muscle is placed under increased stress by pronation, which over time can inflame the tendon, progressively creating posterior tibial tendonitis (Rabbito et al., 2015).

While less common then the previous two, peroneal tendonitis is also seen among lower leg inflammation injuries of runners. Pain is found localized underneath and around the outside of the ankle on the lateral side of the foot (oppositely located from posterior tibial tendonitis). The peroneal tendons are composed of the peroneal brevis (short) and peroneus longus (long), running parallel together along the outside of the foot (under the ankle) and up the leg. Often found in collegiate and professional athletes, the causes are linked to faster running speeds, which places a greater amount of stress on these tendons, and supination, which also commonly occurs at these quicker speeds.

This notion was supported by a study conducted in the American Journal of Sports Medicine. During running, a team of researchers monitored and looked at the differences between firing patterns of the muscles and tendons in the ankle. The subjects (n = 15; healthy runners) ran at three different paces as electrodes tracked the movement and firing patterns of the gastrocnemius, soleus, tibialis anterior, tibialis posterior, and the peroneus brevis. Significant information was discovered. When the pace sped up the peroneus brevis had a significant amplification in activity. When training at quicker paces (such as interval or track sessions), it is important to train this muscle and make sure it is working efficiently because of the extra strain it incurs (Rabbito et al., 1993).

As with most tendon injuries, they are persistent and take significant time to heal. The recovery process, especially at the chronic stage, can be long and difficult. Stretching, strengthening (resistant and proprioceptive exercises), ice/heat, and time off are recommended for most forms of tendonitis. After symptoms have ceased, it is important to include a routine that helps avoid these injuries from recurring. Warming up, gradual build ups, monitoring activity levels, and adding variety into an exercise program can help athletes, especially runners, stay healthy.

[REFERENCES]

Source 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429802/

Rabusin, C. L., Menz, H. B., McClelland, J. A., Evans, A. M., Landorf, K. B., Malliaras, P., Docking, S. I., & Munteanu, S. E. (2019). EFFICACY OF HEEL LIFTS VERSUS CALF MUSCLE ECCENTRIC EXERCISE FOR MID-PORTION ACHILLES TENDINOPATHY (the HEALTHY trial): study protocol for a randomised trial. Journal of foot and ankle research, 12,

Source 2: https://pubmed.ncbi.nlm.nih.gov/8291630/

Reber L, Perry J, Pink M. MUSCULAR CONTROL OF THE ANKLE IN RUNNING. Am J Sports Med. 1993;21(6):805-810. doi:10.1177/036354659302100608

Source 3: https://pubmed.ncbi.nlm.nih.gov/21765219/

Rabbito M, Pohl MB, Humble N, Ferber R. BIOMECHANICAL AND CLINICAL FACTORS RELATED TO STAGE I POSTERIOR TIBIAL TENDON DYSFUNCTION. J Orthop Sports Phys Ther. 2015;41(10):776-784. doi:10.2519/jospt.2011.3545