Today on the Doc On The Run podcast, we’re talking about Achilles tendon calcification in runners with tendinosis.
If you’re watching this because you are looking for something on Achilles tendinosis, I’m sorry, this is one of the worst things that you can get. It is a real serious problem and you have to treat it to get it better. But I think it’s helpful to understand some of the things you actually really need to treat and some parts of it that you may not really want to treat directly or you might want to really think twice before you let your doctor treat it the way that they suggest it.
The first thing is, what is Achilles tendon calcification and how does it relate to tendinosis? Well, I’m going to draw some images that may help. If you can’t read my handwriting, it’s because I’m a doctor. I always get negative comments about that. That’s okay. It doesn’t really hurt my feelings. I know it’s bad and my drawings are even worse. I’m a podiatrist, not an artist.
Here’s what we’re talking about. You’ve got the calf muscle and then of course at the bottom of your foot, you’ve got the heel and the toes and all that. So, you’ve got the heel bone sitting back here, you have the talus bone sitting on top of the heel bone, and you have the navicular and the cuneiforms and the cuboid and all the metatarsal bones that are not really so interesting for this discussion, but that’s more or less your foot. Then you have your tibia sitting on top of your talus. You have the calf muscle, which is the gastrocnemius portion that goes up above the knee and the soleus portion that starts below the knee. You have the soleus here, gastrocnemius is here, and your Achilles tendon is both of those two things.
Now, what is Achilles tendinosis? Well, that’s damage in the tendon where the fibers of the tendon that are all linear start to do a couple of things. One of them is they get thicker and they get wavy or they rupture and they contract and that takes up additional space because instead of being a straight line, it’s a wavy crooked line and it’s bulging within the tendon. You get little what feels like little lumps, little marbles. It gets a lot thicker. You start to notice that you actually have a bulge on the back of the heel because the tendon itself is actually bulging where you have tendinosis. That’s damaged collagen that actually is really a consequence of chronic inflammation that has changed the morphology of the tenocytes or the cells that actually are living and producing collagen within the tendon itself.
You can also get calcification. When you get calcification, you might get an x-ray where it shows up as this sort of this little crusty bits, where it looks like bone spurs in the tendon, and they are bone spurs within the tendon. You can also get them though where you have like little lines of calcification, very subtle that are actually in that area of tendinosis. It just depends upon the x-ray and if you change the contrast and the density and stuff on the imaging on the x-ray, sometimes you can see it.
The question though is should I fix it? The problem with these and when I do x-rays of people that have Achilles tendinosis is they see it, it looks terrible, and they feel like that’s causing the pain. They feel like they’re getting poked basically by the calcium or the spur within the tendon. That’s not really true. Now it’s true that it’s not helpful and it’d be great to have it gone. The problem is that anytime you do surgery on a tendon, we know that one thing is going to happen for sure.
You have what we call sort of cells within the tendon, then you have these exogenous cells that are outside the tendon and anytime we make an incision into a tendon sheath or the paratenon, the covering of the tendon, the tendon itself, a lot of these cells that are not supposed to be in the tendon, get in there and cause disruptive tissue. So, then you get scar tissue and it is never the same. So, if you can fix a tendon without surgery, that’s always better than doing it if it might work either way.
The first thing is that if you do surgery, sometimes when we have these and I’ve done this myself where I’ve gone into surgery and said, “well, it looks like you have a spur here and so, we’re going to go in and we’re going to cut off that spur because it causes pain when you run.” But then when we get into surgery, the x-rays a little deceptive sometimes, and even MRIs or CTs can be a little deceptive sometimes and we get in there and it’s more extensive than we thought. So, we wind up detaching your Achilles tendon and then having to clean out all that calcium stuff and then reattach the tendon and then you wake up with a cast and you’re in a cast for many weeks to try to get it to reattach and heal, so that you can actually run. That’s even more disruptive.
Most of the time though, if you can treat the tendinosis and get it to improve to where your baseline was before, then you can do really well. The problem with most runners that have this issue is they never had baseline x-rays because they didn’t have a problem before. So, you don’t actually know whether or not the calcium was in the tendon for years and years and years. This may have started when you’re running cross country in high school.
If you were running cross country in high school and you had a couple of minor aches and pains and sprains and stuff, and you pull the tendon in a little spot away from the cover of the heel, at the heel bone, when you get that basically the swelling that’s in that area sometimes it will calcify and it will get bone forming in there that you see on the x-ray later.
Now, let’s say that happened in high school. You had a little injury, you got a little calcification in the tendon, but you ran cross country all through high school. You ran in college, you’ve been running for many years and then in your forties or your fifties, you get Achilles tendinosis and some doctors x-ray say, “Oh, you’ve got this calcification in your tendon. We need to go in there and clean that all out.” Well, it wasn’t actually a problem for decades, but you don’t have any proof because you don’t have comparison x-rays from before. So, I think in most cases it’s better to try to treat this non-surgically.
Now there are cases you have to talk to your doctor. I’m not telling you don’t have surgery. Don’t go argue with your doctor because you watch some guy on YouTube, because you listen to a podcast. You want to go in with the knowledge that maybe that calcium thing is not such a problem. Sometimes if we do send you to physical therapy, for example, and we do autophoresis with acetic acid or some other treatments that might reduce that calcification, it might improve. The calcification might actually decrease a little bit.
A lot of times, if you can do some very focused stretching under the direction of your doctor or if you look at some of the stuff in the Achilles tendon course for runners, and we show you how to do some stretches that actually make the tenon more pliable, then the increased pliability in the rest of the tendon might make that part a little more tolerable and then you can get back to training without having any real issues. But you have to think about the fact that the calcium in the tendon, although it looks bad on an x-ray and no it’s not normal, lots of people have it and run normally.
If you can get back to that phase where you can run normally again while leaving it in there, but addressing the other issues with the rest of the tendon, whether that’s a PRP injection or stretching or physical therapy or whatever, that is way better than having surgery because the surgery is disruptive and the healing that has to take place after surgery, including immobilization, use of a cast, use of a fracture walking boot, those things are really, really detrimental to runners.
Make sure you understand those differences between whether or not the calcium is just sort of something that was there before, whether it’s really the true cause of your problem because in many cases, it’s not.
Now, if you found this useful, please like it, share it, subscribe to the channel and if you haven’t checked it out, go check out the Achilles Master Class. It’s a deep dive into all the things that you really need to understand about Achilles tendon injuries if you’re a runner. You can get it for free at docontherun.com/achillesmasterclass and we’ll see you in the training.