The Pump Bump and Achilles Tendinitis

She was the goddess of water in Greek mythology. Both Zeus and Poseidon loved her and did their best to win her hand in marriage until Prometheus warned them of a prophecy that her son would become greater than his father. She married a mortal king instead, and dropped their son into the river Styx to make him immortal – holding him by the heel of his foot.

I had exercised patience regarding the time required to recover from a dislodged peroneal tendon, but when the swelling subsided and I could no longer move the tendon around with my finger there was still a hard bump on the back of my heel. Even relatively easy exercise made it sore. It was time to visit the doctor.

My husband and I sat quietly while the doctor examined my heel. As he left to order the x-ray he mumbled something about a pump-bump. My husband immediately took to his phone and by the time the good doctor returned he had discovered everything there was to know about Haglund’s Heel.

Dr. Haglund was a friend of Dr. Roentgen, the inventor of the x-ray. Haglund began researching the boney anatomy of humans for his dear friend, and came up with a fairly common deviation of the heel bone, which became known as Haglund’s Heel (also Hagulund’s Syndrome or Deformity).

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This deviation is associated with decreased range of motion of the ankle and increasing age, typically hitting women in their 40s, 50s, and 60s after years of wearing high heel shoes. Jumping, running and navigating stairs can exacerbate the condition making inflammation and heel pain worse. It develops gradually, but we usually take notice when the tendon becomes inflamed. In many cases, especially with runners, Haglund’s Heel evolves into Achilles tendinitis.

Insertional Achilles Tendinitis is a common overuse injury among athletes causing stiffness in the heel especially in the morning, pain along the tendon that increases with activity and possibly swelling. A bone spur gradually develops around the tendon that can cause irritation (bone tends to generate new bone in an attempt to heal itself), and eventually the tendon may calcify and harden.

7A184A2D-7D55-4E29-9737-E6D2D4A2A7B6Note: Insertional Achilles tendinitis affects the back of the heel where the Achilles tendon inserts into the heel bone. Non-insertional Achilles Tendinitis causes pain in the lower calf, where the Achilles tendon and calf muscle meet.

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Male and female athletes alike can develop insertional Achilles tendinitis with or without the underlying Haglund’s Heel, but in many cases Haglund’s Heel will trigger or evolve into insertional Achilles tendinitis.

Why it hurts: When a healthy tendon experiences an increased load, it responds by increasing its stiffness to handle the greater demand as it also increases the production of collagen cells. Researchers propose that this non-inflammatory cell response is an attempt by the tendon to increase the cross-sectional area to better handle the load. This short-term adaptation is reversible if the load is diminished or the tendon has a chance to rest before the next stress is applied. Over time a healthy tendon adapts to the stress by growing larger and stronger. An overused or diseased tendon does not recover from the stress and the injury progressively worsens.

The Progression:

Tendinitis is inflammation of the tendon (the suffix “itis” indicates inflammation), in this case of the Achilles. The condition lasts about six weeks although most practitioners view tendinitis as the first in a continuum of tendon injuries that subsequently increase in severity (you’ll also see it spelled tendonitis). If you feel pain in your heel, this is the time to take action.

Tendinosis is a non-inflammatory degeneration of a tendon that can include changes to its structure or composition. These changes often result from repetitive micro-traumas or failure of the tissue to heal and will likely require several months of treatment.

The suffix “pathy” is derived from Greek and indicates a disease or disorder. Tendinopathy is the term also applied to a chronic condition that fails to heal. For example, a runner who has suffered a hamstring tendon rupture that does not heal properly may be diagnosed with tendinopathy.

Insertional Achilles Tendinopathy is inflammation, and later, degeneration of the tendon fibers that insert on the back of the heel bone. Since the Achilles tendon connects the calf’s gastrocnemius and soleus muscles to the calcaneus, or heel bone, by the time you’ve reached the Achilles tendinopathy stage you will likely also notice reduced strength in the calf muscles.

Treatment: The Achilles’ tendon is exposed to greater amounts of strain in the dorsiflexed or upward position where the forward section of the tendon is exposed to low loads. Researchers suggest the lack of stress on this forward aspect of the tendon may cause that section to weaken and eventually fail. The treatment goal of insertional Achilles tendinitis is to strengthen the forward-most aspect of the tendon, which is accomplished through a series of eccentric exercises.

The Alfredson Protocol: The story goes that Hakan Alfredson, an orthopedic surgeon and professor of sports medicine in Sweden, developed Achilles tendon problems in the mid-1990s. When his boss refused his request for surgery because the injury was not yet advanced enough, Dr. Alfredson attempted to deliberately aggravate the injury with a series of exercises. Instead of getting worse, however, his injury disappeared.

These exercises, now known as the “Alfredson protocol” are considered the most effective first line of treatment for Achilles tendinopathy. The eccentric movements are designed to physically stimulate the cells in the tendon as they move relative to each other, causing the cells to initiate a tissue repair process.

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Stand on your toes at the edge of a step (holding onto something for balance). Slowly lower the injured foot until the heel drops below the edge of the step. Return to the starting position (on your toes) by using the non-injured foot. The injured foot should never be used to raise onto your toes.

Perform 2 sets of 20 reps with the knee straight, which strengthens the gastrocnemius muscle, and another 2 sets of 20 with the knee bent to strengthen the soleus muscle. Repeat the exercises twice daily for 12 weeks. If the effort become too easy, add weight to increase the load.

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(The original protocol called for 3 sets of 15 reps with the knee straight and another 3 sets with the knee bent for a total of 180 reps daily.)

Note: as with everything science, there is a corresponding study that found no difference when performing the heel drop using a straight knee only, and performing the exercise from both the straight and bent knee position.

Compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy

Another study published last year involves a 3-prong approach combining the eccentric exercises mentioned above with compression band therapy, or CBT, and Lacrosse Ball Management (basically massaging the tendon using a lacrosse ball).

LBM: Once daily apply firm but comfortable pressure with the lacrosse ball while rotating the ball over the tendon.

The CBT process: Firmly wrap a floss tape around the Achilles tendon as well as the gastrocnemius and soleus muscles starting at the heel (using a 75-90% stretch) and finishing just below the knee. (In the referenced study, a black Theraband© was used.) Perform a ‘flossing motion by slightly shifting weight forward and backwards over the back foot and ankle in a standard soleus stretch position. Perform 3 sets of 10 reps daily.

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I’ve followed the exercise and massage protocol for 4 weeks (although I will admit that I have performed the flossing motion without the band). After not running one step for several months (because it hurt), I ran three times last week with no pain during or after the run. My results have been similar to the results achieved by the test subject at this same interval in the study. At the study’s nine month follow-up, the test subject was exercising up to nine hours each week with no pain. It would be premature for me to claim victory over this injury, but I am cautiously optimistic.

Read more:

Athlete’s Edge: Achilles Tendinopathy

A-Kills-Me Tendon and a Peroneal Mess

The best laid plans often go awry, and I still don’t understand why it needs to be that way. My husband always advised that we should prepare a good plan, and work the plan. If you have a good plan and stick with it, according to his playbook, success is inevitable. My training plans could surely challenge that theory, or perhaps I’ve yet to establish a good plan?

Twenty-eighteen appeared to be the first year we would not be remodeling a house, and I was going to put the extra stress-free time to good use. I spent several weeks researching the most effective way to design a full-year training program, and documented my plan on this blog. Enter the awry part.

It was late February when I noticed my calves were tight. I even mentioned it to my husband. But life gets busy. We forget to stretch. Muscles get tighter, and they take other major body parts down with them.

My Achilles’ tendon got all out of sorts, and finally I started stretching. Except this irritable tendon became inflamed by the sudden attention and swole in disgust.

Not one to give in to a rant from Achilles, I ran through the pain until it settled down and left me alone. It’s a known fact we will almost always lose a battle with overuse injuries. ”Overuse” is not the true source of our ailments anyway. Training error accounts for most of our problems, which makes the question from the first paragraph all the more apt.

Of course, I continued to train through the pain. If I could just survive a minute or two of being uncomfortable, I could run for as long as I wanted pain free.  But the damage was still being done, and it should come as no surprise that eventually things went from bad to worse.


Achilles’ tendon issues will usually diminish when tight calves are resolved. Even if the tendon settles down, it will flare up again if running is resumed when the calf muscles remain tight. The key is to stretch the calves without over-stretching the Achilles.

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Courtesy: Epainassist.com (includes Achilles’ tendon stretches for recovery)

In my case, the peroneal muscles also became tight. This caused pain in the peroneal tendons that run behind the outer ankle bone. Injury of these tendons include tendonitis, tears and subluxation – the latter of which is not pretty in the least.

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DocPod.com

Peroneal injuries are caused by injury/trauma to the ankle, such as a sprain, or from overuse of the tendon (training that does not include sufficient periods of rest). Having high arches also puts you at greater risk for peroneal injury, and could lead to developing a degenerative tear.

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My full-year training plan has been re-worked. Running has been replaced with long walks, and the strengthening phase began last week instead of next month. I have succumbed to a massage that helped relax the calves and the peroneal muscles – something my husband had suggested in early March. The swelling is slowly subsiding, but the tendons remain tender to the touch. This has clearly been a peroneal mess of my own making.

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The Normal Variation: A Lesson on Morton’s Toe Syndrome

I have been equipped with two narrow feet, high arches and a fairly neutral foot strike. I have also been given Morton’s Foot and Morton’s Neuroma.

The “condition,” Morton’s Foot or Morton’s Toe Syndrome, is caused when either your first metatarsal (the bone which the big toe attaches to) is either shorter than the second metatarsal bone or is not stable; has too much mobility. A functionally shortened toe behaves just like a structural short leg, unbalancing the pelvis by dropping one hip lower. Physical stress from the abnormal posture can cause tiny knots in the muscles of the lower leg and calf, which cause similar pain as Achilles tendinitis and plantar fasciitis, among other ailments.

imageAlthough many people associate the condition to having a longer second toe, it is entirely possible to have Morton’s Toe without the presence of a longer toe. It is the bone of the first toe being shorter that causes the problems regardless of the length of the second toe.

Dr. Dudley Morton (1884–1960) was the first to identify the problem and a solution, the toe pad. He was granted a patent for the toe pad in 1932. Maybe like you, I had never heard of this before.

Thru out history the long 2nd toe was referred to as a “Roman Or Greece Foot.” Before Dr. Morton ever wrote about the long 2nd toe in the 1920’s it was written about for some time in various places. One of the most interesting of these publications is the U. S. National Park Service pamphlet about the Statute of Liberty. In it, the history of the Roman and Greek foot, and the Morton’s Toe is given in regard to the feet of the Statue of Liberty. Fredric Bartholdi, the sculptor, was influenced by his classical training and gave the Statue of Liberty the Roman/Greek Foot.

My first knowledge of Morton’s Toe came about as I was training for my first marathon. My toes kept going to sleep or going numb. A little research finally revealed Morton’s Neuroma, a condition that may occur as a result of irritation, injury, pressure – such as from wearing tight fitting shoes, or repetitive stress. Bingo. Runners get all the “repetitive stress” issues.

Morton’s Neuroma manifests itself between the third and fourth toes most commonly and results in numbness or tingling around these toes or sometimes a sharp, burning pain in the ball of the foot.

Somehow my research led me to the conclusion that one vitamin B-12 tablet each day would alleviate this condition….and it has completely. Once in awhile at the peak of training I may feel a pain in the ball of my foot but nothing a little rest or massage doesn’t alleviate.

But now I’m realizing there is more to learn from Dr. Morton, unfortunately.

In addition to the pain sent to the ankles and Achilles tendons, Morton’s Toe is claimed to be the culprit for everything from knee, hip, lower back and neck pain to fibromyalgia. Most distressing to me was that it is also possible it causes stress fractures of the metatarsals.

What I have considered to be overuse and training errors explaining my numerous stress fractures over the years, may actually be the result of how God made me: a normal variation in the structure of the human foot eventually named by this man, Dr. Morton.

Its ok. Imperfect doesn’t mean incapable.

If you are one of the roughly 25% of the population who have Morton’s Toe Syndrome or 80% of the population that may have an elevated first metatarsal, check out some of the websites below for more information.

http://www.triggerpointbook.com/mortons.htm

http://www.footcare4u.com/mortons-toe-what-is-it-what-causes-it-how-to-treat-it/

http://injuryfix.com/archives/mortons-neuroma.php

http://www.mortonstoe.com/index.html