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Computer Graphics	The Achilles Tendon The achilles tendon was never made for sport. But treat it right, give it a rest and it will last you a sporting life-time. The achilles tendon connects the calf muscles to the tip of the heel and transmits their contraction as downward flexion at the ankle, producing heel thrust. The two main causes of achilles tendon injuries are excessive movement and mechanical overloading of the tendon. Achilles injuries are very common in sport, especially in longer distance running and the greater the time spent or mileage run, the greater the risk of injury. it is well known among runners that the harder the surface, the higher the breakdown rate. One may often help an athlete who does a large mileage on roads by asking him to do rather less on a softer surface such as grass and thus relieve symptoms. A third cause of achilles disability is inappropriate sports footwear. For instance, stresses on the unpadded heel, such as jumping with heavy landings, cause jarring and injuries from impacts. Badly designed footwear may rub directly upon the low calf muscle or achilles tendon itself in ski or football boots which press sharply into the back of the leg rather than provide well spread cushioning, or by such features as the built up heel tab seen on many running and training shoe. This tends to press upon the lower achilles tendon at the point of least blood supply, thus causing local inflammatory response to the mechanical friction being applied. Tight shoes may press on the heel itself where the achilles joins the he el bone so that the achilles or the bursa (connective tissue sac) may become inflamed. Also, one of the causes of achilles injuries being surface impact stress, clearly it is an advantage in footwear design to incorporate sole protection both as shock absorbing material, and as heel raise to reduce the movement of the achilles and the stretching forces on it in each landing or take-off. There are two sorts of injury - the ruptures and the inflammations. For practical purposes, the ruptures feature a sensation of "snapping" or "breaking" in the heel cord which is quite unmistakable. In its worst form, the achilles rupture may be total, the patient is unable to stand up on his toes and is aware of gross weakness in the thrusting part of the take-off movement because the heelcord does not transmit the pressure which the calf muscle is trying to apply. This, in the athlete, requires surgical repair as recovery cannot in a reasonable time scale provide sufficient mechanical strength for athletic activities. In recent years, sub-total rupture of the achilles has been recognized and in this case there is usually a "snap" but the main bulk of the achilles tendon is clearly still present. Recovery is either non-existent or, in athletic terms, so slow without operation that again, an operation is required to clear the debris from the partial tear and, if necessary, to patch up the damage by adequate stitching or grafting of new tendon material to make up the deficiency. The inflammations are common injuries and consist of achilles tendon pain, usually coming on in relation to sporting stress such as a change of shoes, or surface or training regime. In the milder stages there is nothing to find except a little pain on touching the achilles tendon firmly and this settles with a few days of rest. A useful tip is to wear a pair of heel pads in all the shoes all the time. Training should obviously be modified considerably and a safe guide is that if there is pain then there should be no training. More severe cases tend to be associated with a creakiness and swelling in the tissue around the back of the heel, often with morning stiffness, plus much tenderness on touching the achilles tendon. This requires more rest and if there is not substantial improvement within 7 to 10 days of rest and simple heel padding, expert advice should be sought without further delay. Physiotherapy can sometimes be symptomatically helpful. Ice, heat, ultrasonic therapy and massage have all claimed some success, but the cardinal feature has to be mechanical relief, i.e. rest, from the mechanical stress causing the breakdown. At this stage there may be a place for steroid injection of the tissues around, but not into, the achilles tendon, but this is not lightly undertaken by the inexperienced. Sometimes the achilles inflammation simply does not settle down adequately with any of these treatments and plagues the athlete till he is finally brought to a halt with his symptoms. At this stage an operation can remove the scar tissue surrounding the achilles tendon and relieve the pressure on it, thus allowing the restoration of free movement and full function. It should now be unusual for an athlete to terminate his career because of achilles tendon pain.