What is a watershed

A watershed is not a garden water feature despite its name!
It is defined in the merriam-webster dictionary as “a crucial dividing point, line, or factor”.

Achilles Watershed

The Achilles watershed area is the area where there is a decrease in blood supply in the tendon
between 3 and 6 cm up from the attachment to the calcaneum.
The blood supply is meant to come down from the musclotendinous junction at the top,
and up from the bony attachment to the heel at the bottom.
This is represented in the diagram opposite by the blue arrows.

The area in the middle (pink) has a lower supply – the Achilles watershed area – where most ruptures take place.

This was first described in 1959 by Lagergren & Lindholm who examined the blood vessels supplying the Achilles Tendon.

This was taken on a stage further by Carr and Norris in 1989 who injected a dye into the vessels of cadavers. They concluded “there was a reduction in both the number and mean relative area of vessels in the mid-section of the tendon.”

In 2000 Stein, Laprell, Tinnemeyer and Petersen used radioisotopes to measure the intra-vascular volume of the human Achilles tendon and concluded “When the tendon was divided into three regions, we found the lowest intravascular volume in the middle region (3–6 cm above the tendon insertion).”

All of these studies used cadavers and the average age of the cadavers was early 70′s!
There is a decrease in blood supply to the Achilles Tendon with increasing age so perhaps these subjects
are not the best for the projection of results onto a fit and healthy population of athletes.

Blood flow in chronic Achilles tendinopathy disputes Achilles Watershed Area

Aström in 1994 measured blood flow and reported a significantly lower tendon blood flow at the insertion (bottom end), but otherwise even vascular distribution – no Achilles watershed area in symptom-free individuals.
More recently in 2008 an article by Knobloch stated “we found that in symptomatic tendinopathy neovascularisation is associated with a significantly increased capillary blood flow in the Achilles tendon at the point of pain” This means that there is an increase in blood flow at the mid-portion area of the Achilles tendon when painful.

For the ANSWERS – click on the BLUE TEXT LINKS

1. Have I got an Achilles Tendonitis Injury?

What are the symptoms of Acute and Chronic Achilles Tendonitis. What is the difference between Insertional and Mid-Tendon Achilles Tendon Injuries?  These Videos will help you decide.
Click Do I Have an Achilles Tendonitis Injury?

2. Painful Achilles Tendon – How do I get rid of the pain?

How you get rid of Painful Achilles Tendons depends on how recent the injury is.
Advice is given for Acute Achilles Tendonitis including what activities to substitute for running, how to apply an Ice Block massage. Different advice is given for Chronic Achilles Tendinosis.
Click Painful Achilles Tendon – How do I get rid of the pain?

3. When can I get back to running with Achilles Tendon Problems?

How long have you had the pain in your Achilles? Less than 4 weeks? More than 4 weeks?
Have you had the Achilles pain before? Can you do 3 sets of 15 reps of the Eccentric Calf Exercise and be pain-free?
Your answers to all these questions are important…. 
Click When Can I Start Back Running with Achilles Tendon Problems?

4. Do I need to change the way I run or my running shoes?

New Running Style for Achilles Tendonitis? Does your running style predispose you to Achilles Tendon injury? Find out here by watching a cool video analysis of before and after re-training.
New Running Shoes for Achilles Tendonitis? It is recommended that you change your shoes every 300 to 500 miles. If your shoes are past this mileage they may not be providing the support and control that they did initially. It may also be that the shoes you currently use are not best suited to your foot type and style of running.
Click Do I need to change the way I run or my running shoes?

5. Will rest cure Achilles Tendonitis or do I need surgery?

My advice for what it’s worth would be to not undergo surgery until you have completed at least 8 weeks of Eccentric Calf Exercises and show no lasting signs of recovery. But read the article and make our own mind up!
Click Will rest cure Achilles Tendonitis or do I need surgery?

6. What is Achilles Tendonitis?  

Achilles Tendonitis (or its other spelling – Achilles Tendinitis) is an acute flare up of tissues around the tendon.
It is not that common! It is short lasting – only a few days.
Achilles Tendinosis however is a very common injury. It is a chronic degenerative condition lasting for ever!
It’s a bit like a puppy – not just for Christmas but for LIFE!
Click What is Achilles Tendonitis?

7. What treatment options have I for Achilles Tendonitis pain?

DIY Injury Rehab, Physiotherapy, Orthotics, Injections, Shockwave Therapy and Surgery are all discussed.
Click Achilles Tendonitis Treatment Options

8. Why do I have a painful swelling in my Achilles Tendon?

With Achilles Peritendonitis / Peritendinitis / Paratenonitis it is the tissues immediately surrounding the Achilles Tendon that become inflamed. With Achilles Tendinosis there may still be thickening of the tissues surrounding the tendon but in addition there are areas of local breakdown of the internal structure of the actual tendon itself. This can produce lumps or nodules that can be felt through the skin.
Click Lump on Achilles Tendon

9. How did I get Achilles Tendonitis?

Classically the main causes are associated with overuse. Other factors that can predispose a runner to Achilles Tendonitis problems are discussed.
As are Medical conditions associated with an increased risk of Achilles Tendonitis.
Who gets Non-Insertional Achilles Tendonitis and Insertional Achilles Tendonitis?
Click Causes of Achilles Tendonitis

10. How do I stop it coming back?

If you have most of these symptoms then you almost certainly have Achilles Tendonitis Injury / Tendinopathy.
There are a few other problems such as sciatica and local nerve irritation that may give you similar pain but you will not get the localised swelling in the tendon.

There is one other type of Achilles Tendinosis that does not produce a thickened Achilles Tendon

Insertional Achilles Tendonitis / Tendinosis

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This depends on your Doctor.
The pain of Achilles Tendinopathy is not from the degeneration changes in the tendon but apparently from new blood vessels and their nerve supply. These new blood vessels appear as part of the repair process.
It is thought that doing eccentric exercises may help to minimise the formation or even perhaps reduce this neovascularisation (new blood vessel growth).

The surgery strips away the paratenon which surrounds the Achilles Tendon and the surgeon may also remove any dead (necrotic) tissue and calcification in the body of the tendon. By removing the new blood vessels and their nerves the pain is diminished.

My advice for what it’s worth would be to not undergo surgery until you have completed at least 8 weeks of eccentric exercises and show no lasting signs of recovery.

Find out more about Achilles Tendon Surgery at Surgical Repair of Achilles Tendon Rupture

Does Rest Cure Achilles Tendonitis?

Rest will settle the pain of Achilles Tendinopathy.
Settling the pain is not the same as a cure!

If you haven’t done it yet read Achilles Tendonitis – What Is It?

Rest will allow the inflammation to calm down but you will still have the tendon degeneration taking place.
Type-III collagen is laid down which can’t handle the stress of running.
So as long as you don’t want to exercise properly again – rest up!

Answer

NO! NO! NO!
You need to exercise properly and stimulate repair that is strong and lasting.

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Achilles Tendonitis or Achilles Tendinosis?

Achilles Tendonitis (or its other spelling – Achilles Tendinitis) is an acute flare up of tissues around the tendon and is short lasting – only a few days.

Achilles Tendinosis is a chronic degenerative condition lasting for ever!.

It’s a bit like a puppy – not just for Christmas but for LIFE!

Once you’ve got it I’m afraid to have to tell you that you’ll never be without it!

However that doesn’t mean that you have to stop running or exercising – in fact quite the opposite but I’ll come back to that later.

Achilles Tendinitis

Tendinitis or paratenonitis is an inflammatory reaction in the body of the Achilles Tendon itself or more commonly in the paratenon that can surround the tendon.
The inflammatory response is a reaction to micro tears and this produces pain and swelling locally in the paratenon and surrounding soft tissue structures such as an associated bursa. The bursa is a small fluid filled sac found at the base of the tendon as it attaches to the heel bone.

Achilles Tendinosis

Tendinosis is non-inflammatory condition which is as a result of degenerative changes in the structure of the tendon. These degenerative changes produce thickening of tendon and compromise the integrity of the tendon itself.

Normally there is a constant cycle of breakdown and repair in the tendon but now due to chronic inflammation of the paratenon this has led to more “breakdown” than “repair”.

In the repair phase the collagen fibres (the main fibres of the tendon) that are laid down are not of a good enough quality and strength to produce effective healing.

If you were to examine a tendon at this stage, you would see varying amounts of dead tissue, small tears running along the length of the tendon and perhaps calcium deposits in the tendon. All of this weakens the tendon and makes the possibility of rupture more likely.

Recovery

The good news is that recovery is possible.
In severe or persistent cases it may be necessary to have surgery to strip the paratenon off and clear away the dead areas and remove the calcified areas in the tendon before starting on a rehab program.

The key to recovery is relative rest – that is avoiding the activities that were aggravating the problem in the first place WHILE starting activities that promote stronger and more effective healing.

Exercises that progressively load the tendon produce the correct type of collagen fibres in the repair phase which in turn produces a stronger and healthier tendon. [Find out more here]
Remember however that when you stop exercising that the degenerative process still continues. As you take a break and do nothing your tendon gradually weakens and it will not be able to withstand the same forces when you start back.
This happened to me a few years ago. I had rehabilitated my tendon well and built up to running a few half-marathons. I took 3-4 weeks off due to increased work commitments and my Achilles pain came back within a mile when running downhill!!
So be warned keep doing your exercises when you stop running.

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