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Archived Comments for: Strained achilles tendon complicated by nocturnal dyspepsia probably caused by ibuprofen: a case report

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  1. An old Mexican saying ad hoc for this case

    MANUEL ENRIQUE ACOSTA MEZA, UMF 27 Instituto Mexicano del Seguro Social

    15 July 2008

    It was pleasant to me to read your new and personal clinical case, always very eloquent and interesting. I am simply putting in your consideration a very old Mexican saying , ad hoc for this case, “Always remembers that it is not the same the three musketeers, that fifteen years later”.

    Best wishes

    Competing interests

    Competing interest none

  2. Return of my ache

    Richard Smith, Cases Journal

    4 August 2008

    Three night ago I went for a run on Clapham Common, something I do regularly, and after my run--of about 3km--the ache in my Achilles heel returned. It wasn't anything like as bad as after I ran in Bethesda, but it was bad enough to give me a slight limp for 12 hours.

    I wonder if this is something that I'm going to have to live with for the rest of my life, whether it will be bad if I run further, whether it might disappear, and whether anything cane be done about it. I'm sceptical that medicine has much to offer--but maybe I'm wrong.

    Competing interests

    I'm the original author of the case, the patient, and the editor in chief of Cases Journal.

  3. Run to death!

    Monappa Hegde, Retd. Vice Chancellor, Manipal University, India

    4 August 2008

    Dear Richard,

    I have not been able to understand why human beings, in the name of fitness, run while they are made by nature only for walking. The four legged animals are made to run as they have a secure centre of gravity. We still have got similar knee joints to those with four legs. May be, million years from now our knee joints might mutate to let us run if people keep running. Each time we run our centre of gravity falls outside. To prevent that the ligaments around the most unstable knee joint get undue strain while the joint cartilage might get damaged. The same happens to the ankle to a lesser extent.

    I wonder if there is any one who keeps running regularly but still has normal knee and ankle joints, Achilles tendon being a part of that ankle mechanism. Almost all sports persons have had ankle and knee problems.

    Despite all these people keep running, goaded by the billion dollar running outfit industry's advertisements. The metabolic end product, at the end of the day, remains the same whether one runs or walks-body weight into distance run (walked). If one wants to get the same effect one has only to spend more time walking compared to running. The only benefit seems to be saving time. That too, periodic running might be still more dangerous!

    I have written about it extensively elsewhere and there is a good editorial by George Burch, the then editor of American Heart Journal, entitled "Run to death". Vigorous sports and running stimulate the cyclic AMP even in a heart muscle cell that is tired and might even push the cell to initiate VF-runner's sudden death. The motivation to run might suppress the breathlessness due to early pulmonary oedema which might not register in the thalamus-substrate competition!

    NSAIDs, irrespective of their class, induce dyspepsia either symptomatic or otherwise. Pain needs a pill; the latter might thrill but could, potentially, kill! NSAIDS are the leading cause of ADRs. If you stop running what could help you most is hot fomentation, using warm saline for deeper penetration of the heat, daily twice to stimulate new blood vessels to grow to help heal the sprained tendon coupled with adequate rest to the tendon. Nature heals; we only dress the wound!

    Teleologically, why not try to understand nature and follow her rather than go against nature using our acquired knowledge, most of it being only information which, in fact, is full of noise where an occasional signal gets drowned in the noise all around!

    Yours ever,


    Competing interests




    4 August 2008

    Dear Richard:

    I sincerely think that there is hope in your case, however you must take this condition seriously, and seek the expertise of a professional sports medicine physician.

    Achilles tendon overuse injuries are commonly associated with strenuous physical activities such as running with non systematical preparation (eventual running). The occurrence of Achilles tendon overuse injuries is highest in middle-and long-distance running. Many terms have been used to describe the Achilles tendon disorders. Because of the highly confusing terminology for Achilles tendon disorders, it was recently recommended that the clinical syndrome, characterized by a combination of pain and swelling in and around the Achilles tendon, accompanied by impaired performance, should be called Achilles tendinopathy. Tendinopathy can be divided into peritendinitis and tendinosis (tendon degeneration), and these entities may coexist in the same painful tendon.

    Among the Achilles tendon disorders, the most common clinical diagnosis is tendinopathy (55–65%), followed by insertional problems (retrocalcanear bursitis and insertional tendinopathy) (20–25%). The remaining cases are partial tears, previously undiagnosed complete ruptures, and various peritendinous problems.

    As in your case, the most common symptom of this disease is the pain-induced limitation in sports and related physical activities. Normal daily activities are usually less compromised, depending on the severity of the condition, but in chronical phases, exercise-induced pain is still the cardinal symptom, whereas in the worst case the pain and discomfort may become constant, occurring even during light walking.

    This repetitive exposure to pathologic strains (4–8% of strain) injures the tendon at the microscopic level (microtears) and tend to make this condition chronical.

    You must seek attention for this condition, since it has been reported that this chronical condiction may precede Achilles tendon rupture, even without strenuous exercise.

    I am hoping you take my humble advice and leave the worrying for someone else, and take care of yourself.

    Best wishes

    M Enrique Acosta Meza Nuñez

    Competing interests