Achilles Tendon Problems
The Achilles tendon is the thickest and strongest tendon in the human body. It is a non elastic, fibrous tissue that attaches the calf (gastroc and soleus muscles) to the heel bone (calcaneus). The primary function of the Achilles tendon is to transmit the power of the calf muscles through the foot to allow for push off when the body is being propelled forward. It also plays an important role in absorbing significant ground reactive forces associated with running and jumping. It is a very powerful tendon however under certain circumstances it can become weak and susceptible to the following injuries.
Achilles tendonitis is an inflammatory condition with a characteristically abrupt onset over a short period of time and often is the result of a specific injury or change in activity. Typically it is described as a sharp pain just above the heel bone which commonly will occur at the start of exercise which will subside as the exercise continues as the tendon “warms up”.
- A sudden increase in the frequency or intensity of an activity
- Less recovery time or loss of recovery time between aggravating activities
- Improper footwear or change in training surface
- Uphill Running
- Weakness of the calf muscles, specifically eccentric strength
- Loss of ankle joint range of motion
- Overpronation- foot instability can often result in compensatory foot overpronation which places more stress on the Achilles tendon
If treated promptly, Achilles tendonitis is generally short lived. The following recommendations and treatment interventions often facilitate its resolution.
- Orthotics: The implementation of orthotics either “off the shelf” or custom made to rectify overpronation and alter the biomechanics of the ankle and foot are often very beneficial in the treatment of Achilles tendinitis
- Footwear: An athletic shoe that isn’t appropriate to your foot type can be the cause of your symptoms particularly in runners. A knowledgeable specialist can evaluate your shoes and watch you walk or run to ensure that they are a proper fit for you.
- Activity Modification and Rest: Use pain as your guide. Avoid aggravating weight bearing activities and replace them temporarily with swimming and or cycling to allow the tendon relative rest. Complete rest should be avoiding since the Achilles tendon requires loading to heal.
- Ice: Icing your Achilles tendon for 10-15 minutes several times per day will reduce the inflammation characteristic of Achilles tendonitis.
- Medication: Your doctor may prescribe over the counter or prescription anti-inflammatories to reduce inflammation.
Calf stretching- Stand in a lunge position with the leg to be stretched behind your opposite leg, facing the wall. Place your hands on the wall. Lock the knee of the leg to be stretched and keep your heel on the ground. Lunge forward until a stretch is felt in the calf. Hold 1 minute, repeat 2-3 times. To stretch the other calf muscle, the soleus, keep this position but allow the knee of the leg to be stretched to bend. Lunge forward again until a stretch is felt in the calf. Hold 1 minute, Repeat 2-3 times. Alternatively, drop your heel off a step or stand on a slant board to also stretch the calf holding for 1 minute, repeating 2-3 times.
Eccentric strengthening of the calf muscles- Stand on the top of a step on your tip toes with your knee straight, slowly lower the heel down until it is past the level of the step. Repeat 10 times, 3 sets.
Achilles tendinopathy is a completely separate condition. Achilles tendinopathy is a degenerative, not inflammatory, condition. It most often occurs in athletes generally between the ages of 35 and 45 and is degeneration and micro tearing in and around the tendon commonly caused by overuse and repetitive activities such as running. Achilles tendinopathy is often misdiagnosed as being Achilles tendonitis and therefore individuals with this condition are often treated improperly. When treated properly and and within the first 6 months of onset at a clinic such as Atlanta Sports Medicine the best outcome is often achieved.
- Decreased flexibility of the calf muscles
- Diminished Blood Supply to the Achilles tendon
- Age- Achilles tendinopathy is more likely to occur in individuals between the ages of 35 and 45.
- Body Weight and Height
- High arches or pes cavus deformity
- Ankle Insatability
- Foot Overpronation- A lateral heel strike when running which will cause compensatory overpronation placing more strain on the Achilles Tendon
- Improper footwear
- A change in training techniques
- Poor running form
- Prior Injuries
- Change in training surfaces
Assessment and Diagnosis
Currently the assessment tools of choice for diagnosing Achilles tendinopathy are Ultrasound and MRI. Both diagnostic tools are able to visualize the affected area and determine the degree of tendon degeneration. A grading system is commonly used to describe the degree of injury. Grade I is normal, Grade II is an enlarged tendon, and Grade III is an enlarged tendon with diffuse degeneration and microtrauma throughout. Grade III tendons are at a much higher risk for tendon rupture. Dr. Ched Garten,a staff physician at Atlanta Sports Medicine, is highly trained in the use of Ultrasound Imagery in the diagnosis of pathological conditions of tendons such as Achilles tendinopathy.
- Orthotics- Either off the shelf or custom, orthotics are advocated to improve the biomechanics of the foot and ankle to help alleviate undue stress to the Achilles tendon
- Footwear- wearing an athletic shoe appropriate to your foot type is instrumental in preventing and treating Achilles tendinopathy
- Activity Modification and Rest- Avoidance of aggravating activities or modification of activities to allow for relative rest of the Achilles Tendon are important in the treatment of Achilles tendinopathy.
- Heat- because Achilles tendionopathy is not an inflammatory condition it will respond to heat as opposed to ice. Apply moist heat to the affected area for a maximum of 15-20 minutes 2-3 times a day. If sensation in this area is compromised avoid heat to avoid burning.
Calf stretching- Stand in a lunge position with the leg to be stretched behind your opposite leg facing the wall. Place your hands on the wall. Lock the knee of the leg to be stretched and keep your heel on the ground. Lunge forward until a stretch is felt in the calf. Hold 1 minute, repeat 2-3 times. To stretch the other calf muscle, the soleus, keep this position but allow the knee of the leg to be stretched to bend. Lunge forward again until a stretch is felt in the calf. Hold 1 minute, Repeat 2-3 times. Alternatively, drop your heel off a step or stand on a slant board to also stretch the calf holding stretch for 1 min, repeat 2-3 times.
Eccentric strengthening of the calf muscles- Leading research indicates that loading the Achilles tendon eccentrically can help facilitate healing. Stand on the top of a step on your tip toes with your knee straight, slowly lower the heel down until it is past the level of the step. Repeat 10 times, 3 sets.
Deep friction massage to the Achilles tendon has been shown to be highly effective for the treatment of Achilles tendinopathy accompanied by static stretching to restore normal flexibility of the affected tissue
Ultrasound- Ultrasound can be useful in increasing blood flow to the tendon allowing for collagen remodeling and tissue remodeling.
Dry Needling– Dry needling is an invasive procedure which can be performed by three of Atlanta Sports Medicine’s physical therapists where in a solid, very thin needle (similar to an acupuncture needle) is driven into the muscle with the goal of illiciting a local twitch response. The procedure is highly effective in reducing muscle tightness by targeting myofascial trigger points.
- PRP– New research supports the use of Platlet Rich Plasma in the treatment of tendinopathies including Achilles Tendinopathy. During this procedure, which can be performed at Atlanta Sports Medicine, the patient’s own blood is drawn and placed in a centrifuge to collect platlet rich blood. The harvested blood is then injected directly into the Achilles Tendon at the area of degeneration. The thought is that plasma cells enhance tissue repair processes and stimulate the body’s release of growth hormone. PRP has been found to be very effective in the treatment of Achilles tendinopathy.
- Surgery- If conservative treatment lasting at least 6 consecutive months, surgery may be indicated when there is a gross loss of function and disruption in the individual’s quality of life. The goal of surgery is to remove any adhesions or degenerative nodules within the Achilles tendon to restore normal blood flow and to stimulate cells to resume the healing process.
Achilles Tendon Rupture
Rupture of the Achilles tendon occurs when a stretch or load to the Achilles tendon is beyond its physiological limits. The tendon rupture can be either partial or complete and is most often the result of a traumatic injury during a sport related activity. Rupture of the Achilles tendon is one of the most devastating injuries which the competitive and recreational athlete can suffer. Overall it is not as common an injury as, for example, tendonitis of the elbow, but it is much more difficult to treat in the higher levels of competitive sports. Although it is not entirely avoidable, there is much that can be done to reduce your chances of suffering such an injury.
The tendocalcaneus (Achilles tendon) is the thickest and strongest tendon in the human body and it is non elastic and fibrous. It is approximately 15 cm long and begins in the mid-aspect of the calf and extends distally (towards the foot) to its insertion on the heel bone (calcaneus). It originates from three separate muscles which join together to form the strong muscular group which is responsible for pushing the foot downward to provide the push-off which propels the body forward during locomotion. Rupture often occurs in individuals involved in sports that require sudden bursts of pivoting, jumping and running such as squash and basketball.
The classic history of the injury is that it usually occurs in males, although it certainly occurs in females as well, and these individuals are often the weekend warrior type. It most commonly affects people aged 30-50 but can cross all age groups. The classic history is a sudden onset of pain in or just below the calf with the report of a direct blow sensation and inability to walk. If an Achilles tendon rupture is suspected, play should be suspended and immediate medical attention found.
In the non athletic population, the Achilles tendon becomes weak and thin from disuse making it more vulnerable to injury in older individuals. In addition, the use of certain medications and certain medical illnesses can make the Achilles tendon more vulnerable and susceptible to injury.
The medical and surgical treatment of an Achilles tendon rupture is often debated. Depending on the degree of tear (complete or partial) the individual is either immobilized in a cast or walking boot or scheduled for surgery. With either intervention, there is a long period immobilization of up to ten weeks followed by a prolonged course of physiotherapy. The physicians and physical therapists at Atlanta Sports Medicine are highly skilled in the treatment of Achilles tendon rupture. Surgical repair is beneficial ruptures occurring in the more distal, lower, aspects of the Achilles tendon which are closer to the insertion on the calcaneus (heel bone).
For the competitive athlete, an Achilles tendon rupture can be a career-ending injury despite prompt and vigorous surgical or casting treatment. Although the athlete is able to recover, they rarely attain the high level of sport which they were at prior to the injury.
It is obvious that the best thing to do with the injury is to avoid it in the first place. This can be done very simply with stretching exercises prior to the workout. All stretching exercises, whether they are done for the Achilles tendon or for any other muscle group in the body should be done slowly and carefully without any bouncing. The affected area should be put on a stretch just to the edge of discomfort but still comfortable. The stretch should be held for 1 minute and repeated two to three times prior to working out for the best results to be obtained. Doing so promotes flexibility protects the tendon from injury. Stretching should be part of every athletes warm up to prevent this devastating injury.