Provided by Mandy Huggard of The Training Room.
Contact Mandy via email or 856-874-1166
Anatomy
The achilles tendon is the connection between the heel and the most powerful muscle group in the body, the calf. This has long been known as a site prone to disabling injury. Forces up to 12 times body weight (9kN) may arise during sprinting. The achilles tendon joins two muscles: the two heads of the gastrocnemius and the soleus. The gastrocnemius heads arise from the posterior portions of the femur above the knee. The soleus arises from the posterior aspect of the tibia and fibula (lower leg).
The gastrocnemius is a muscle that crosses three joints: the knee, the ankle, and the subtalar joint. The functioning of these joints and influence of other muscles on these joints has a significant effect on the tension that occurs within the achilles tendon. For example tight hamstrings impact the functioning of the ankle joint and increases tension in the achilles tendon.
The achilles tendon does not have a rich blood supply. It has been documented that the weakest blood supply is between 2 and 6 centimeter up from the calcaneus (heel). This is often the site of pain and thickening.
Symptoms
Achilles tendinitis is one of the most common injuries in sport accounting for 6 to 17 percent of all running injuries. It typically affects male athletes between ages 40-60 years old. Most commonly is occurs in athletes especially those engaged in a high degree of running and jumping. Risk factors can be intrinsic, including deformities such as bowed lower legs, an overly pronated foot, tight or underdeveloped hamstrings, a high arched (cavus) foot, or extrinsic such as inadequate training shoes and training techniques.
Studies have shown a spectrum of inflammatory and other changes in both the tendon proper and in its surrounding sheath, the paratenon, ranging from inflammation in the surrounding tissue only to degeneration of the tendon proper.
The diagnosis of Achilles tendonitis is a clinical one, being made from a history of pain in the tendon and the examination findings including, i.e. swelling, warmth, tenderness and loss of function. The difference between acute and chronic tendinitis is shown by the rapidity of onset of symptoms and their response to pre-activity warming-up. In the acute situation, symptoms are of rapid onset but can be helped markedly, if not totally, by warming-up exercises. Chronic tendinitis is of more insidious onset and symptoms are not helped by the warm-up.
Pathology
There is evidence that acute and chronic tendinitis are different clinical entities, probably requiring different therapeutic approaches. Acute tendonitis is a condition with a recent onset usually less then 14 days. There is often a specific run or activity that can be recalled as the culprit for the start of the pain. A true tendonitis is one where the tendon or sheath that surrounds the tendon is inflamed. This is not the situation with most cases of Achilles tendonitis.
Chronic tendonitis is actually a misnomer. This chronic condition has more recently been named Achilles tendonosis due to the lack of inflammation at the cellular level. This is more of a degenerative process where the tendon has undergone repetitive stresses and broken down as a result. Tendonosis can generally not be detected on physical examination although a thorough history will provide insight. The tendon should be examined for localized bulbous thickening that can suggest a partial tear and potential predisposition for rupture. The degeneration can be visualized through diagnostic studies such as ultrasound or MRI.
Contributing Factors
Most importantly at the onset of pain in the achilles tendon you should look closely at your training, shoes and your flexibility program.
60-70% of running injuries relate to training errors. Sudden increases in training can result in achilles tendonitis. Also excessive hill running or the start of hill running can be the cause along with the addition of speed work. Training modification is necessary to prevent further potentially long lasting injury. Backing off your runs both in quantity and intensity is critical. Listening to your pain with activity and following activity. Do not try to run through the pain.
Several characteristics of shoes have been shown to be contributory to achilles tendonitis. This includes a sole that is too stiff. This makes the achilles work harder in the push off. The other shoe design factor is excessive heel cushioning. These air filled heels allow the heel to sink lower into the shoe which put further stress on the achilles tendon. Changing shoes to ones without these features may help in recovery.
A major factor in injury is the flexibility of the posterior leg muscles including the calf and the hamstrings. Stretching should be performed as a preventative measure along with a proper warm-up prior to running.
Treatment Program
- Active rest
- Cut back mileage
- Lower intensity
- Avoid hills, speedwork, pltometrics
- Gentle stretching of gastroc and soleus
- Ice Massage
- After activity 5-6 minutes
- Nonsteriodal anti-inflammatories
- Alleve, Advil, Motrin etc 7-10 days
- Check running shoes
- Replace if heel is worn
- Replace if excessive heel shock absorption (soft air sole cushion, excessive gel ship absorption)
- Replace if shoe is excessively stiff at the “break point” (ball of foot)
- Physical therapy
- Massage
- Ultrasound
- Therapeutic exercise addressing strength, flexibility and muscle imbalances throughout the entire lower limbs
One form of exercise that has become a favorable treatment method for achilles tendonitis is eccentric training. Eccentric training is performing a negative contraction (releasing the load vs. lifting the load). Research has suggested that it probably stimulates collagen growth by means of physiologic feedback loading. More recently, eccentric training has been associated with reduction in tendon thickness, decreased pain, and restoration of normal tendon architecture. Investigators have also evaluated the correlation between good clinical results with eccentric training and a marked reduction in neovascularization of the tendon. There are some good references in the scientific literature, but this is no replacement for being on a supervised rehabilitation program from a skilled physical therapist.
References
1. Maffulli et al. Tendinopathy of tendo achillis. JBJSBr. 84 (1).p1-8.2002
2. Paavola et al. 2002Current Concepts Review: Achilles Tendinopathy. JBJS. 84-A: 2062-2076; November 2002
3. Komi et al. In vivo measurements of Achilles Tendon Forces in Man. Med Sci Sports Exer. 16:165-6; 1984
4. Biomechanical Loading of Achilles tendon during normal locomotion. Clin Sports Med. 1993: 11;521-531
5. Classification of Achilles Tendon Disease. Puddu G. et. al.. Am J Sports Med. 1976; 4:145-150
Provided by Mandy Huggard of The Training Room.
Contact Mandy via email or 856-874-1166
