Monday, 13 February 2017

Achilles Tendonitis: The awkward “ACHe in the Achilles”!

That really puts the ache in the Achilles!

The Achilles tendon is the largest and strongest tendon in the body. The Achilles tendon is responsible for absorbing shock when subjected to loads and it takes the load before the rest of the body does. The tendon is attached to the heel bone and the calf muscle which helps to push the foot off the ground when moving. The tendon begins on the heel bone and attaches into the middle of the calf. Most runners and sports players are susceptible to Achilles tendon injury due to the high stress and repetitive loads during running and jumping.

Achilles tendinosis


Sever’s disease is heel pain in adolescents because of growth spurts. The heel bone grows quicker than the Achilles tendon, which results in a tight tendon. Over time, repeated stress and impact on the tendon causes the tendon to pull on the growth plate, resulting in inflammation. This condition can resolve with just rest, however some sports massage and kinesiology taping to the calf muscle can help with recovery.

Tendinosis is degenerated tissue whereas Achilles tendonitis is inflammation of the tissue. The difference between the two is tendonitis lasts for a few weeks or less, tendinosis is more chronic. Research has shown that when there is constant and chronic pain, the tendon is degenerative (tendinosis), with thickening, scar tissue and possibly partial tearing. The pain may be in the lower part of the calf, spread along the tendon or at the lower part of the tendon where it attaches to the heel bone. There is pain with activity and when starting to walk after periods of rest.



The main causes are:
  •         Amount of mileage ran
  •          The alignment of the foot (high arch, low arch)
  •          Rotated Pelvis (normally longer leg would reveal thickened Achilles because of impact)
  •          Tight calf muscles and muscular imbalance between calf and shin muscles.


Tendons have a longer healing time compared to other tissues because of their poor blood supply. So, going out running or playing sports and adding repeated amounts of stress on the tendon is going to slow this healing down. Therefore, it is important to rest from these repetitive activities and high impact sports because it will cause more thickening and scar tissue to form. Instead, try low impact aerobic exercises like the cross-trainer, rower or the stepper to help maintain fitness.

60% of athletes benefited from an intensive, heavy load eccentric heel drop exercise routine alone (Maffulli et al, 2008). Therefore, the heel drop exercise will be an integral part of the rehab program for treating tendon pathology. Eccentric loading promotes a greater reduction in Achilles tendon thickness immediately after exercise (Grigg et al, 2009). Most studies show that eccentrically controlled exercise is better than concentric exercise for the recovery of tendons. The 12 week program consists of 3 sets of 15 heel drops with the knee straight and the knee bent. Watch the video below to find out how to perform this exercise.



The treatment is very clear and successful but there can be several other causes contributing to Achilles tendon pain, especially when the pain keeps coming back. It could be poor calf and/ or foot strength, poor movement patterns, unfitting footwear or weakness in the glutes. The glutes eccentrically control foot pronation, if the glutes lack control, it means increased pressure on the Achilles. Nothing works in isolation. Your glutes AND hamstrings help to extend the hip. All muscles and fascia work together to create movement. But if something goes wrong e.g. if your glutes do not extend the hips, the calves will do the movement instead.


TOP TIPS

  •         Wear a brace if walking is difficult and painful.
  •         Avoid repetitive exercise and sports to allow time for tissue healing.
  •     Ice and Heat program (for acute tendonitis).
  •          Gentle calf stretching, including gastrocnemius and soleus (early phase).
  •          Get some sports massage on the calf muscle and cross friction massage to the tendon (later stages, after inflammatory phase).
  •          Foam rolling to the calf muscles (there is a trigger point in the lower calf that can refer pain into the Achilles).
  •          Start the eccentric heel drops to help regenerate and improve the blood flow to the area.



References:

Maffulli N, Walley G, Sayana MK, . Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil 2008; 30: 167784.

Grigg NL, Wearing SC, Smeathers JE. Eccentric calf muscle exercise produces a greater accute reduction in Achilles tendon thickness than concentric exercise. Br J Sports Med 2009; 43: 2803.

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