Prevention Better Than Cure?
WE DO BOTH!
18 Stepney Rd,
Scarborough,
YO12 5BN
01723 363332
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Prevention Better Than Cure? WE DO BOTH!
18 Stepney Rd, Scarborough, YO12 5BN 01723 363332 |
Achilles Pain - symptoms, treatment, rehab and prevention
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Possible causes of pain in the achilles region Most common
Less common
Not to be missed
The achilles tendon is the thickest and strongest tendon in the body. It is the combined tendon of the Gastrocnemius and Soleus muscles (calf muscles). The tiny Plantaris muscle also inserts on to the achilles tendon. Those most at risk Overuse achilles tendon injuries are common in many sports especially runners. Most of these injuries occur in men with the majority being middle aged. Those who supinate or pronate have a higher risk of achilles problems. It has also been found that weaknesses in core stability (controlling the position of the pelvis) can add to the problem. You have to remember movement requires co-ordination, the sequence of body parts is called the kinetic chain. each kinetic chain has its own sequence of which the basics is proximal to distal (closest to the trunk to furthest away). Injuries and adaptations in some areas of the kinetic chain can cause problems not only locally but distally. If the core is weak the distal link must compensate for the lack of force delivered through the more proximal links. These changes can cause alterations in techniques and decrease performance. Useful tests to differentiate between problems - Grasping the muscle bulk of the calf muscles and squeezing will cause the heel to move towards the achilles, you must be relaxed it helps if someone else does this. If there is no movement the achilles may be ruptured or partially torn either way it needs further referral for a MRI scan and surgery as soon as possible. Feel the area both in a relaxed state and during static contraction (pushing against a wall so the joint does not move but the muscle is still working). A tendon injury will be less painful on contraction, if it is the paratenon this will be more sore. Use a pincer grip on the affected area and passively move the ankle through dorsi-flexion and plantar-flexion. If it is the paratenon the pain will not vary, if it is the tendon the movement will cause pain when the cystic area of the tendon is moved between the fingers. If pain is produced on passive plantar-flexion it may be posterior impingement, compare this to mid range isometric plantar-flexion which will be pain free if impingement is present. Achilles problems can take time before they are fully healed. There is limited blood supply to this area so healing is a slow process. Seeing a specialist can help you to learn how to control this condition yourself with only a few appointments necessary to keep progress and advance exercises when needed. The sooner you see a specialist when symptoms start the quicker you can get back to your sport. Prevention
Getting some orthotics made to help correct over pronation is advised especially if excessive. Using a heel raise can help off load the achilles. Make sure you warm-up fully before any exercise. Stretching is very important it helps the muscles recover and keeps muscle flexibility. Strengthening the calf muscles eccentrically can help decrease injury. Plyometrics is a form of training that can help to strengthen and prepare the achilles for explosive sports. Balance training can help improve reactions to uneven ground. Any activity that challenges your ability to balance, and keep your balance, will help what's called proprioception: - your body's ability to know where it's limbs are at any given time. Be aware of the importance of good footwear. A good pair of shoes will help to keep your ankles stable, provide adequate cushioning, and support your foot and lower leg during the running or walking motion.
References used Paul Goodyer. Techniques in musculolskeletal rehabilitation (2001). McGraw Hill. P.Brukner, K.Khan. Clinical Sports medicine. (2002) (revised 2ED). McGraw Hill. D.Morrissey. Management of achilles tendinopathy. SportEx medicine online article. |
Achilles Tendinopathy - degeneration of the achilles tendon Symptoms This typically affects the middle third of the tendon and may be accompanied by an inflammation of the tendon paratenon. Degeneration and micro tears that heal poorly results in a thickened, swollen and painful tendon which causes pain during and after exercise. Morning stiffness is a sign of ongoing inflammation. The onset of pain may be sudden or gradual but noticeable. Severity of pain can range from minor to severe. The duration can be for days up to years. Disability can be minimal able to continue to not being able to walk without pain. A tender nodule may be present and the extent of tenderness may be pinpoint extending through to several centimetres. A deep nagging ache will occur during and after running or other weight bearing activities particularly up hill. You may experience stiffness after resting in the area of the achilles and heel. Pain may be present when performing a heel raise.
Causes
Injury to the achilles occurs when the load applied either in a single episode or more often over a period of time exceeds the ability of the tendon to withstand that load. Treatment Treatments in the clinic will follow the PRICE regime if the injury is an acute episode. Ultrasound may be used if very painful to the touch, ice treatments can be soothing with gentle joint mobilistations. When inflammation has settled ultrasound maybe used to warm-up the area before applying sports massage to the site of the cyst (frictions). Massage will also be completed to the calf muscles to reduce any tightness which might be contributing to the problem. After this treatment stretching can be done, of which I tend to use PNF stretching. Some patients may benefit from further ankle joint mobilisations, to help with any stiffness present particularly dorsiflexion. As part of my treatment I will also get the patient to perform some type of strengthening exercises, these are good for taking base line measures to show improvement and also show the patient clearly what to do at home. The type of exercise included starts with simple heel raises and ankle movements until pain allows the patient to perform eccentric controlled dorsiflexion. Research shows that eccentric training to be very beneficial in treating achilles problems. This is because it results in improved muscular damping of the high forces generated by impact loading. I always use ice after to soothe the area as it can be quite a painful treatment. Many athletes will still be able to continue with their sport, but don't go berserk. Keep the session short and do a thorough warm-up before and stretching routine after. If the condition is painful stop try an alternative like swimming or cycling to off load the achilles. All upper body strength and core stability work can still be achieved. Most lower limb strengthening can also still be done but again let the injury control the intensity. To complete at home The patient must comply to a home rehabilitation programme for the condition to improve and recover. Regular use of ice post exercise for fifteen minutes repeated again after an hour is great. It will help to minimise any aggravation. Stretches will be shown and are very important. Below shows the main stretches to be completed.
(taken from SportEx medicine) Strengthening will be targeted at eccentric control for the ankle plantar flexors and also extensors of the hip and knee. Other exercises include strengthening the ankle everters and inverters to help control dynamic foot control. They also help the plantarflexors. The standard exercise used is the heel drop (pictures shown across).
Progression should only happen when the previous exercise is pain free before and after. You can expect to feel pain at the beginning of the programme and when progressing. Remember to do a good warm-up before and stretching after followed by ice. Return to full activity must be gradual. On return, a heel raise can be used to reduce the load on the achilles (in both shoes). Jogging is to be commenced gradually by 10% each week, when reaching 30-40 minutes pain free, speed can start to be implemented. Sprints and hill work should be the last types of training to be introduced. |
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Treatment protocal i tend to use - some treatments i will get the patient to
perform as a home regime. 3 x treatments per week for the first 3 weeks with no running done (instead use stationary bike or pool running as alternatives, and postural drills). During this time the patient should wear heel lifts in both shoes to reduce the stress on the injured achilles tendon. By the end of the 3 weeks the fibrous adhesions should be broken down and the painful part of the treatment plan is complete. The treatment plan has to involve factors such as pain relief (ice), increased vasodilation (massage and ultrasound), and breaking of fibrous adhesions around the tendon and sheath (friction massage). Weeks 4 and 5 should allow the tendon to recover and ultrasound together with soft tissue work administered 3 x weekly will promote healing. Removal of heel lifts is now advised in order to provide passive re-stretching of the tendon. No running should be done during this time. Weeks 6 and 7 should involve 2 x treatments per week with active stretching after home exercises. Ensure a gentle stretch of both soleus and gastrocnemius calf muscles and hold the progressive stretch for 2 minutes at a time. Begin strength conditioning by performing 20 repetitions of calf raises 3 x daily, the stretching can then follow. Complete the process by icing the area when stretching is completed. Week 8 Replace heel lifts in running shoes and begin half pace jogging for 15 minutes every other day, stretch off gently after exercise and ice. Heel lifts should only be worn in running shoes now and not during daily activities. Treatments of electrotherapy and soft tissue work should continue twice per week. A gradual increase in distance should follow over the weeks with a gradual increase in pace and if pain free the heel lifts should be removed. When heel lifts are removed during running, reduce pace and distance again to accommodate the extra stretch on the tendon. This can be gradually increased as before until back to full fitness. During rehabilitation try and avoid running up hills which may stretch and irritate the tendon. This treatment plan is only a guide and may be customized to suit different individuals but I have used this formula many times with great success. The skill of the therapist is vital in the programme and if they rely only on machines for treatment it will not be successful. A skilled hands on approach needs to accompany the electrotherapy treatments and the home exercise rehab programme has to be undertaken.
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picture
showing fusiform swelling of a partial rupture 
The
right achilles shows signs of inflammation of the paratenon. The right achilles
is shown to be much thicker 
