What is an Achilles tendon injury?
The Achilles tendon starts from the back of the heel bone (calcaneus) & runs upwards to calf muscle. A tendon attaches a muscle to a bone. The achilles is the insertion of the calf muscle into the heel bone.
Problems with the Achilles tendon are common in runners and are frequently aggravated after a sudden or rapid increase in exercise intensity or distance. It commonly occurs in novice runners who lack the tendon & muscle development to withstand the sudden increase in loading.
While most people refer to this condition as Achilles tendonitis (itis meaning inflammation), it is now recognised that the condition is not inflammatory in nature & therefore the term Achilles tendinopathy is now applied to the condition.
It can be difficult to differentiate between an Achilles tendon injury and a partial Achilles tendon tear. Most athletes will encounter Achilles pain at some point during their career; most of us can recall developing such Achilles pain at some stage in our lives.
Causes of Achilles tendon injuries
As discussed, the latest research is moving away from viewing Achilles tendon overload injuries as being inflammatory in nature. It is now thought that changes take place at a cellular level in the tendon and that these changes may take place due to lack of loading capacity or strength in the calf & achilles. Also poor movement patterns and control as high up as the hip and trunk region are critical factors in managing and preventing achilles pain.
Once it is understood that Achilles tendon overload is not an inflammatory process then it is also clear that rest is not the answer to addressing an Achilles Injury.
Rest is, however, vital in cases of Achilles tendon rupture & so obtaining an accurate diagnosis is vital in order to guide appropriate management
Achilles tendinopathy commonly develops in athletes who perform repetitive running or jumping activities. It may come on suddenly if a rapid increase in exercise intensity takes place or may occur gradually over several months.
With an Achilles tendon injury, early intervention is vital to prevent progressive worsening of the pain. Deterioration is likely to occur as long as the underlying cause of the condition remains unaddressed.
Prolonged pain after waking in the morning is an indicator of a condition that has deteriorated significantly.
Common causes of Achilles tendinopathy:
- A sudden increase in training load
- Training on a hard surface or recent change in surface
- Poor running technique
- Poor muscle balance & control
- Inadequate footwear
Treatment of Achilles tendon injury
The longer the condition is present the more challenging it is to correct and the longer the rehabilitation process required. To prevent an Achilles tendon injury it is important to maintain a consistent exercise regimen with increments of no more than 10 percent in distance or intensity in a given week.
When we run, we transmit up to 2.5 times our body weight through each leg at impact thus creating significant load through the Achilles.
A progressive strengthening programme is required to increase the ability of the Achilles tendon to withstand this load. This should be combined with soft tissue work to break down any scar tissue that may have developed in the calf muscle.
Oftentimes, flawed running technique may be a significant contributory factor in development of Achilles pain and this must be rectified prior to returning to running. A full assessment of your running technique is critical prior to returning to running.
The rehabilitation period for an Achilles tendinopathy varies significantly but changes in tendinopthy structure will take place over several weeks to months.
Achilles tendon tear
In the worst case scenario a complete rupture of the Achilles may occur & this will require surgery as well as a plaster or a walking boot for six weeks or more.
An Achilles tendon rupture is the most frequent tendon injury in the lower limb, with an incidence of 18 per 100 000 individuals each year, most of whom are middle-aged, male amateur athletes.
Rehabilitation of such an injury will take a number of months & proper adherence to a physiotherapy rehabilitation programme is vital.
Physiotherapy after Achilles tendon surgery
How soon after surgery should I start Physiotherapy?
The evidence is suggesting more and more that the best outcome is achieved after achilles surgery by commencing physiotherapy immediately. Traditionally, physiotherapy interventions have been delayed due to a perceived risk of damage to the surgical site. However, the first 12 weeks post-surgery are known to be a vital window for obtaining neuromuscular changes in the calf muscles. Research by De la Fuente et al. (2017) found that immediate (i.e. one day post-surgery) rehabilitation after achilles surgery (tenorrhaphy) with controlled weight-bearing and mobilisation achieved more rapid recovery versus a traditional delayed rehabilitation programme.
One of the measurements of recovery after achilles tendon injury is the capacity of the person to perform a complete single-leg heel raise. Research by Fuente et al. (2018) compared the outcome of immediate physiotherapy versus a more traditional delayed physiotherapy intervention on single-leg heel raise capacity after achilles surgery (tenorrhaphy). 26 soccer players took part in the study. The authors found that only the immediate rehabilitation group obtained a full restoration of heel raise capacity, whereas the delayed rehabilitation group did not. The delayed rehabilitation group were immobilised in a fixed cam walker boot for 28 days. In contrast, the immediate -rehabilitation group began physiotherapy day-1 post-surgery at a frequency of 3 times per week. They performed controlled range of motion exercises involving mobilisation into plantarflexion, gait training using crutches, and deep ankle muscle activation without contraction of the calf muscles. The second phase (days 29-56) involved controlled stretching, isometric and concentric strengthening, and gait training using crutches with weight-bearing as tolerated based on pain levels.
During the first phase, patients in the immediate rehabilitation group lay supine and performed 120 cycles per week (4 series with 10 repetitions 3 times per week) between full plantar flexion and −15° of dorsiflexion without resistance on days 1 to 7.
On days 8 to 14, patients performed 120 cycles (4 series with 10 repetitions 3 times per week) between full plantar flexion and −15° of dorsiflexion against a yellow theraband
On days 15 to 21, participants performed 180 cycles (4 series with 15 repetitions 3 times per week) between full plantar flexion and −7° of dorsiflexion against a red theraband.
Days 22-28 involved 180 cycles (4 series with 15 repetitions 3 times per week) between full plantar flexion and 0° of dorsiflexion against a red theraband.
For the second phase, immediate and traditional group patients performed 240 cycles per week (4 series with 20 repetitions 3 times per week) between full plantar flexion and 0° of dorsiflexion against a blue theraband.
During the third phase, both groups performed 300 cycles per week (4 series with 25 repetitions 3 times per week) between full plantar flexion and full dorsiflexion.
Deep Plantar-Flexion Exercises.
To prevent tendon adherence i.e. where the fibres of the achilles tendon adhere to adjacent tissues, patients performed 360 cycles per week (4 series with 30 repetitions 3 times per week) of active flexor hallucis longus and flexor digitorum longus contractions without resistance while lying on their back.
To strengthen the plantar flexors, patients performed 3 types of heel-raise exercises: a sustained 2-legged heel raise, a 2-legged heel raise, and a 1-legged heel raise.
Stretching was introduced during the second and third phases to recover the same range of motion as the uninjured limb.
Patients enhanced the plyometric capacity of the plantar flexors during days 57 to 70. They performed 300 two-legged heel raises per week between −15° of dorsiflexion and full plantar flexion (4 series with 25 repetitions 3 times per week) with the upper extremities supported by parallel bars to assist with posture and to emphasize a fast heel raise and a slow, controlled heel drop.
For days 71 to 84, patients performed 300 one-legged heel raises per week (4 series with 25 repetitions 3 times per week)
On days 71 to 84 of the third phase, patients performed 180 running takeoffs per week, starting against a vertical wall (4 series with 15 repetitions 3 times per week), to enhance the takeoff capacity of the plantar flexors.
How effective is Acupuncture for Achilles Tendinopathy?
Research published in the journal Physiotherapy Practice and Research examined the effectiveness of acupuncture in treating achilles pain. The participants were randomised to receive either acupuncture or the control sham acupuncture treatment
The authors found a significant improvement in function and decrease in pain in the acupuncture group when compared with the controls.
This corroborates the findings of Zhang et al. (2012) who reported significant functional improvement and decreases in pain in individuals undergoing acupuncture
Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013;19(12):900-904. doi:10.1007/s11655-012-1218-4. https://pubmed.ncbi.nlm.nih.gov/23263998/
For further information on conditions treated go to: www.physioclinic.ie/conditions