ACHILLES TENDONITIS (TENDINITIS)

It is estimated that Achilles tendonitis accounts for around 11% of all running injuries. The Achilles tendon is the large tendon at the back of the ankle. It connects the large calf muscles (Gastrocnemius and Soleus) to the heal bone (calcaneus) and provides the power in the push off phase of the gait cycle. The Achilles tendon can become inflamed through overuse as well as a number of contributory factors. The Achilles tendon has a poor blood supply which is why it is slow to heal.Achilles tendonitis can be acute or chronic. Acute Achilles tendonitis may happen as a result of overuse or training too much, too soon especially on hard surfaces or up hills.

Symptoms of Achilles tendonitis (tendinitis)

Symptoms for acute inflammation of the Achilles tendon are: ·

  • Pain on the tendon during exercise. Achilles pain will gradually come on with prolonged exercise but will go away with rest.
  • Swelling over the Achilles tendon.
  • Redness over the skin.

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You can sometimes feel a creaking when you press your fingers into the tendon and move the foot. Chronic Achilles tendinitis may often follow on from acute Achilles tendinitis if the acute tendon injury is not treated properly or allowed to heal. Chronic Achilles tendonitis is a difficult condition to treat, particularly in older athletes who appear to suffer more often. The pains experienced during the acute phase of the injury tend to disappear after a warm up but return when training has stopped.

Eventually the injury gets worse and worse until it is impossible to run.

Symptoms for chronic Achilles tendonitis are similar to those of acute tendonitis as well as:

  • Pain and stiffness in the Achilles tendon especially in the morning. This pain may be described as diffuse along the tendon rather than specific.
  • There may nodules or lumps in the Achilles tendon, particularly 2cm above the heel.
  • Pain in the tendon when walking especially up hill or up stairs.
  • Chronic tendonitis differs from acute tendinitis in that it is more of a long term persistent problem.

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Causes of Achilles tendinitis

  • Overuse. Too much too soon is the basic cause of overuse injuries, however other factors can make an overuse injury more likely.
  • Running up hills will mean the Achilles tendon has to stretch more than normal on every stride. This is fine for a while but will mean the tendon will fatigue sooner than normal.
  • Overpronation or feet which roll in can place an increased strain on the Achilles tendon. As the foot rolls in (flattens) the lower leg rotates inwards also which twists the Achilles tendon place twisting stresses as well as stresses along its length.
  • Wearing high heels consistently and then expecting to run 5 miles in flat running shoes puts abnormal strain on the Achilles tendon making it stretch further than it is comfortable.

Treatment of Achilles tendonitis (tendinitis)

What can the athlete do?

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  • Rest and apply cold therapy or ice (not directly onto the skin).
  • Wear a heel pad to raise the heel and take some of the strain off the Achilles tendon. This should be a temporary measure while the Achilles tendon is healing.
  • See a sports injury professional who can advise on treatment and rehabilitation.

What can a Sports Injury Therapist or Doctor do?

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  • Prescribe anti-inflammatory medication.
  • Identify the causes and prescribe orthotics or a change in training methods.
  • Tape the back of the leg to support the tendon.
  • Apply a plaster cast if it is really bad.
  • Use ultrasound treatment.
  • Apply sports massage techniques.
  • Prescribe a rehabilitation programme.

Some might give a steroid injection however an injection directly into the tendon is not recommended. Some specialists believe this can increase the risk of a total rupture.

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Scan with an MRI or Ultrasound. If you look after this injury early enough you should make a good recovery. It is important you rehabilitate the tendon properly after it has recovered or the injury will return. If you ignore the early warning signs and do not look after this injury then it may become chronic which is very difficult to treat.

REHABILITATION

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The following sports massage guide is intended for information purposes only. We recommend seeking professional advice before attempting any self help treatment.

Aims of rehabilitation

  • Decrease initial pain and inflammation.
  • Improve flexibility.
  • Improve the strength of the joint. ·
  • Re-establish neural control and co-ordination.
  • Return to full fitness.

Decreasing pain and swelling

Ice – apply for 20 minutes at least three times a day. Every two hours if possible for the first day.

Identify the cause of the injury.

Training too much too soon, training on hard surfaces, wearing the wrong shoes or shoes that are too old and not warming up are possible reasons for the injury occurring. Also, if you over pronate, the Achilles is twisted putting more strain on it.

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Rest

use crutches if needed. A good taping method is available which supports the tendon.

Place a heel lift of about 1cm into both your shoes to help take the stress off the tendon. Do not leave it there for ever and only use if you are or intend stretching. If the calf muscles adaptively shorten, an increased strain will be placed on the Achilles tendon in future.

Anti-inflammatory medication can be taken (under Doctors advice of course).

Maintain fitness by non weight bearing exercise such as cycling if pain allows. There is still a strain on the tendon when cycling and swimming so if your injury is bad rest only.

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Improving flexibility

Concentrate on improving the flexibility of the calf muscles (Gastrocnemius and Soleus). This will reduce the strain on the Achilles tendon.

Two stretches in particular are important, one with a straight leg for the Gastrocnemius muscle and one with the leg bend to target the Soleus muscle.

Stretching should be done regularly, three times a day initially and should be maintained long after the injury has healed to prevent the injury returning.

Use sports massage techniques. This will help prevent adhesions (sticky bits) forming. These adhesions stop the tendon sliding smoothly in its sheath.

Sports massage should also be used on the calf muscles themselves to aid in improving the flexibility and general condition of these muscles.

Strengthening

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The aim is to strengthen the calf muscles and the Achilles tendon. It is important that you strengthen the tendon in the stretched position. See strengthening exercises.

Start off with three sets of 10 and gradually increase day by day making sure you do not over-do it. If it is painful or sore afterwards then rest for a day and reduce the workload.

Improving proprioception (neural co-ordination)

It is possible that the neural control or co-ordination of the ankle has been affected, especially if the injury has been bad and required a sustained period of rest.

Standing on one leg with your eyes closed is a good way of developing proprioception. This will help prevent spraining the ankle in future and is a good all round strengthening exercise for the ankle. Aim for 2 minutes without wobbling.

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Returning to full fitness

When you have gone at least a week without pain then you can begin to return to training. If you feel pain when returning to training then stop. Begin each training session with a walk to warm up followed by stretching.

After training apply ice or cold therapy to the tendon for 10 minutes to help prevent inflammation from returning.

Day 1: walk 4 minutes jog 2 minutes repeat four times

Day 2: rest

Day 3: walk 4 minutes jog 3 minutes repeat three times

Day 4: rest

Day 5: walk 3 minutes jog 4 minutes repeat 4 times

Day 6: rest

Day 7: walk 2 minutes jog 6 minutes repeat 4 times

Continue this gradual progression until you can confidently run and resume normal training. Gradually increase the duration of your runs. No more than 10 % per week is usually recommended. If your sport demands sprinting then gradually increase the speed.

Continue with the stretching and strengthening programmes. It is important to do these even if you do not gain pain at this stage. Continue for at least three months. Continue to ice the tendon after training. You should now be ready to start back in full training but never neglect stretching and strengthening of the Achilles tendon or the injury might return.

Prevention of Achilles tendinitis

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Achilles tendinitis can be prevented by understanding the possible causes of the injury:

  • Training too much too soon.
  • Training on soft surfaces such as grass or sand for long periods of time. The soft surface allows the heel to drop more, so placing more strain on the tendon.
  • Wearing the wrong shoes or shoes that are too old.
  • If you over pronate, the Achilles is twisted putting more strain on it.
  • Not warming up properly.
  • Failing to stretch properly.

SPORTS MASSAGE

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The following sports massage guide is intended for information purposes only. We recommend seeking professional advice before attempting any self help treatment.

How can sports massage benefit the rehabilitation of this injury?

Sports massage techniques can be applied to the calf muscles at the back of the lower leg to improve muscle condition and flexibility and so take some of the tension off the tendon. Massage techniques can also be applied directly to the tendon to aid the healing process.

Transverse mobilization

With the first finger of one hand and the thumb of the other hand, alternate to apply transverse pressure. This pulls the tendon across one way and then the other.Oil is not really required to perform this technique. If there is too much oil left over from calf muscle techniques then wipe it off to enable a good grip of the tendon. The technique will mobilize the tendon making it more supple. Apply for about 5 minutes. Transverse mobilizations are best incorporated in the calf muscle routine.

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Cross frictions

With the first two fingers apply gentle pressure in a transverse direction to the Achilles tendon. Again, too much oil and the therapist will find they are unable to apply the technique correctly.Apply frictions for between 2 and 5 minutes.

Circular frictions

Place a finger each side of the Achilles tendon and apply pressure in a circular direction. Aim to feel the tendon underneath the fingers. If there is or has been a partial rupture then the therapist may find a particular lump or bump in the tendon that is sensitive. Massage may be uncomfortable but should not be so painful that the athlete tightens up. This is unlikely to be of benefit. Apply frictions for between 2 and 5 minutes. The above techniques can help to reduce swelling, aid circulation and prevent the build up of adhesions (sticky bits that prevent the tendon from sliding properly in its sheath). It may also help to apply ice or cold therapy after treatment for 10 minutes. Light massage can usually be performed daily, however for deeper techniques alternate days may be more appropriate allowing the tissues time to recover.

It is important to assess the results of treatment both afterwards and the next day.

Has pain and swelling increased?

If so then discontinue.Achilles tendon massage will work best when applied in conjunction with massage for the lower leg especially calf muscles.

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