What is achilles tendinopathy?

Achilles tendinitis is a relatively common condition characterized by tissue damage and pain in the Achilles tendon. The calf muscle at the back of your leg comprises of two muscles, one of which originates from above the knee joint (gastrocnemius), the other of which originates from below the knee joint (soleus). Both of these muscles insert into the heel bone via the Achilles tendon. These two muscles are responsible for push off, tendon is place through the Achilles tendon when you push off of your toes, when you walk, run, and jump.   During contraction of the calf, tension is placed through the Achilles tendon. When this tension is excessive due to too much repetition or high force, damage to the tendon occurs. Achilles tendinitis is a condition whereby there is damage to the tendon with subsequent degeneration and inflammation.

   

What are the causes of Achilles tendinitis?

Achilles tendinitis most commonly occurs due to repetitive or prolonged activities placing strain on the Achilles tendon. This conditions typically occurs due to:  
  • excessive walking, running or jumping activities,
  • from tight calves,
  • following a sudden forceful force thru the Achilles tendon beyond its limit,
  • a sudden acceleration or forceful jump,
  • following a calf or Achilles tear or poorly rehabilitated sprained ankle,
  • individuals with poor foot biomechanics or inappropriate footwear,
  • with long distance running, biking, walking, sailing or any endurance activity,
  • pressure points exerted on the tendon from high tech shoe, rigid reinforcing materials applying a focal pressure point.
   

What is the prognosis of achilles tendinopathy?

Patients with this condition typically experience pain in the region of the heel and back of the ankle. Initially, patients may only experience an ache or stiffness in the Achilles region typically at night or first thing in the morning.  As it worsens you may only feel it following activities that place stress on the Achilles tendon or at the end of your walk or run. Eventually it will be painful throughout the activity and then all of the time and even at rest. Often the problem is deceiving because once you warm up it disappears, later to return when you are resting at night. In severe cases, patients may walk with a limp or be unable to weight bear on the affected leg. Patients may also experience swelling, tenderness on firmly touching the Achilles tendon, weakness and sometimes palpable thickening of the affected Achilles tendon when compared with the unaffected side. The diagnosis is easy the recovery period depends on how long the condition has persisted and the state physical of your calves.   Occasionally, and if tendinitis is severe and leads to the rupture of a tendon, you may need surgical repair. But most cases of tendinitis can be successfully treated with rest, physiotherapy, massage therapy, and medications to reduce pain.

   

What activities may aggravate Achilles tendonitis?

  • Running especially uphill or on uneven surfaces
  • Walking, standing and virtually everything in standing
  • Heel raises, hopping, jumping
  • Basketball, tennis, squash, baseball, badminton, curling and virtually every sport in standing.
   

How can physiotherapy and massage therapy do for achilles tendinopathy?

A thorough subjective and objective physiotherapy examination is usually sufficient to diagnose most tendinitis. Occasionally, further investigations such as an Ultrasound, X-ray or MRI scan may be required to assist with diagnosis and assess the severity of the condition.   Most patients with this condition heal well with appropriate physiotherapy and massage therapy. This, however, can be a lengthy process and may take up to 6 months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with this condition.   Common to this condition are restrictions and tightness within the various calf muscles, those that attaches the Achilles tendon to the heel bone i.e. soleus, gastrocneumius and joint restrictions in the ankle that limit range of motion. Most of the focus early on by physiotherapy and massage therapy is vigorous releasing of the calf musculature to reduce tension on the Achilles and reduce inflammation. This typical characteristic of muscle tightness is found in both those who have lived an active lifestyle and by who have lived sedentarily lives.  High heel shoes, fast aggressive walkers, skipping, activities of repetitive hoping and jumping such as boxing, activities what require speed and footwork quickness, and individuals who stand walk a lot during their day are predisposed to Achilles tendonitis. Subsequently it becomes a problem in those that live an active lifestyle and is often related to a lack of recovery techniques that are preventative such as regular massage and or soft tissue techniques.   Achilles tendonitis may get worse with repetitive strengthening exercises and improve with soft tissue techniques such as active release, massage therapy, specific deep tissue techniques, myofascal techniques and heat.  Sometimes this is in conjunction with a heel lift to ease the tension. Laser therapy is also very effective in reducing inflammation. When inflammation has reduced, direct scar tissue techniques such as friction massage performed on the tendon directly to breakdown thickening and reduce the risk of recurrence.   Repetitive contractions and strengthening may irritate some and require close supervision and progression of load and repetition. The challenge is to determine if a lack of range of motion or soft tissue suppleness is primary or if a weakness in the muscles of plantar flexion is primary and then develop a treatment plan to effectively address these conflicting strategies.  Some, but less commonly, a muscle weakness finding is evident and the patient may benefit from a eccentric strength training program where both load and speed are progresses during eccentric movements where the heel drops quickly over a step to create a quick loading effect and challenge the tendon.   Most people develop tendinitis because their jobs or hobbies involve repetitive motions, which put stress on the tendons needed to perform the tasks. Physiotherapists understand human movement, biomechanics and the medial sciences. Our physiotherapists are trained in kinesiology, the sport sciences. Using proper technique is especially important when performing repetitive sports movements or job-related activities and we can evaluate your movement patterns.

   

Physiotherapy and Massage treatment may comprise of:

  • massage
  • Low  Intensity Laser Therapy is also very important to heal the damaged tissues
  • devices including crutches, braces, heel lifts, and night splints to rest the affected tissues
  • stretches – although stretching is not effective on it own
  • joint mobilization
  • ice or heat treatment
  • exercises to improve strength, flexibility, core stability and balance
  • education advice so we can be strategic and design a personal improvement plan
  • anti-inflammatory advice
  • activity modification advice
  • hydrotherapy
  • biomechanical correction including teach proper functional movement skills
  • footwear, training surface, and equipment advice
  • a gradual return to activity program
  • shockwave therapy
   

How can exercise and physical development help after achilles tendinopathy?

The Kinetic Chain

Our body functions best and with minimal stress when it is in optimal alignment and posture. Proper structural correction is achieved with proper footwear and support. Proper functional mechanics requires skill development and neuromuscular training and is the science of motor learning. The kinetic chain is a integrated functional unit of systems that work interdependently to allow structural and functional efficiency. It is made of the soft tissue system (muscle, ligament, tendon, and fascia), the Neural system ( peripheral nervous system of nerves and the central nervous system or brain), and the Articular system (joints). If any of these systems do not work efficiently, compensations and adaptations may occur in the other systems. A dysfunction in the kinetic chain leads to decreased performance and predictable patterns of injury.  Imbalances may result from postural stress, a pattern of overload, repetitive movement, a lack of core stability, and a lack of neuromuscular efficiency. All functional movement patterns involve deceleration, stabilization and acceleration, which occur at every joint in the kinetic chain and in all planes of motion at varying speeds.   Optimum posture and alignment provides optimal structural and functional efficiency to the kinetic chain. If one component is out of alignment, it creates predictable patterns of tissue overload and dysfunction, leads to decreased neuromuscular control and initiates the cumulative injury cycle. Muscle imbalance leads to abnormal neuromuscular control leads to overloaded tissue and tissue fatigue which leads to inflammation and eventually leads to tissue trauma or injury. The most common patterns of compensation are the Pronation Pattern of the lower body and the Forward Head Pattern of the upper body and these two patterns are the focus of our screen examination and our subsequent corrective preventative exercise plan. Identification of biomechanical imbalances in a way that is specifically related to the multi planner movements and that involves acceleration, deceleration, stabilization and occurs at multiple speeds in those specific body positions and posture activities of daily living.  Assessment of the muscular system (functional anatomy) the articular system (functional biomechanics) and the neural system (motor behavior) becomes important in the prevention and treatment of overuse injuries and repetitive strains. In order to live a healthy and active lifestyle, one has to train their body the way it moves during daily functional movements.

   

Exercise Training and Physical Development

Foot stability and posturing is the most important physical training that you can do to prevent and maintain good foot mechanics and reduce abnormal stresses on the tendons and muscles of the lower extremity. As for Achilles tendonopathy itself, often strength training will cause more tightness and subsequently overload the tendon and make it worse. This overuse injury often does well with soft tissue techniques and laser techniques.  By decreasing inflammation initially, strengthening exercises may be less aggravating and more effective. We must remember that our calves are typically strong and tight and overused simply by virtue of the functional demands placed on these muscles as we ambulate. To prevent this from happening, recovery techniques such as massage should be a part of your regular routine.    

How can low intensity laser therapy help achilles tendinopathy?

Low Intensity Laser Therapy (LILT) is the use of monochromatic light. Meditech Bioflex has been producing this technology for 20 years and has an extensive in house clinical lab.   The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This process also enhances the body's natural healing propensities.   Low Intensity Laser Therapy does not heat or cut tissue. Unlike many pharmacological treatments that mask pain or only address the symptoms of the disease, Laser Therapy treats the underlying condition or pathology to promote healing. The technology utilizes superluminous laser diodes to irradiate diseased or traumatized tissue with photons. These particles of energy are selectively absorbed by the cell membrane and intracellular molecules, resulting in the initiation of a cascade of complex physiological reactions, leading to the restoration of normal cell structure and function.   The process is curative and therefore results in the elimination of symptoms including pain. In addition, it enhances the body’s immune system response and facilitates natural healing. The therapy is completely safe and has no adverse side effects. The technology is highly effective in the treatment of musculoskeletal conditions, arthritis, sports injuries, wound healing and a wide range of dermatological conditions. Whiplash injury typically involves injury to muscles, ligaments, and joints and typically involve several levels and a more wide spread area of injury due to the force full nature of the injury. Muscles of the neck, although short, cross over several joints and so the discomfort is generally more global initially. Laser therapy directed by multiple diodes are able to reach these tissues.    

Physiological effects of Low Intensity Laser Therapy

With LILT there is an increased production and release of:  
  • Endorphins which - natural analgesics
  • Cortisol – a precursor of cortisone
  • Growth hormone – instrumental in tissue repair
  • ATP – improves and regulates cellular metabolism
  • An increase in protein synthesis – collagen, DNA, fibroblasts
  • A facilitated venous and lymphatic flow
  • Increased angiogenesis – the elevation of oxygen saturation
  • Enhanced immune response
  These responses are some of the many processes that accelerate cellular regeneration (cartilage, epithelium) and restore normal cell morphology and function. Treatments are typically 25 minutes to over 1 hour depending on the condition and area being treated   The most popular technical / clinical information requested is available on the Meditech website under Laser Reports. You may visit the Meditech website research section directly for detailed abstracts, case profiles and articles on a variety of topics relating to the use of low intensity laser therapy in the treatment of various medical conditions.  

What life style and self-care measures can you do for yourself to relieve achilles tendinopathy?

To treat tendinitis at home, Rest, Ice, Massage, and sometimes Heat. This treatment can help speed your recovery and help prevent further problems.  
  • Rest. Avoid activities that increase the pain or swelling. Don't try to work or play through the pain. Rest is essential to tissue healing. But it doesn't mean complete bed rest. You can do other activities and exercises that do not stress the injured tendon. Ask your physiotherapist which activity is best. Although rest is a key part of treating tendinitis, prolonged inactivity can cause stiffness in your joints. After a few days of completely resting the injured area, gently move it through its full range of motion to maintain joint flexibility.
  • Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 15-20 minutes, several times a day. Ice packs, ice massage or slush baths with ice and water all can help. For an ice massage, freeze a plastic foam cup full of water so that you can hold the cup while applying the ice directly to the skin.
  • Heat. For more chronic tendon conditions, and if the goal is to release tight soft tissue, heat can be helpful in increasing blood flow to the muscle and tendon. This includes deep heat, moist head, and hydrotherapy
  • Over the counter Meds. Ask your doctor about medications. You can also try over-the-counter medications, such as aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) or acetaminophen (Tylenol, others), in an attempt to reduce the discomfort associated with tendinitis.
  • Physiotherapy and Massage Therapy. Book an appointment with your physiotherapist and massage therapist for an assessment and treatment. Soft tissue techniques that release the tension in the muscles and or release the myofascial tensions placed on the extensor tendon will not only rehabilitate the injury but also prevent further injury and reoccurrence.
  There are many decisions to be made when it comes to the care of and prevention of all types of overuse injuries including some tendonitis. An experienced practitioner, a well executed assessment process, and a well thought out personal improvement plan can help.

   

Prevention

To reduce your chance of developing tendinitis, follow these suggestions:  
  • Develop Strength and fitness. Often those who develop tendonitis have are not prepared physically to perform either the volume or intensity of the activity which they participate in. If your goal is to be active, talk to your physiotherapist to help you develop the components of fitness that are most important to the activities that you do.
  • Prepare your muscles to play. Strengthening muscles used in your activity or sport can help them better withstand stress and load.
  • Recover from activity and get ready for the next. Ask your therapist about the strategies that are best for you to recover from your specific activity. Heat, ice, massage, baths, stretching and include.
  • Warm up first. Before you exercise, take time to increase your core temperature and break a sweat and then stretch in order to maximize the range of motion of your joints. This can help to minimize repetitive microtrauma on tight tissues. Remember, regular massage by your physiotherapist and or your massage therapist helps too. 
  • Use appropriate footwear for each activity. If possible, get an foot  assessment and recommendations from your physiotherapist about the best footwear for you given your specific assessment findings. For some, cushion is important, for others correction is important, some require a lower heel cup and others a more rigid sole to prevent the great toe from being strained.
  • Mix it up. If one exercise or activity causes you a particular, persistent pain, try something else. Cross-training can help you mix up an impact-loading exercise, such as running, with lower impact exercise, such as biking or swimming.
  • Improve your technique. If your technique in an activity or exercise is flawed, you could be setting yourself up for problems with your tendons. Consider taking lessons or getting professional instructions when starting a new sport or using exercise equipment.
  • Ease up. Know your body. If you are not fit to perform the activity ease up, avoid activities that place excessive stress on your tendons, especially for prolonged periods. If you notice pain during a particular exercise, stop and rest. If you are unable to progress and develop your sport, seek help from a physiotherapist who understands how to develop athletes.
 

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