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Achilles tendonitis

achilles pain sheboygan wi

Achilles Tendon Pain

Achilles Tendonitis, Tendonopathy

Did you know that the achilles tendon is the strongest and largest tendon in the human body? This isn't by accident, as it has to transmit a lot of force through foot, ankle, and leg. It is constantly under intense pressure, as exercises such as running continually places up to pressure up to 12.5 times your body weight each step.  

The Achilles tendon may be acutely strained or ruptured due to an excessive stretch or force.  Strains occur when the collagen fibers are stretched by more than 4%. Ruptures occur when stretch exceeds 8% (4,5).  

Unlike acute injuries that cause inflammation, tendinopathy is characterized by repeated overloading, microtearing, failed healing, and subsequent tendon degeneration (3,4,6,7). The process begins with collagen fiber disruption and ends in a disorganized healing process that fails to regenerate a “normal” tendon. Failed healing is blamed on an ineffective microvascular system (8,9).  

I have flat feet, does that affect the achilles tendon?

Hyperpronation stresses the medial  attachment of the Achilles tendon (10). 

Does the achilles tendon have any blood supply?

Contrary to popular belief, it does! Although, there is what is called a "watershed area", which is 2-6cm above the heel.  This area has very little blood flow, has a smaller tendon cross section, and is subject to repetitive excess motion.  This is the most common site for degeneration and rupture (12,13). 

How common are achilles tendon injuries?

Achilles tendon injuries affect between 250,000 and 1 million people per year in the United States (14,15). Most are middle-aged males 30's to 40's (14,16).  Interestingly, Achilles tendon injuries occur more frequently on the left side (16). Patients who have had a previous achilles tendon rupture are at significantly higher risk for tendon rupture on the other side (17).  

Who is most likely to have an achilles injury?

Two-thirds of all Achilles tendon injuries involve athletes. (18) Runners are up to 10 times more likely to suffer Achilles tendon injuries (18). The  Athletes are at greater risk during speed training or sprinting (19).  Runners who assume a midfoot or forefoot strike pattern (rather than heel strike) may be at even greater risk of injury (20). Not surprisingly, a higher risk has been identified in other sports that involve running or jumping. The most likely sports to produce an Achilles tendinopathy: running (53%), soccer (11%), dance (9%), gymnastics (5%), racquet sports (2%), football (1%) (14,21).

Are there risk factors for achilles injury?

Risk factors for Achilles injury include improper warm up, overtraining, running on hard surfaces, excessive stair or hill climbing, improper arch support/ footwear, poor conditioning, and abruptly starting activity after a period of inactivity (19,22-26).  Wearing high-heeled shoes may lead to shortening of the calf muscles, predisposing women to Achilles tendinopathy (27). Intrinsic factors include over pronation , flat feet,  calf inflexibility or weakness, limited ankle dorsiflexion, and limited subtalar joint motion (14,22-26). Systemic risk factors include diabetes, hypertension, inflammatory arthritis scubas psoriatic arthritis or rheumatoid arthritis, gout, obesity, and the use of corticosteroids or quinolones (broad spectrum antibiotics) (28,81,84). 

What does an achilles tendonitis feel like?

Complaints include pain or tenderness in the tendon or heel that intensifies with activity, especially walking or running. Patients may report difficulty when attempting to stand on their toes or walking steps- particularly down stairs. Morning pain and stiffness are common. Patients may report warmth and swelling that increases throughout the day, related to activity. 

Is my big toe somehow connected to this injury?

Limited hallux motion (your big toe)  has been associated with Achilles tendon pain (33).  This can be assessed by inspecting the inside of your shoe.  If there is a lack of wear on the first toe with lots of wear on toes 2-5, you may not be utilizing your big toe properly during the push off phase of your gait. 

Do I need X-rays for achilles pain?

Radiographs are often unnecessary for the diagnosis of Achilles tendinopathy (35).  Ultrasound may be an efficient cost-effective means of evaluating the Achilles tendon (39). Ultrasound or MRI may help identify and define tendon pathology.

What are the treatment options for achilles tendonitis and pain?

Nonoperative treatment is the most common treatment for Achilles tendinopathy (81).

What about ice or heat and ibuprofen for achilles pain? 

“Traditional” treatment plans based solely on rest, therapy modalities, orthotics, and NSAIDs have failed to demonstrate benefit for Achilles tendinopathy patients (41).  Passive modalities including ice, ultrasound, electrical stimulation, and low-level laser also lack support (42). 

What is the current standard for achilles tendonitis pain treatment? 

The current standard of care for Achilles tendinopathy includes a combination of rest, eccentric rehabilitation, and correction of mechanical faults through manual therapy and other treatments. Studies have demonstrated excellent results in up to 85% of patients undergoing appropriate conservative care. (43) Initially, patients may need to limit or stop activities that cause pain. Significant strains may require the use of crutches or a boot. Runners may need to switch to swimming, cycling, or other activities that limit stress to the Achilles tendon. Patients should avoid shoes with an excessively rigid heel tab to reduce irritation.

Eccentric exercise programs are effective for treating Achilles tendinopathy. (41,44-54) Eccentric training is more effective than concentric training for reducing pain and improving function (52,55).  In fact, research suggests that eccentric strength training programs are more than twice as effective as concentric programs for the treatment of Achilles tendinopathy (52).  

What is the best rehab exercise for achilles tendonopathy?

A proven program by Alfredson (45) incorporates single leg eccentric heel drops off the edge of a step. Heel drops should be performed with the knee both straight and bent, three sets of 15 repetitions, twice per day for 12 weeks. Heel drops should occur slowly on a 4-10 second count. (56).  The patient should use the non-injured leg to return to the “heel up” start position, thereby avoiding concentric contractions. Moderate pain during this exercise is acceptable but if pain is excessive, the patient should assist downward motion with the non-injured leg.

How do I know if I am doing enough or too much exercise?

Increases in night pain indicate the current rehab load is excessive. Progression advances when the patient tolerates a given level of tensile load. (92). 

What are the best manual therapies for achilles tendonopathy?

Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the calf muscles. IASTM can be used to release adhesions within the Achilles tendon. As an additional benefit, IASTM may accelerate healing, possibly via controlled microtrauma (57,78-80). Manipulation may be necessary to eliminate restrictions in the kinetic chain, particularly within the ankle (58).  Clinicians may consider the use of a 7-15 mm heel lift (bilaterally) to minimize dorsiflexion stress. Arch supports or orthotics may be necessary to correct hyperpronation (76). 

How can I go about increasing my training?

Athletes should introduce new activities slowly and avoid increasing activity, particularly running, by more than 10% per week. Runners should begin on smooth, shock-absorbent surfaces and start out at a lower intensity and distance- first increasing distance, then pace. Athletes should avoid training on hard or un-level surfaces, including hills. 

What are the return to play guidelines for the achilles tendon?

Return-to-play criteria for Achilles tendon strains or ruptures include the “Triple 5” (60):

1. Ankle dorsiflexion is within 5 degrees of the uninjured side,

2. Calf circumference (measured 10 cm distal to the tibial tuberosity) is within 5 mm of the uninjured side

3. The patient is able to perform 5 sets of 25 single leg heel raises

What about other treatment options?

Patients who fail a trial of conservative care should be referred, but proven alternatives are scarce. Medical co-management is of limited benefit in this case. NSAIDs may relieve symptoms but have little long-term effect on outcome (61,62).

What about cortisone injections?

Cortisone injections are unproven for the treatment of Achilles tendinopathy and carry a possible increased risk of tendon rupture (63,64).

What about shockwave therapy or PRP injections?

Extracorporeal shock-wave therapy (ESWT) or platelet-rich plasma (PRP) injections are controversial alternatives. (65-68) ESWT (originally developed as lithotripsy) is thought to break up calcific deposits and stimulate fibroblast activity to encourage healing and may be appropriate for Achilles tendinopathy. (81,82,91). PRP treatments consist of injecting platelet-rich plasma into a tendon to create a concentrated trigger of growth factors and chemoattractants for macrophages and fibroblasts, which gradually repair the damaged collagen. (69) Some clinicians suggest benefit from PRP injections, but others refute its usefulness for Achilles tendinopathy (81,83).

What if I have a achilles tendon rupture? Do I need surgery?

Surgical management is often considered for Achilles tendon ruptures, although several studies, including at least one randomized clinical trial, suggests at least equivalent results between surgical and conservative management (59,71,72,85)

At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition.  We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiroractor in Sheboygan by the Sheboygan Press. 

Evidence Based-Patient Centered-Outcome Focused

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