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The Achilles tendon is the largest tendon in the body and connects the
calf muscles (gastrocnemius and soleus) to the rear part of the heel bone
(calcaneus). This tendon transfers the power of the calf muscles to the
heel allowing one to rise up on the toes and push off with the toes.
Injuries of the Achilles tendon range from acute and chronic tendonitis (or tendinosis - see
Achilles Tendon Pathology) - to
partial and complete ruptures. In acute and sub-acute (2-6 weeks
duration) Achilles tendonitis, the tendon is not torn but is inflamed.
The tendon area may be swollen, red and painful to the touch. Often,
there is pain when the athlete first rises in the morning but dissipates
once the tendon is warmed-up during the day. If the tendon continues to
be used, microtears occur which heal with scar tissue which is not as
elastic nor is as strong as the original tissue. As the injury becomes
chronic, adhesions begin to develop between the tendon sheath and the
tendon which can permanently change the anatomy of the area. The
athlete may feel a crackling or grinding sensation while rubbing the
tendon or while lightly pinching the tendon when the foot is moved up
and down.
The Achilles can withstand a force of 1000 pounds without tearing.
Despite its tremendous strength, the Achilles tendon is the second most
frequently ruptured tendon in the body. Most ruptures occur about two to
three inches from where the tendon inserts on the heel bone. This area
is the narrowest part of the tendon and has the poorest blood supply.
(Tears may also occur in the belly of the gastrocnemius muscle.) Ruptures
occur most often in the "weekend warrior" ages 20 to 50. The most common
mechanism of injury is a quick and powerful toe off and flexion of the
foot, as in sprinting.
In an acute Achilles tendon rupture the athlete will usually feel pain,
not necessarily severe, or a "popping" sensation in the calf area. It
is also described as a feeling of being kicked or shot in the calf.
Often, the athlete will lose the ability to push off on the injured side.
In a complete tear of the Achilles there will be a palpable defect in the
tendon. The doctor will do a test where the patient's injured calf is
squeezed. The test is considered normal if this squeeze causes a plantar
flexion (bending downward) of the foot. If no foot movement occurs,
this solidifies the diagnosis of a complete tear. If the tear is a
partial one, the aforementioned test may be negative, but a palpable
defect may still be present. Achilles tendon ruptures can be treated
by surgical repair of the tendon or non-surgically by cast
immobilization.
Overuse/overtraining, poor foot biomechanics, improper shoes, lack of
flexibility, fatigue, poor conditioning, running without warming-up, a
hard running surface and a sudden overstretch of the tendon are all causes
of Achilles tendon injuries. Shoes with a proper fitting and sturdy heel
counter are essential. Athletes who excessively pronate or have a high
arch may need an orthotic to correct foot dysfunction. Training on
various surfaces, avoiding excessive pounding (too much hill training), a
proper warm-up and calf stretching exercises for both the gastrocnemius
and soleus are important for injury prevention.
Initial treatment for Achilles tendonitis includes rest and ice.
Cortisone shots are not used as they can cause even greater deterioration
of the tendon. Application of ointments like Traumeel or Arnica can
speed healing. Microcurrent (a type of electrical stimulation which
uses microamperage instead of milliamperage) is very effective at
wound healing, especially if used during the first week after the
injury. The most important part of the care is to remove the
adhesions caused by the tearing of the Achilles tendon. This can be
accomplished using techniques like
Active Release Techniques® and/or
Graston Technique.
A heel lift (of about 1/8 - 3/8 inch) or compression
brace can be used if necessary. The heel lift will shorten the distance
over which the tendon must work thereby reducing the stress on the
tendon. The lift is used temporarily until the problem resolves.
A compression brace can help prevent further tearing of
the tendon. Stretching of the soleus and gastrocnemius is added
and performed gradually. Stretching of the gastrocnemius is done
by putting two hands against the wall, one foot foreword and one foot
back. Keep the knee of the rear foot locked. To stretch the
soleus, the same position is used except bend the knee of the rear
foot. The heel of the leg being stretched must be kept in contact
with the floor in both stretches. Hold each stretch for 10-20
seconds and relax.
Strengthening exercises for the Achilles tendon include toe raises and
moving the foot inward and outward against the resistance of exercise
tubing. Start with 2 sets of 10 reps and built to 3 or 4 sets of 25+
reps.
Restoring both strength and flexibility after injury is important, but
an often forgotten part of rehabilitation is called proprioception.
Proprioception is defined as joint position sense or the ability of a
joint and the surrounding tissue (muscle, tendon, ligament) to provide
structural integrity and functional orientation during dynamic activities.
If not restored, recurrent injury is likely. Balance training on a wobble board
can be used to help restore proprioception of the foot and ankle after an Achilles
tendon injury. A progression can then be made to hopping drills when pain and
swelling is gone and a normal gait is attained. Proper shoe fit and training
techniques should be discussed with your doctor and coach.
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Achilles
Tendon Injuries