Solve and avoid Achilles is­sues


Athletics Weekly - - Contents -

ACHILLES ten­don in­juries af­flict run­ners about 10 times more fre­quently than nonath­letes of the same age.

From Achilles tenosyn­ovi­tis, Achilles ten­dini­tis, Achilles tendi­nosis, Achilles rup­ture to Achilles tendinopathies, most of us have ex­pe­ri­enced the pain of them at some point in our ca­reers. But what causes them and how do we treat and avoid them?

The Achilles ten­don is the thick­est ten­don in the hu­man body. It at­taches the plan­taris, gas­troc­ne­mius and soleus mus­cle to the pos­te­rior tuberos­ity of the cal­ca­neus serv­ing its main func­tion to plan­tar flex the foot.

It is sur­rounded by a con­nec­tive tis­sue sheath also known as a para­ten­don. This struc­ture is highly vas­cu­lar and al­lows the ten­don to glide more eas­ily with move­ment. All con­di­tions are treat­able, but with vary­ing de­grees of suc­cess. With the cor­rect di­ag­no­sis and ap­pro­pri­ate man­age­ment mea­sures put in place, re­cov­ery will usu­ally take around three months.

But since the treat­ment op­tions avail­able are so vastly con­tro­ver­sial, the risks and ben­e­fits of each op­tion need to be thor­oughly as­sessed and matched to each in­di­vid­ual case be­fore a fi­nal de­ci­sion is made, so make sure you con­sult a med­i­cal ex­pert if you are plagued by the prob­lem. In the mean­time, here’s a guide that might help you.

Achilles tenosyn­ovi­tis

This is in­flam­ma­tion of the sheath sur­round­ing the ten­don. It com­monly causes fi­bro­sis and scar­ring within the sheath re­strict­ing the range of mo­tion of the Achilles ten­don. Symp­toms ex­pe­ri­enced with this con­di­tion in­clude pain, ten­der swelling around the Achilles and crepi­tus on move­ment of the an­kle joint.

Causes for this con­di­tion re­late to hav­ing a tight calf and Achilles com­plex, chang­ing the vol­ume of train­ing com­pleted or chang­ing the type of footwear be­ing worn.

What to do: Man­age­ment op­tions for Achilles tenosyn­ovi­tis can be di­vided into short and long term plans. Firstly, rest from the ag­gra­vat­ing sport. Se­condly, at the time of the in­jury, ice and com­pres­sion should be ap­plied for about 10-15 min­utes ev­ery hour for 3-4 hours. This will ease pain along with re­duc­ing swelling and in­flam­ma­tion.

Non-Steroidal Anti-In­flam­ma­tory drugs may be given for a few days to a week to re­duce in­flam­ma­tion also. Longer term man­age­ment of Al­fred­son’s ec­cen­tric heel drops (see panel op­po­site), mas­sage and a change in footwear is rec­om­mended.

Achilles tendinopa­thy

This is an um­brella term for clin­i­cal con­di­tions in and sur­round­ing the ten­don. Med­i­cally speak­ing, tendinopa­thy is due to non-in­flam­ma­tory, in­tra-tendi­nous col­la­gen de­gen­er­a­tion with fi­bre dis­ori­en­ta­tion and thin­ning.

Un­der ex­am­i­na­tion, the over­all bulk of the Achilles ten­don will in­crease while its over­all strength will de­crease. There two types of tendinopa­thy – in­ser­tional, where the Achilles joins to the cal­ca­neus – and non-in­ser­tional, oc­cur­ring ap­prox­i­mately two to six cen­time­tres from this point. Symp­toms in­clude in­creas­ing pain, stiff­ness around the ten­don.

What to try: Heat and light walk­ing are known to im­prove the symp­toms whereas stren­u­ous ac­tiv­ity is likely to ex­ac­er­bate them.

There are three main re­sponse stages. Firstly, re­ac­tive tendinopa­thy is a short-term

re­sponse whereby the Achilles thick­ens and stiff­ens in an at­tempt to re­duce the load be­ing placed upon it. The ten­don dis­re­pair is due to de­lin­eation of the ten­don fi­bres.

Fi­nally, in the de­gen­er­a­tive tendinopa­thy stage, which is more com­mon in older ath­letes, due to chronic over­load­ing, col­la­gen be­comes dis­or­gan­ised and the ma­trix be­gins to break down. In­creased vas­cu­lar­ity and neu­ronal in­growth con­trib­ute to this stage.

Achilles ten­dini­tis

Achilles ten­dini­tis is in­flam­ma­tion of the Achilles ten­don it­self. There are two main lo­ca­tions where this oc­curs: firstly, at the in­ser­tion point where the ten­don at­taches to the cal­ca­neus and se­condly, at the mid-point of the ten­don. In both cases the dam­aged ten­don fi­bres may cal­cify pro­vid­ing symp­toms of stiff­ness and pain.

There are many the­o­ries about what trig­gers it in­clud­ing overuse of the Achilles, mus­cle im­bal­ance or weak­ness, de­creased blood sup­ply and ten­sile strength with ag­ing or even malalign­ment such as hy­per-prona­tion.

The teno­cytes them­selves pro­duce Sub­stance P and prostaglandin E2, in­flam­ma­tory me­di­a­tors, in re­sponse to in­creased load­ing. This sub­se­quently leads to de­lin­eation of the ten­don fi­bres.

What to try: There have been nu­mer­ous stud­ies con­ducted to de­ter­mine the best treat­ment for Achilles ten­dini­tis, but the out­come re­mains un­clear. Ac­cord­ing to the Na­tional In­sti­tute for Health and Care Ex­cel­lence (NICE), first line man­age­ment for Achilles tendinopathies in­cludes rest; stop­ping the pre­cip­i­tat­ing sport that caused the in­jury.

Pro­vide anal­ge­sia for the pain it­self. Non­S­teroidal Anti In­flam­ma­tory Drugs (NSAIDs) are ad­vised for an acute in­jury but longer term parac­eta­mol would be prefer­able due to the lower risk of side ef­fects.

In terms of eas­ing symp­toms, the ap­pli­ca­tion of ice packs or cold com­presses to the area im­me­di­ately af­ter the in­jury will be of some ben­e­fit.

Achilles tendinopa­thy

A to­tal of 66% of Achilles ten­don prob­lems oc­cur in run­ners and it is down to char­ac­ter­is­ti­cally chronic overuse of the Achilles ten­don while train­ing. Other causes of tendinopa­thy in­clude ex­treme over­load­ing such as rapid in­crease in train­ing vol­ume, poorly fit­ting footwear, change in run­ning sur­face or ex­ces­sive prona­tion of the foot. There’s also a ge­netic link with Achilles tendinopa­thy.

What to try: The treat­ment of Achilles tendinopathies is mul­ti­fac­to­rial and


ONE of the rec­om­mended ex­er­cise pro­grammes based on ec­cen­tric heel drops was de­vised in 1998 by Dr Hakan Al­fred­son, a Swedish sports medicine doc­tor. It is known as “Al­fred­son’s heel drop pro­to­col” and the ex­er­cise reg­i­men com­prises three sets of 15 heel drops twice daily for 12 weeks.

The ex­act tech­nique to per­form these ex­er­cises in­volves the pa­tient stand­ing on a step with both heels over­hang­ing. The pa­tient lifts the in­jured heel off the step and raises the good heel to plan­tarflex the foot, still on the step.

Se­condly, the weight is trans­ferred onto the in­jured foot in the plan­tar flexed po­si­tion, over the edge of the step.

Fi­nally, to com­plete the ex­er­cise, the heel is slowly low­ered over the edge of the step over ap­prox­i­mately 10 sec­onds un­til the foot is in the dor­si­flexed po­si­tion. A vari­a­tion is to bend the in­jured leg. This puts more weight through the ten­don to strengthen it fur­ther.

highly con­tro­ver­sial. Ini­tial ap­proaches would be the same as rec­om­mended for Achilles tendi­nosis. Ev­i­dence sug­gests that ec­cen­tric re­ha­bil­i­ta­tion pro­grammes pro­mote the most ef­fec­tive out­comes. The Achilles re­sponds to this type of ex­er­cise as the fi­bres of the ten­don are re­or­gan­ised to deal with a higher load.

You could also try or­thotic de­vices that marginally lift the heel or sup­port the arch with the aim of re­duc­ing the strain on the ten­don while it heals.

Lau­ren Gow­land is a fifth-year med­i­cal stu­dent at Lan­caster Med­i­cal School and a mem­ber of Black­pool, Wyre and Fylde AC

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