ACHILLES TENDINOPATHY HOLDING YOU BACK?

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It seems like most of us have suffered from an ankle injury at some point in time, but what could it be and how can it be treated?

Achilles tendinopathy: The Achilles tendon runs from the back of the lower leg to the back of the heel bone. When this tendon becomes inflamed you may get pain, swelling, warmth, crepitus and nodules on the tendon. The pain and stiffness make its difficult to walk normal due to the limited normal range of motion. The tendon may feel stuff in the morning and can be painful to touch. The pain and dysfunction could change in different footwear and running surfaces. It is an overuse injury and mostly associated with sports such as running, tennis and dance.

Tight calf muscles will exert more tension due to the lack of flexibility and lead to injury over time. This causes a reduction in rang of motion in ankle dorsiflexion (when the foot moves up). Therefore, this increase the foot to pronate more (roll inwards) and prevents it from pushing the foot off from the ground. The imbalances cause compensation to occur in knee joint which then also effects the hip joint.

Wearing footwear that does not fit properly can cause injury. Poor ankle joint stability can cause recurring ankle sprains. Therefore, it is important to strengthen the muscles, ligaments and tendons around the ankle.

 

Treatment:
Anti-inflammatory phase:

RICE should be used for early injury protection and pain reduction: Rest the foot from weight bearing to reduce aggravating the damaged tissue which could lead to further injury. Resting for 3-5 days will help prevent any pressure placed on the tendon in the early phase. Use a surgical boot/sandal. Apply ice for 3-4 times a day for 16 minutes to reduce pain and swelling. The evidence is anecdotal but suggests it is effective in the acute phase when injury is warm/hot. This helps to decrease blood flow which reduced haemorrhaging and swelling. The aim is to prevent secondary injury. Avoid anti-inflammatory medication (aspirin, ibuprofen) in the first 2-3 days as this causes further bleeding and delayed healing. Compress by using an elastic bandage around the ankle for 2-3 days. This helps reduce swelling by minimising blood flow to the damaged tissue and enhances the cooling effect of ice. Make sure the bandage is not too tight as this may stop blood flow, so loosen it if it feels painful. This helps reduce the amount of heat and with the return of normal circulation to the lymphatic drainage. Elevation by placing foot up such as on a stool while resting and with ice. This encourages venous return back to the heart and helps with removals of waste products through the lymphatic system.

 

Footwear:

  • Make sure patient has adequate shoes such as trainers
  • Evidence shows that lace-up or semirigid supports are more effective than tape or elastic bandages.
  • Place heel lift of about 1cm into shoe for 6 weeks
  • Helps take stress off tendon
  • Address footwear. Make sure your footwear is not worn out. Wear footwear with good cushioning to support shock absorption.
  • If the foot is excessively pronated (where the toes roll inwards and lesser toes point out) then consider buying anti pronating shoes or anti pronating orthotics which can biomechanical correct your foot posture and relief heel pain. A heel cup can be inserted in the shoe to reduce the range of motion in the ankle joint while it heels.

Ankle brace: can help to provide some support within he joint and reduce pain.

 

Massage:
  • Helps lengthen the muscles which reduces tension in the tendon.
  • Improve function of tendon
  • Improves blood flow to tissue and helps prevent further injury
  • The injury will feel stiff and sore early on, but will become less painful as the muscle heals.
  • Stretching helps to improve blood flow to the muscles, stretching an injured muscle will speed up the recovery by improving blood flow to the area.
  • Good blood flow is important for an injured muscle as the healing tissues need oxygen to get better.
  • And the more oxygen brought to the tissues by the extra flow of blood, the faster you’ll be back in action.
  • However, be careful not to stretch too soon after an injury as this could actually make it worse rather than improve it.\

 

Stretching:
  • Helps to prevent scar tissue build which can re-tear in the future.
  • Mature scaring takes 6 weeks to repair
  • Tight muscles will increase friction between tendon and bone
  • Stretching lengthens the muscle to reduce tension and reduce pain and inflammation
  • Also if tight muscles were the original cause then stretching can prevent re-injury.

 

    1. Stretches:Regaining full range of motion by prescribing stretching exercises, to do for 3 weeks:
    2. Achilles tendinopathy: Calf stretches against wall, 3 sets of 15-30 seconds, 5 times a day.

 

 

Muscle strengthening:
  • Strengthening helps the collagen fibres within the tendon to realign and also helps develop the strength needed for running.
  • Improves ROM and muscle function.
  • Strengthens the anterior and posterior muscle groups.
  • Restore Eccentric Muscle Strength:
  • Calf muscles work in two directions. They push you up (concentric) and control you down (eccentric).
  • Most Achilles injuries occur during the controlled lengthening (eccentric) phase.
  • Do 15 x 3 heel raises a day for 6 weeks to improve ankle dorsiflexion.
  • Restore Concentric Achilles Muscle Strength:
    • Calf strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises. You may also require strengthening for other leg, gluteal and lower core muscles depending on your assessment findings.

 

Proprioception:
  • Use wobble board: sit on chair or stand and place feet on top of board
  • Stand for 30s maintaining balance
  • Build up to 2 mins a day and gradually and do for 6 weeks.
  • Improves balance and coordinated movement
  • Strengthens tendon and prevent re-injury from occurring.

 

Exercises/stretches :

 

Lengthens muscle/reduces tension.

  • Soleus: both knees bent and

lean into wall.

  • Gastrocnemius: front knee

bent and lean into wall.

*Hold both for 30s and swap.

  • Kneeling shin stretch.

 

 

Muscle strengthening

 

  • Ankle flexion:
    • Sit on table or bench with legs dangling down
    • Put weight on foot and pull up/ slowly lower down
    • 2 set of 5
    • Inner ankle lift: Sit on chair, ankle on top of leg
    • Push foot and resist – hold 30s
    • Or use theraband and raise 5-10 times

 

  • Heel raises (including bent):
    • Start on flat surface/ gradually move to steps
    • 3 sets of 15, slowly come down.
    • Start on body weight/ move to weights

 

 

Proprioception:
  • Wobble board or wobble cushion.
  • Stand for 30s – build to 2 mins a day
  • Improves balance and coordination
  • Strengthens tendons
  • Prevents injury

 

by Ramnik – IG  @podiatrist

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