ACHILLES TENDINITIS

Achilles tendinopathy treatment

Achilles tendinitis is one of the most common overuse injury in active people and athletes.

IS ACHILLES TENDON REALLY INFLAMED?

Studies show that there are no inflammatory cells present in patients experiencing pain in the Achilles tendon. Therefore this condition should properly be named Achilles tendinopathy. The word tendinopathy means that there is a degeneration of the tenocytes (tendon cells) in the Achilles tendon.

Incidence and Prevalence

Achilles tendinopathy is a condition more prevalent in middle aged males.

Types of Achilles tendinopathy:

1. Mid portion 2-6 centimeters from insertion of the tendon to the heel

2. Insertion

Anatomy

Achilles serves as a conjoined tendon of the gastrocnemious and soleous muscles. The average length of Achilles tendon is 12 cm. It changes its orientation by twisting 180° to its insertion onto back side of the heel.

Degeneration of achilles tendon

RISK FACTORS

Intrinsic

  • Decreased ankle dorsiflexion
  • Abnormal subtalar joint range of motion
  • Decreased strength of ankle plantarflexors
    (muscles pushing the body off)
  • Increased foot pronation

Extrinsic

  • Fluoroquinalone (antibiotic medicine)
  • Diabetis
  • Hypertension
  • Arthritis
  • High cholesterol
Risk factors
Diagnosis clinic

DIAGNOSIS

Clinical history and examination is usually sufficient, however diagnostic ultrasonography is very accurate and preferred in determining the stage and extent of Achilles tendinopathy.

DIFFERENTIAL DIAGNOSIS

Usually clinical history is very revealing however diagnostic ultrasonography or MRI assists in differentiating location in the Achilles tendon. Radiology also assists in staging tendinopathy which is very important for treatment options.

PROGNOSIS

According to research young athletic individuals respond to treatment faster than middle age adults. For such young patients the treatment may take up to three months, whereas for middle age adults treatment may take up to six months.

TYPES OF ACHILLES HEEL PAIN TREATMENT

Intervention is based on scientific evidence.

Some interventions although having low scientific evidence may work clinically.

Eccentric loading

Types of achilles heel pain treatment

Taping – insertional type

Athletic taping

Manual therapy

Manual therapy in NYC

Laser and Iontophoresis, ultrasound, steroid injections, plasma injections – all have very low to no scientific evidence.

Achilles Tendonitis Doctor
at NYDNRehab

Dr. Kalika
ACL rehab and return to sport

At NYDNRehab we have extensive experience treating Achilles tendinopathy in runners as well as the non-athletic population. Based on sonographic evaluation and gait (running) analysis we create an individual treatment plan. Treatment options may very depending on type and stage of Achilles tendinoopathy and may involve: combination of manual therapy, eccentric loading exercises, force production exercises, ESWT (Extracorporeal Shock Wave Therapy). Research shows that by far the greatest results were achieved with any type of Achilles tendinopathy by combining ESWT with eccentric loading exercises.

MULTIFACETED
APPROACH

What does successful treatment
of tendinopathy requires:

  • • Patient/athlete education
  • • Inflammation control if inflammation is present
  • • Regenerative treatment (ESWT)
  • • Gradual tendon strenghtening
  • • Loading optimisation (loading and unloading)
  • • Improvement in biomechanics and motor control
  • • Improvment in kinetic chain relationships
  • • Motor variability
  • • Landing or running mechanics
  • • Ergonomics
  • • Training errors
  • • Reversing sensory motor adaptation

Testimonials

In order to avoid treatment for the wrong condition precise diagnosis is best way to deal with this type of injury. High-resolution diagnostic ultrasonography is readily available and is preferred. Another option is an MRI .

Achilles Tendinopathy

Athletes, fitness enthusiasts and other physically active people who experience pain in the Achilles tendon are often diagnosed with tendinitis, which is defined as inflammation of a tendon.But is your Achilles tendon actually inflamed?

Numerous studies indicate that in most people complaining of Achilles tendon pain, there are no inflammatory cells present. Therefore, the terminology referring to tendon pain has shifted to tendinopathy, meaning that some type of degeneration has occurred in the tendon cells.

Physically active middle-aged males are the most likely to report Achilles tendon pain. Roughly 89 percent of Achilles injuries are sustained by men between the ages of 30 and 50. However, tendinopathy can occur in both sexes, active and sedentary. Twenty-four percent of athletes and about 50 percent of runners develop Achilles tendinopathy at some point.

Anatomy and Function of the Achilles Tendon

As the largest and thickest tendon in your body, the Achilles tendon plays an important role in your lower kinetic chain, enabling you to walk, run, jump and rebound with forceful power. During walking, the Achilles can handle stress loads of almost four times the body weight, and eight times or more of the body weight during running.

The tendon is formed where the powerful calf muscles, the gastrocnemius and the soleus, merge at the base of the lower leg, connecting them to the heel bone. The Achilles tendon works with the muscles of the calf to plantar flex the foot at the ankle, pointing the toes downward. The Achilles tendon has poor blood supply, mostly coming from the posterior tibial artery.

Symptoms of Achilles Tendinopathy

Achilles tendinopathy typically falls under one of two categories:

  • Noninsertional Achilles tendinopathy occurs in the middle portion of the tendon, and is more commonly seen in younger active patients.
  • Insertional Achilles tendinopathy occurs where the tendon inserts into the heel bone, and may occur in anyone, even physically inactive people. It is most often associated with long-term overuse in middle-aged runners.

The main symptoms of Achilles tendinopathy are pain felt behind the heel at the back of the ankle when walking or running, and pain and stiffness upon waking after sleep.

Causes of Achilles Tendinopathy

When demands placed on the Achilles tendon exceed its capacity to meet them, tendinopathy occurs. It may result from a single incident of acute trauma, but more often than not, it results from repetitive microtrauma, where the breakdown of tendon tissue worsens over time.

Common underlying causes of Achilles tendinopathy include:

  • Tight or weak calf muscles
  • Structural or mechanical foot abnormalities
  • Ill-fitting, worn or non-supportive footwear
  • Sudden change in exercise type, duration, frequency or intensity
  • Obesity

Extrinsic risk factors for Achilles tendinopathy may include certain medications, arthritis and metabolic disease.

Diagnosis of Achilles Tendinopathy

During clinical diagnosis, the doctor will examine your foot and ankle and ask questions about your physical activities and the history of your ankle pain. Diagnostic ultrasound may be used to get real-time images of the structures of your foot, to confirm diagnosis, assess the degree of damage, and rule out other causes of your ankle pain.

Treatment for Achilles Tendinopathy

Traditional treatment approaches for Achilles tendiopathy include:

  • Rest from physical activity
  • Ice to reduce inflammation
  • NSAIDs like ibuprofen or naproxen for pain and inflammation
  • Corticosteroid injections
  • Orthotic shoe inserts or heel lifts
  • Athletic taping
  • Eccentric loading of the calf muscles
  • Stretching

At NYDNR, we design our treatment protocols based on the latest scientific research and evidence. Your individualized treatment plan may include some or all of the following:

  • ESWT (extracorporeal shockwave therapy), proven to be one of the best methods to increase blood flow and promote tissue regeneration in the Achilles tendon.
  • 3D Video Force Plate/EMG gait analysis and retraining, to identify mechanical deficiencies in walking and running gait that may contribute to Achilles tendinopathy, and correct them.
  • C.A.R.E.N (compter assisted rehabilitation environment): This state-of-the-art virtual reality technology can be used on its own or with other methods to provide progressive treatment of Achilles tendinopathy.
  • Training in biomechanics and motor control to eliminate training errors.
  • Gradual tendon strengthening.
  • Patient education.

Young athletic patients often respond to treatment more quickly than middle-aged adults, with recovery taking about three months for younger patients and up to six months for adults.

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

image

Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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