Achilles tendon injuries commonly affects people who subject their feet, legs and body to alot of repetitive pounding and quick dynamic pushoffs. Over the years, I’ve participated in many different running and jumping sports…basketball (my first love!), karate, track & field (junior high triple-jump champ!), and most recently taekwondo at All Star Martial Arts. In the past 2 months, things have started to take their toll on my 40 years young Achilles tendons and I’ve entered the early stages of injury…which has served as a stimulus for me writing today’s bog post!
But I’m not going to talk about my Achilles tendons because I’ve only just started doing some self-treatment on it. Instead, let me share the story of one of my patients, David.
David is a 50 year old, transportation business owner who still enjoys taking part in his favorite past time: soccer. He plays in a local Aurora mens’ league throughout the year both indoors and out. It’s how he stays fit and how he beats the stress of work and life.
Back in May, David came by my Richmond Hill chiropractic clinic on the referral of a teammate who had seen me previously for successful treatment on his shoulder pain. David told me that he had gradually developed pain in both of his Achilles tendons over a period of 2-3 months. He experienced quite a bit of stiffness in the morning getting out of bed that would loosen up somewhat after moving around. But during the workday, there would always be some low grade stiffness. He continued to play soccer despite what he called the ‘minor irritation’, but would definitely feel more stiff and sore the next day. Lately, the pain had become more constant and he had to resort to talking some Advil before soccer games. He knew it was getting progressively worse and figured it was time to get it fixed.
David’s symptoms were pretty consistent with most folks who come to me for treatment of the Achilles. It often occurs in ‘older’ athletes and is of a gradual onset with achiness, stiffness and soreness being the early warning signs. However, once it becomes severe, each step you take can be very painful. Three types of Achilles injuries are possible: insertional, paratenonitis and non-insertional.
The least troublesome of the Achilles tendon overuse injury is paratenonitis. This injury represents an inflammatory reaction in the outer sheath of cells that surround the tendon. The first sign of this injury is a lump you can feel that forms a few inches above the Achilles attachment. Treatment for Achilles paratenonitis is to reduce the swelling with frequent ice packs. Wearing a night brace can also be effective with paratenonitis because tissues immobilized in a lengthened position heal more rapidly.
If the paratenonitis gets worse, it may eventually turn into a non-insertional Achilles tendinosis. This injury involves degeneration of the tendon approximately 2-4 cm above the attachment on the heel. Because this section of the tendon has such a poor blood supply, it is prone to injury and tends to heal very slowly.
Insertional tendinitis refers to inflammation at the attachment point of the Achilles on the heel. This type of Achilles injury is extremely difficult to treat and typically occurs in high-arched, inflexible individuals, particularly if they possess a Haglund’s deformity. Because a bursa is present near the Achilles attachment, it is common to have an insertional tendinitis with the retrocalcaneal bursitis.
As the body tries to go through the repair process, fibroblasts or collagen producing cells create different types of collagen during different stages of healing. However, because most people do not give the tendon adequate time to remodel and heal by not appropriately engaging in relative rest, a repeated series of small partial tears begin to form and actually act to ‘over’ lengthen the tendon. And typically what we see is a unequal increase in the range of ankle dorsiflexion (pointing toes towards the head) on the injured Achilles side. This is what was exhibited in David’s case.
I mentioned the need for ‘relative’ rest. With David, that meant several weeks off from the ballistic sport of soccer while he actively engaged in exercise that would assist recovery and proper remodeling of the Achilles tendon…much to his chagrin.
One particularly effective treatment protocol is to perform heavy-load eccentric calf muscle exercises. Research has shown that these exercises have been repeatedly shown to be highly effective in the management of non-insertional Achilles injuries. The next time your family doctor recommends trying a cortisone injection for the Achilles pain, tell him you’ll try eccentric exercises instead…cortisone injection have been shown to lower the stress necessary to rupture the Achilles tendon. You can kiss your sport season goodbye after that!
Another thing I got David to do were some closed kinetic chain tibialis posterior muscle exercises. A weak tibialis posterior muscle can cause compensatory stress placed on an already overworked Achilles tendon.
Besides aggressive strengthening exercises, another effective method I used with David is a form of deep-tissue massage called Graston Technique. This technique involves the use of stainless steel instruments scraped over affected tissues. Many of my patients fondly refer to them as “Dr. Keith’s medieval torture tools”. The theory behind this type of aggressive massage is that induces microtrauma that stimulates fibroblasts to accelerate repair of tissues in the extracellular matrix (e.g., collagen, elastin and proteoglycans). Using laser therapy after a Graston session also helps with pain improvement and tissue healing. Lately I’ve also been experimenting with kinesiology tape on the Achilles and other muscle injuries…it’s that stuff you see the Olympic beach volleyball players wearing. Neat stuff.
7 weeks after starting treatment, I cleared David to return to play. He’s happy soccer player once again. 🙂
Now it’s my own turn. Admittedly, sometimes it’s hard to follow the doctor’s advice! I can’t engage in ‘relative’ rest quite yet. I have 3 more weeks of training until my Taekwondo black belt test on August 18th…after that I will gladly engage in some rest!!!
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Your soon-to-be-black-belt-in-Taekwondo chiropractor,