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Posted: June 6, 2004

Sportsmedicine: Achilles Tendonitis and Achilles Tendon Injury - Prevention & Treatment Strategies

Every week I get asked for information on Achilles tendon injury. So instead of constantly referring people to other sites, I thought it was time to write an article on Achilles tendon injury myself.

Achilles injuries are commonly associated with sports that require a lot of running, jumping and change of direction. Excessive twisting or turning of the ankle and foot can result in a rupture or strain. The sports that are most susceptible to Achilles injury include running, walking, cycling, football, basketball and tennis.

What is an Achilles tendon Injury?

Firstly, let's take a look at where the Achilles tendon is located and what it does.

As you can see from the diagram above, the Achilles tendon is located at the rear (posterior) of the bottom half of the lower leg. In the diagram it is represented by the thick band of connective fibre that runs from bottom of the Gastrocnemius muscle to the heel bone.

The Achilles tendon is used to plantar flex the foot, or point the foot downward. This allows a person the run, jump and stand on one's toes.

The Achilles tendon is the strongest tendon of the body, and able to withstand a 1000 pound force without tearing. Despite this, the Achilles ruptures more frequently than any other tendon because of the tremendous pressures placed on it during competitive sports.

There are two main types of injuries that affect the Achilles tendon; Achillis Tendonitis and Achilles Tendon Rupture.

Achilles Tendonitis is simply an inflammation of the tendon, and in most cases is caused by excessive training over an extended period of time.

Achilles Tendon Rupture, on the other hand, is a tear (or complete snapping) of the tendon, and usually occurs as the result of a sudden or unexpected force. In the case of a complete rupture, the only treatment available is to place the lower leg in a plaster cast for 6 to 8 weeks, or surgery. As both of these treatments are beyond the scope of this newsletter, we'll be focusing the rest of this article on Achilles Tendonitis.

Causes and Risk Factors

There are a number of causes and risk factors associated with Achilles Tendonitis. One of the most common causes is simply a lack of conditioning. If the tendon, and muscles that connect to the tendon, have not been trained or conditioned, this can lead to a weakness that may result in an Achilles injury.

Overtraining is also associated with Achilles Tendonitis. Doing too much, too soon places excessive strain on the Achilles tendon and doesn't allow the tendon enough time to recovery properly. Over time small tears and general degeneration result in a weakening of the tendon, which leads to inflammation and pain.

Other causes of Achilles injury include a lack of warming up and stretching. Wearing inadequate footwear, running or training on uneven ground, and simply standing on, or in something you're not meant to. Biomechanical problems such as high arched feet or flat feet can also lead to Achilles injuries.

So what are some of the things you can do to help prevent Achilles Tendonitis?

1. Warm Up properly
A thorough warm up is essential to get the body ready for any activity. A well structured warm up will prepare your heart, lungs, muscles, joints and your mind for strenuous activity. If you'd like to know more about the warm up, visit http://www.thestretchinghandbook.com/archives/warm-up.htm.

2. Plyometric Training
Plyometric drills include jumping, skipping, bounding, and hopping type activities. These explosive types of exercises help to condition and prepare the muscles, tendons and ligaments in the lower leg and ankle joint.

3. Balancing Exercises
Any activity that challenges your ability to balance, and keep your balance, will help what's called proprioception: - your body's ability to know where it's limbs are at any given time.

4. Stretch and Strengthen
I'll cover these in a lot more detail a little later on when I discuss rehabilitation and conditioning exercises.

5. Footwear
Be aware of the importance of good footwear. A good pair of shoes will help to keep your ankles stable, provide adequate cushioning, and support your foot and lower leg during the running or walking motion.

Earlier we took a look at exactly what an Achilles injury is. We had a look at the muscles and tendons that make up the Achilles; what happens when an Achilles injury occurs; and the major causes and risk factors that contribute to Achilles injury.

In this section 2, we're going to outline a detailed strategy for the complete treatment and rehabilitation of Achilles tendonitis. Firstly, we'll look at the importance of the immediate treatment (the first 48 to 72 hours), and then we'll outline the ongoing treatment necessary for a full recovery.

Immediate Treatment

The immediate treatment of any soft tissue injury is vital. Proper care and treatment now will go a long way towards a full recovery later.

Without a doubt, the most effective, initial treatment for Achilles tendonitis is the R.I.C.E.R. regime. This involves the application of (R) rest, (I) ice, (C) compression, (E) elevation and obtaining a (R) referral for appropriate medical treatment.

Where the R.I.C.E.R. regime has been used immediately after the occurrence of an injury, it has been shown to significantly reduce recovery time. R.I.C.E.R. forms the first, and perhaps most important stage of injury rehabilitation, providing the early base for the complete recovery of injury.

When an Achilles injury occurs and the tendon has been damaged there is a large amount of uncontrolled bleeding around the injury site. This excessive bleeding causes swelling, which puts pressure on nerve endings and results in increased pain. It is exactly this process of bleeding, swelling and pain that the R.I.C.E.R. regime will help to alleviate.

R.I.C.E.R.

R: (rest) It is important that the Achilles and lower leg be kept as still as possible. This will help to slow down blood flow to the tendon and prevent any further damage.

I: (ice) By far the most important part. The application of ice will have the greatest effect on reducing bleeding, swelling and pain. Apply ice as soon as possible after the injury has occurred.
How do you apply ice? Crushed ice in a plastic bag is usually best. Although blocks of ice, commercial cold packs and bags of frozen peas will all do fine. Even cold water from a tap is better than nothing at all.
When using ice, be careful not to apply it directly to the skin. This can cause "ice burns" and skin damage. Wrapping the ice in a damp towel generally provides the best protection for the skin.
How long? How often? This is the point where few people agree. Let me give you some figures to use as a rough guide, and then I'll give you some advice from personal experience. The most common recommendation is to apply ice for 20 minutes every 2 hours for the first 48 to 72 hours.
These figures are a good starting point, but remember, they're only a guide. You must take into account that some people are more sensitive to cold than others. Also be aware that children and elderly people have a lower tolerance to ice and cold. Finally, people with circulatory problems are also more sensitive to ice. Remember to keep these things in mind when treating yourself or someone else with ice.
Personally, I recommend that people use their own judgement when applying ice to themselves. For some people, 20 minutes is way too much. For others, especially well conditioned athletes, they can leave ice on for much longer. The individual should make the decision as to how long the ice should stay on.
My personal recommendation is that people should apply ice for as long as it is comfortable. Obviously, there will be a slight discomfort from the cold, but as soon as pain or excessive discomfort is experienced, it's time to remove the ice. It's much better to apply ice for 3 to 5 minutes a couple of time an hour, than not at all.

C: (compression) Compression actually achieves two things. Firstly, it helps to reduce both the bleeding and swelling around the Achilles, and secondly, it provides support for the ankle and lower leg. Use a wide, firm, elastic, compression bandage to cover the entire ankle and lower leg.

E: (elevation) Simply raise the injured leg above the level of the heart at all possible times. This will further help to reduce the bleeding and swelling.

R: (referral) If the injury is severe enough, it is important that you consult a professional physical therapist or a qualified sports doctor for an accurate diagnosis. They will be able to tell you the full extent of the injury.

Before we finish with the initial treatment and move onto the next phase of the rehabilitation process, there are a few things that you must avoid during the first 72 hours.

Be sure to avoid any form of heat at the injury site. This includes heat lamps, heat creams, spas, Jacuzzi's and saunas. Avoid all movement and massage of the injured area. Also avoid excessive alcohol. All these things will increase the bleeding, swelling and pain of your injury. Avoid them at all costs.

After the first 48 to 72 hours?

So what happens after the first 48 to 72 hours? Let's first take a quick look at how damaged tendons repair themselves.

When any damage occurs to the soft tissue (muscles, tendons, ligaments), the body immediately goes into a process of repair. Where the individual fibres have been ruptures, or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen. Or, as it's more commonly known, scar tissue!

When a tendon is torn or strained, you would expect that the body would repair that damage with new tendon. In reality, this doesn't happen. The tear or rupture, is repaired with scar tissue.

Now this might not sound like a big deal, but if you have ever suffered an Achilles injury, (or any soft tissue injury) you'll know how annoying it is to keep re-injuring that same old injury, over and over again.

Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged tendon in an effort to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. In some cases it's even possible to see and feel this bulky mass under the skin.

When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished, but flexibility of the tissue is also compromised.

So, how do we get rid of that annoying formation of scar tissue?

Firstly, you must keep active! Don't listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity.

Light activity will not only promote blood circulation, but it will also activate the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system.

Before we move on, a quick word of warning. Never, Never, Never do any activity that hurts the injured area. Of course you may feel some discomfort, but NEVER, NEVER push yourself to the point where you're feeling pain. Listen to your body. Don't over do it at this stage of the recovery, you've come too far to blow it now.

To remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is commonly used by physical therapists (or physiotherapists), and primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.

You see, the Achilles tendon receive very little blood supply, as compared to a muscle for example. So it's vitally important to increase the blood flow to the injured area. This will help supply the tendon with the oxygen and nutrients they need for a speedy recovery.

Physical Therapists accomplish this aim by using a number of activities to stimulate the injured area. The most common methods used are ultrasound and heat.

Ultrasound, or TENS (Transcutaneous Electrical Nerve Stimulation) simply uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues.

Secondly, to remove the unwanted scar tissue it is vital that you start to massage the injured tendon and connecting muscles. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that.

To start with, the Achilles tendon may be quite tender. So start with a light stroke and gradually increase the pressure until you're able to use firm strokes.

Concentrate your effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue.

Just a few final points before we move on. Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body.

Also, I recommend you purchase a special ointment to use for your massage called "Arnica". This special ointment is extremely effective in treating soft tissue injuries, like sprains and tears. You can purchase this ointment at most health food shops and pharmacies.

As usual, I've gone on way too long, and I'm not finished with this topic yet. I still need to cover the rehabilitation and conditioning exercises needed to get your Achilles tendon back to 100%, but I'm going to have to leave it till next issue. This final part of the rehabilitation process is vitally important, and I think it deserves an entire issue.

© 2003, Walkerbout Health. All rights reserved.

Article by Brad Walker. Brad is a leading stretching and sports injury consultant with over 15 years experience in the health and fitness industry. For more articles on the prevention & treatment of sports injury, subscribe to The Stretching & Sports Injury Newsletter by visiting www.thestretchinghandbook.com.

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