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The achilles tendon (the heel cord), is a large tendon that is an extension of the two largest calf muscles. It travels down the back of the lower leg and attaches to the heel bone. The achilles tendon transmits the strong forces of the large gastrocnemius/soleus muscle group at the back of the calf from the lower leg to the foot.

achilles_tendonitis_pic.jpgAchilles tendonitis (tendinitis) is an extremely painful, and often debilitating aggravation of the tendon. Harm to this valuable tendon can make it hard or even impossible to walk. Most frequently, a debilitating injury to the tendon is the result of an accumulation of smaller stresses that cause small tears over time, although a sudden, single incident, such as jumping, can also be the cause of a serious problem.

Most injuries of the achilles tendon do not result from recent acute injury, but as stated above, develop gradually over weeks or months. These are "overuse" or "misuse" conditions caused by excessive and/or repetitive motion, often associated with poor biomechanics. The end result is a microtrauma injury: The body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or when the pain is eliminated by medication), continued stress eventually can lead to complete failure, with a resulting acute tear of the tendon.

Generally, the appearance of symptoms is gradual. The pain may be relatively minor at first, but continuously worsens if the individual tries to "work through" the pain. Many achilles tendonitis sufferers associate their initial discomfort to the aches and pains that have to do with age or fatigue. In severe cases, a total rupture of the tendon can arise, resulting in traumatic injury and intense pain that makes walking virtually impossible and may even require corrective surgery.

Athletes and performers, such as dancers, whose activities contain not only running and jumping, but sudden starts and stops, are especially vulnerable to achilles tendonitis. Also at risk are women who regularly wear high-heeled shoes then switch to sport shoes for exercise because the tendon and muscles have gradually conformed to the shortened position caused by wearing high-heels. When this occurs, the change to exercise or flat shoes forces the achilles tendon to stretch further than it is accustomed to, hence producing stress and inflammation. If possible, high-heels should not be worn everyday. But, if it is not possible, then stretching every morning and night can help to keep the achilles tendon lengthened.

As mentioned above, achilles tendonitis is oftenachilles_rupture_1.jpg age-related, especially in men who are athletes. As a person ages, the arch tends to flatten causing over-pronation and increased stress on the achilles tendon, as well as the calf and foot muscles. Achilles tendon conditions are also prevalent in those who exercise infrequently, such as the "weekend warrior" and in those who are just novices at exercise. In both cases, muscles and tendons have little flexability due to inactivity. Therefore, people who are just commencing to exercise after a long layoff should stretch properly, start slowly, and increase gradually.

It's not surprising that abnormal biomechanics of the foot and ankle can cause problems with the largest tendon in the leg. Symptoms usually are described as diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or stair climbing, and relieved somewhat by wearing higher-heeled shoes or boots. Palpation will reveal tender thickening of the peritendon, and there may be crepitus (joint noise) during plantar and dorsiflexion of the injured foot. Often, a recent increase in activity levels (such as more stair climbing) or a change in footwear is reported by the patient.

Rehabilitation of the Achilles Tendon

Despite the origin, if you are experiencing achilles tendonitis symptoms, it is vital for you to see a qualified professional. Conditions such as tendinitis and tears of this tendon require appropriate rehabilitation to prevent continuing problems and disability. Dr. Pisarek is a highly-skilled professional who can help you to manage the ailment before it becomes severe.

With acute injury an initial period of relative rest is needed. Occasionally, the weakened tissues will tear through, resulting in a ruptured achilles tendon. This may require surgical repair and a period of rest before rehabilitation can begin. During this period, however, exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (the "crossover effect"), and helps to prevent atrophy. Initial treatment also should include heel lifts to reduce the strain on the Achilles tendon, and crossfiber friction to improve circulation.

Complete return to function will require attention to range of motion, functional strength and orthotics (orthotic support):

  • Range of motion: In addition to appropriate foot and ankle adjustments, stretching of the tight and shortened gastrocnemius/soleus muscle complex is a necessary part of achilles tendon rehabilitation. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. The standard is the "runner's stretch," performed against a wall. Patients with tightness and pronation will often allow the foot to flare outward while stretching, which forces the medial arch to drop. This tendency must be carefully corrected, with the foot positioned straight ahead and the medial arch kept elevated. It is even better for the patient to perform the stretches with corrective orthotics in place.
  • Functional strength: Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation. These exercises should be progressed to closed-chain, heavily loaded eccentric exercises to stimulate collagen fiber re-orientation and strengthening. One example of these exercises requires that the patient sit on the edge of a stair, perform a toe raise-up, then rapidly drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg.
  • Orthotics (Orthotic support): A shoe insert made with shock-absorbing material will help decrease the amount of stress on the feet, legs, and back during running. Orthotics have been found to be quite useful in the long-term improvement of running biomechanics. While there is still controversy regarding exactly how and why orthotics are so useful, there is solid empirical evidence of their benefits to runners, both for treatment and prevention of overuse injuries. As described above, most achilles tendon problems develop from poor foot and ankle biomechanics, and control of pronation is needed to prevent recurrent injuries. Custom-made, flexible orthotics are now available that can support the hindfoot, midfoot and forefoot, thereby providing biomechanical control throughout the entire gait cycle.

Physiotherapy and Laser

At Advanced Healthcare, Dr. Pisarek has successfully used various physiotherapeutic modalities such as: kinesiology tape, ice, heat, ultrasound and interferrential currents in the management of achilles tendinitis, providing there were no contraindications to treatment present.  Over the past few years, Dr. Pisarek has also found that the application of low level laser therapy (LLLT) has shown to be very effective in reducing the pain and inflammation of tendinitis, and, appears to promote healing. Laser therapy for tendinitis may reduce the need for surgery and cut the healing time for tendinitis by as much as 50%.

The photons from the laser beam stimulate the cells of the damaged tissues increasing cellular reproduction and growth, increased blood flow and oxygen supply to the tissues thereby promoting faster tissue regeneration with wound healing and minimizing scar tissue formation. Laser therapy for tendinitis is also said to promote nerve cell regeneration.

If left untreated, tendonitis could become chronic and lead to a rupture (or tear) of the tendon, which would then require surgery. Even after surgery, permanent damage may not be avoided. So it's best to get any symptoms you may have of tendonitis checked out as soon as they arise.

Conclusion:

Achilles tendon injuries can be successfully rehabilitated conservatively with hands-on treatment. Steroid injections and casting are seldom used these days. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary. Chiropractic joint mobilization techniques, correct stretching and strengthening exercises can be demonstrated and monitored in Dr. Pisarek's office. One of the most important long-term goals is to reduce any tendency to pronate excessively. In addition to custom-made orthotics (Footmaxx) , all runners should be encouraged to wear well-designed shoes that provide good heel stability with a small amount of additional heel lift. This helps prevent achilles tendon problems, and is especially important in athletes who run more than a few miles at a time.

Prevention of Achilles Injuries:

Prevention of achilles tendonitis can be achieved with slowly increasing activity, purchasing quality foot wear, stretching, and cross-training. People who have had a history of achilles problems need to be conservative with their exercise and training programs. Big problems and injuries to the achilles tendon occur most commonly after ignoring small problems and pains. Pain is a warning sign something is wrong. Ignoring the problem often creates a more extensive injury.

Prevent small achilles injuries from becoming large injuries that require more time and treatment to correct by calling Dr. Pisarek today at (416) 633-3000.

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I have been a patient of Dr. Pisarek for a few years now. Every morning I have to say "thank you Dr. P.!". Your care and your treatment renew my energy... no more pains in my lower back, knee and foot. With your help I lost 20 pounds and I am keeping it off. I am really grateful to you and your wife Hilda for taking care of me. My retirement got a new meaning, thanks to you.

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