Injury assessment – Achilles Tendinopathy

Published 2nd October 2020 by mymo

In addition to gait analysis and running shoe recommendation, mymo customers will also be able to access additional running-related content.

As part of our market research, we asked you to rank in order, what added-value services you would like mymo to provide. You said you would like access to a virtual therapist a offering professional advice and guidance around injury prevention and strengthening exercises.

In this post, we wanted to show you one of those videos so you can see what they look like and how they will benefit you. We will be focusing on typical ‘running-related injuries’ and in this first one, we look at Achilles Tendinopathy. The detailed video is up to 24 mins long but please read Kev’s expert advice and assessment below.

What is going on with my tendon

When we have tendon pain, it’s often down to a disruption in collagen fibres or micro tears. We must bear in mind sometimes the pain does not correlate with damage, we may have a lot of pain but very small micro tears, think of a paper cut for example. A paper cut can be a lot of pain but very minimal tissue damage.

The body starts to lay down new fibers to replace the damaged ones, but it is thought to do so in a disorganised way. The new collagen fibres look much like a bundle of spaghetti when viewed on a microscope, unlike a healthy tendon which is in a smooth, parallel, aligned appearance.

Performing heel drops can help realign fibres so the Achilles can function better, as well as strengthening our healthy fibres.

History taking

A case of too much too soon? Have you recently increased mileage, intensity (such as more speed work or hills) or frequency (such from running 3 times per week to 5-7)?

Have you started running consecutive hard training days without recovery days?

Have you had a change in shoes – too much training in racing flats can be a prime example.

Has there been a change in the surface you run on such as track to cross country or vice versa?

Our tendons, muscles, bones and ligaments have a great capacity to adapt to load but only if done gradually. Hard training stresses and breaks tissue down, and recovery is where the magic happens.

Other key points to consider are work – are you on feet all day, and/or in uncomfortable work shoes? Stress can affect the body’s ability to recover too as well as poor sleeping, as can previous injuries even when they happened many years ago.

We must look at the whole person, not just the injured area.

Assessment

The starting point is always to watch how a person is walking. Are they showing any pain or limping? For Achilles, I’d usually have the patient on a plinth and check their active range of motion next.

On plantar flexion, dorsiflexion, inversion and eversion, I check their ability to actively point toes down, back towards shin and in and out. Then I passively test the ankle joint, where I would guide them through the above movements to their end range, testing the integrity of the ankle joint, seeing if there are any restrictions or pain.

We’d then move into some more functional tests. For runners I like to see how their ankle performs when weight bearing, so as we see in the video, we would test range of motion standing for soleus and gastrocnemius. Often with Achilles issues we may find dorsiflexion restricted due to pain, or be aware that dorsiflexion may have been restricted previously to injury and be a factor in causing the new injury.

Next, I like to see how the Achilles functions doing some calf raises (this will also guide me in terms of rehab, for example if someone can’t perform one calf raise, me prescribing 3×15 calf raises single leg and heel drops is going to be counterproductive). I would look at the patient performing calf raises on a single leg, straight leg and bent leg, or if they are struggling to weight bear, we start with a double leg effort. Next, I would get the patient on a step to see how the Achilles copes with eccentric load (the calf/Achilles complex to contract and lengthen). Another good test is hopping and seeing the patient on the treadmill assessing gait

Sometimes over pronation can cause a whipping effect on Achilles, but I would look further up the kinetic chain such as knee control, pelvic drop and arm swing. It’s also useful to watch the patient from the side – are they right up on toes? Any asymmetries? Over striding?

All of these things give me a clearer picture of the patient’s Achilles, and helps me to structure a personalised, tailored rehab plan for the individual.

Treatment

The bit everyone wants, and expects a magic “fix”

Unfortunately, there is no quick fix, we can just help to put the injured area in its optimal environment to aid the body’s amazing healing process. We may get some reduction in pain post treatment, but as I say to patients, “it isn’t the hour in the clinic which will heal you, but what you do in the other 23 hours of the day.”

Achilles treatment may include deep tissue massage to the calves (and hamstrings/glutes if required), transverse frictions on Achilles – like a strumming on guitar motion, however I would avoid this if synovial sheath or bursa is suspected.

Your therapist may also offer other modalities e.g. shockwave, ultrasound or acupuncture.

Rehab exercises

There is no magic recipe, it is down to what we find in our history taking and assessment. If the patient’s pain is less than a 5/10 on single leg calf raises, we may start with 3×15 single leg calf raise with straight and bent leg (both legs), then some eccentric calf raises on the step using the ‘Alfredson et al’ protocol going up on two and down on one.

Sets and reps (repetitions) are a guide and always good to have a regression option if they irritate the injury and a progression option that can make it more challenging. Again, we want to ‘stress’ the Achilles to provoke adaptation and healing. Eccentric heel drops have been shown to help reorganise the structure of Achilles tendons. Only when pain allows, we may combine some other exercises as shown in the video such as doing a squat, bridge or lunge with added heel raise. Some people may find a heel raise in their shoe can also help to offload the Achilles.

Can I run?

The question I’m most often asked! I try to ask patients to rate their pain on a scale of 1-10 with 10 being the worst. I like to know pain during activity, but often more importantly is their pain 24-48hrs post activity, between 1-4 I find is acceptable. I err on the side of caution, as overdoing it or no change in load can quickly escalate. A score of 4-6, I’d maybe advise rest or at least a reduction in mileage and more recovery, a break from speed work too, 7+ the tendon sounds very reactive, and I’d advise a rest till the pain settles.

The key is to listen to your body, only increase the load if pain is easing. It’s much better to take a step back when pain is minimal than ‘run through it’ and maybe end up with chronic Achilles tendinopathy and a longer lay off!

Differential diagnoses and other issues to be aware of are tibialis posterior tendinopathy (often further toward inner ankle bone), retro calcaneal bursitis, peroneal tendinopathy (more forward toward outer ankle). Insertional Achilles tendinopathy is usually more around heel bone.

All of the above will need a different rehab plan so as always, if you’re unsure don’t guess, get it checked by your therapist.

Thank you for taking your time to read this and watch our video https://vimeo.com/453112068

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