Friday, May 23, 2014

Your Achilles Heel: Dealing with Achilles pain



Overuse injuries are the “Nature of the Beast” when it comes to training for something like the Barber Beast on the Bay.  One of the most common overuse injuries in runners is Achilles Tendonitis or Achilles Tendinopathy. Tendinopathy is a descriptive term for clinical conditions arising from tendon injury and overuse both within and around tendons.1 Several years of research on overuse injuries have shown that the term “tendonitis” is a misnomer in most people with tendon pain, because the suffix “-itis” implies an active inflammatory process. We know now that most tendon pain lacks the presence of inflammatory cells,2 and the treatment surrounding tendon injuries has changed dramatically in recent times.
Previous “old school” treatment for Achilles “tendonitis” included: rest, ice, ultrasound, electrical stimulation, iontophoresis with Dexamethasone, stretching, night splints, heel lifts, shoe orthotics, immobilization, etc.  In cases where frank inflammation is present, treatments are effective in relieving symptoms, and these treatments are still recommended at the early onset of Achilles pain. However, when symptoms persist to a chronic stage, or when these treatments have failed, a fairly new exercise regimen has been shown to be effective in 90% of people with pain in the mid-tendon and 30% of those with pain at the insertion of the tendon (at the heel).3-5
This newer regimen involves eccentric loading of the Achilles tendon.  Eccentric exercises are those where a muscle is lengthening while it is contracting.  For example, with a bicep curl, the eccentric portion of the exercise is when you’re lowering the weight back down toward the resting position.  In the case of the Achilles tendon, eccentric exercises are known as heel drops. Hakan Alfredson, an orthopaedic surgeon in Sweden, found that the eccentric regimen can take up to 12 weeks to completely resolve the symptoms, especially when the symptoms have been present for several months. He points out the “need for patients to complete the exercise protocol despite pain in the tendon. If patients experience no tendon pain doing the program, the load should be increased until the exercises provoke pain.  This idea sounds counter intuitive; however, Alfredson discovered this as an effective exercise when he was experiencing Achilles pain himself.  He had asked one of his colleagues to perform surgery on him, and they refused.  He attempted to rupture his tendon (so that surgery was necessary) using the most difficult contraction that a tendon must perform (eccentric), and found his symptoms improving. This lead to several studies on the effects of eccentric exercise on tendinopathy, particularly, Achilles tendinopathy. Of course, stretching prior to and after each run is still recommended to prevent the onset of Achilles tendinopathy. 



The symptomatic Achilles in this picture is the right.  A. Rise up onto the non-symptomatic side to avoid concentric (shortening) contraction of the symptomatic Achilles. B. Then place symptomatic foot onto step with toes pointing down. C. Finally, lower all of your body weight, eccentrically (lengthening) with the symptomatic foot, so that heel drops below the step.





If you’re experiencing Achilles tendon pain with your Beast on the Bay training, and rest, ice, and stretching have been ineffective in relieving your pain, you may benefit from eccentric loading of the tendon. It is imperative that other conditions are ruled out, such as Achilles tendon tears, posterior impingement, os trigonum, and osteoarthritis prior to starting an eccentric loading regimen. Contact the experts at Saint Vincent Rehab Solutions prior to beginning an eccentric loading regimen.


References



  1. Mobasheri A, Shakibaei M. Is tendinitis an inflammatory disease initiated and driven by pro-inflammatory cytokines such as interleukin 1β? Histol Histopathol 2013; 8:955-64.

  2. Maffulli N1, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology.  Arthroscopy 1998; 14(8):840-3.

  3. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-6.

  4. Fahlström M, Jonsson P, Lorentzon R, et al. Chronic Achilles tendon pain treated with eccentric calf muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-33.


     5. Roos E, Engstrom M, Lagerquist A, et al. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy: a randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004; 14:286-95. 



 


Jason Dudzic, PT, MSPT, OCS, Cert. MDT
Board Certified Orthopaedic Physical Therapist
Saint Vincent Rehab Solutions
814.452.5231

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