By Dr. Brian Abelson DC. Calgary, Alberta,
Canada
In this article…
|
Athletes suffer from
three common types of injury to the Achilles Tendon:
 Paratenonitis – usually referred to
as Achilles Tendonitis.
Tendinosis. – This is usually a non
tender palpable nodule or cord at the Achilles tendon.
Rupture of the Tendon (either
partial or complete).
|
Paratenonitis:
|
Is an inflammation of the Paratenon - a sheath surrounding the Achilles tendon. Paratenonitis is
often caused by repetitive strain or over-use. This injury is common in triathletes.
|
|
Tendinosis:
|
Refers to degeneration within the tendon due to a previous tear.
This condition can be felt as a palpable tendon nodule very close
to the heel. The nodule is formed by the accumulation of scar tissue.
Circulation to the
Achilles tendon is very poor, especially near the heel, resulting in poor
oxygen supply. This results in poor
healing and formation of microscopic tears, causing the tendon to thicken.
Chronic Achilles Tendinosis can lead to a complete
rupture if it is not treated and rehabilitated correctly. If not addressed,
this condition may be a warning sign of worse things to come.
|
|
Ruptured Tendon:
|
A complete rupture is where the tendon has completely separated
from the Calcaneus (heel bone). This can occur when Paratenonitis and
Tendinosis were not correctly treated and rehabilitated.
Surgical intervention is the only solution to this condition.
|
|
|
About the Achilles Tendon
The Achilles tendon is the strongest and
largest tendon in the body. It is extremely vulnerable to injury due to its limited
blood supply and the numerous forces to which it is subjected.
The Achilles tendon is known as a co-joined
tendon. This tendon directly joins into
Gastrocnemius and the Soleus muscle (calf muscles). The Achilles tendon transmits the force of the calf muscles
(Gastrocnemius and Soleus) to produce the push-off during walking, running, and
jumping.
The area of the tendon (approximately 2 to
6 cm above its insertion into the Calcaneus) has the poorest blood supply, and
therefore heals the most slowly. This makes it extremely susceptible to injury.
Causes of Achilles Tendon
Injuries
|
|
In triatheletes, the
most common cause of injuries to the Achilles tendon is overpronation,
inflexibility, or lack of strength.
The repetitive stresses caused by
running and cycling can cause friction and inflammation. The body responds to
inflammation by laying down scar tissue (adhesive tissue) in an attempt to
stabilize the area. Once this happens, an ongoing cycle begins that worsens
the condition.
Inflexibility is often caused by the
build-up of these adhesions, either within the soft tissue or within
structures above or below the tendon’s kinetic chain.
In
cyclists, the initial stress is often caused by having a low saddle height.
This low saddle height can result in excessive dorsiflexion of the foot,
which stresses the Achilles Tendon.
In
runners, too rapid an increase in mileage, hill training without proper
strengthening, and recent or inadequate changes to running gear can cause
injuries to the Achilles Tendon.
A
tight muscle is a weak muscle. Runners with weak, or unstable calf muscles
place increased stress on their Achilles Tendon. Weakness in the Gastrocs and Soleus can cause abnormal
pronation during the stance phase of the normal gait cycle.
|
Always Consider the Kinetic
Chain
Any restrictions in the kinetic chain of
the Achilles tendon, either above or below the tendon, can affect the
functioning of the Achilles tendon. Such structures would include:
|
1. Hamstring muscles - The upper portion of the gastrocnemius
(superficial calf muscles) are in contact with biceps femoris,
semitendinosus, and semimembranosis
(three sections of the hamstrings).
2. Plantaris muscle - This
muscle inserts into the middle one third of the posterior calcaneal surface
(heel bone), just on the inside of the Achilles Tendon.
3. Popliteus muscle - This
muscle is involved in medial knee rotation. When it is restricted, it may
cause increased stress on the lower extremities.
4. Flexor Hallicus Longus, Flexor Hallicus Brevis, and the Tibialis
Anterior, muscles. These muscles are involved in cases of increased pronation
and hyperpronation.
|
The above illustration shows the posterior
muscles that are located further up
the kinetic chain from the Achilles Tendon.
|
The Injury Process
Hyperpronation,
muscle restrictions, or lack of flexibility
of the Achilles tendon creates increased stress, internal pressure, or a
state of friction that leads to inflammation.
|
  
Hyper-pronation
Inflexibility
Decreased Strength
Decreased Performance
Major Injury
|
|
  
|
The
Cumulative Injury Cycle
|
|
|
Chronic irritation to
the Achilles tendon leads to small tears within the tendon, making the tendon
susceptible to further injury and causing a build-up of scar tissue within
the tendon.
Once the inflammatory condition has started, even the simple task of just standing can put
considerable internal pressure on the Achilles Tendon.
This constant internal pressure limits circulation to the tissue resulting in
decreased delivery of oxygen to soft tissues. Decreased oxygen causes several
biochemical changes that result in the formation of yet more adhesions within
the Achilles Tendon. This in turn
creates more restrictions, inflammation, and swelling.
The body responds to inflammation by
laying down additional scar tissue (cross fibers across the tissue) in an
attempt to stabilize the affected area. This scar tissue:
Restricts motion.
Reduces circulation.
Inhibits nerve function.
Causes ongoing friction and
pressure.
Results in the production of yet
more cross fibers and adhesions across inflamed soft tissues.
|
Copyright Dr. Mike Leahy
Ineffective Treatments
We have seen numerous case of Achilles
Tendonitis that were needlessly prolonged or that became chronic problems due to
the application of ineffective treatments. Improper treatment of an Achilles
Tendon injury can lead to major problems.
Cross friction massage often irritates this
area, increasing the time required for recovery rather than reducing recovery
times.
Additional problems often arise when a
therapist uses direct, heavy pressure and tension over the Achilles Tendon.
Steroid injections should be avoided whenever
possible. Research has shown the
steroid injections cause an increase in the incidence of rupture of the
Achilles tendon.
At the very least, many of these treatments
have drastically decreased the Triatheletes level of performance.
The Need for a Specific
Diagnosis
|
|
It is extremely important to be as specific as possible when
identifying the soft tissue structures involved with this condition.
Different athletes may present with identical pain
patterns at the Achilles tendon, yet they may have completely different
structures that are impairing motion or causing the injury.
Before treatment takes place, an extremely specific
examination and diagnosis must be performed.
It is important to look past the initial point of pain
and identify all the other structures that are involved in the kinetic chain.
|
Treating Injuries to the
Achilles Tendon with ART
Active Release Technique (ART®)
is very successful at treating this type of injury since it removes restrictive
adhesions between both the superficial and deep tissue structures along the
entire kinetic chain.
Trained ART practitioners perform a
biomechanical analysis of athletes to determine where the restrictions are
located along the entire kinetic chain.
ART treatments are specific and based upon the individual needs of each
athlete. It is not a cookbook approach to treating a non-specific diagnosis.
For example:
If the fascial tissue anterior to the
tendon is restricted (which commonly occurs in this condition), ART procedures
can be used to release the adhesions.
Other structures in the kinetic chain
are similarly treated.
ART® finds the specific tissues that are
restricted and physically works them back to its normal texture, tension, and
length by using various hand positions and soft tissue manipulation
methods. While breaking up the
adhesions can be uncomfortable at times, it is important to reproduce the
symptoms.
Effective treatment of the Achilles tendon,
or of any soft tissue injury, requires an alteration in tissue structure that
breaks up the restrictive cross-fiber adhesions and restores normal function to
the affected soft tissue areas. When executed properly, this process
substantially decreases healing time, treats the root cause of the injury, and
improves athletic performance.
With ART we often see immediate improvement after treating
the involved structures.
Post Treatment Exercises
Strengthening
the Calf muscle and the entire related kinetic chain is extremely important in
order to ensure that injuries to the Achilles Tendon do not return.
Strengthening
exercises are only effective if they are executed after the adhesions
within the soft tissue have been released.
Attempts to strengthen muscles bound by adhesions often cause the
structure to become more restricted, which in turn causes additional tension
within the soft tissue.
Research has shown that using eccentric
contractions (lengthening of the muscle during
contraction) is one of the most effective types of
strengthening exercises for the calf muscles. This concept can be applied to
the entire kinetic chain.
In addition to the strengthening component, stretching, and
balance exercises continue to be key components in correcting the problem to
ensure that the problem does not reoccur.
Finding an ART Practitioner
You can find a qualified ART provider by visiting the official
Active Release Techniques website at. www.activerelease.com.
You can also call ART headquarters at 1-888-396-2727. At your next
Ironman race, look for the ART Performance Care tent. Our soft tissue experts are
available to help you reach your full potential.
Dr. Brian Abelson
DC, ART
Dr. Brian Abelson is
Clinical Director of Edgemont Chiropractic Clinic. Dr. Abelson is a native
Calgarian who graduated from Palmer College of Chiropractic West with an award
for clinical excellence, holds a Level 3 Active Release Certification, and is
an ART Assistant Instructor. He is also
the author of the award winning
websites: www.drabelson.com and www.activerelease.ca .
Author: Dr. Brian Abelson
Editor: Kamali Abelson, Rowan Tree Consulting Ltd.
Edgemont Chiropractic Clinic
Bay #10, 34 Edgedale Drive N.W.
Calgary, Alberta, T3A-2R4