Dr. Pribut on Achilles Tendonitis, Tendinopathy and Tendinosis

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Dr. Pribut on Achilles Tendonitis, Tendinopathy and Tendinosis



Achilles Tendonitis, Tendinopathy and Tendinosis
The Scoop On Achilles Tendon Injuries
by Stephen M. Pribut, D.P.M.
Achilles Tendon Pain: Symptoms and Causes
Achilles tendonitis is the bane of many runners. You shouldnot allow this to turn into a chronic and troubling malady leadingto moans about how it will never end, contributing to roadsidesstrewn with air cushioned clad runners, all with ice packs attachedto their heels. First, we will review some basic informationabout the achilles tendon.

The Achilles tendon is the connection between the heel and themost powerful muscle group in the body. This has long been knownas a site which is prone to disabling injury. Forces up to 12 times bodyweight (9kN) may arise during sprinting. This tendon is namedafter Achilles, who according to myth, was protected from woundsby being dipped in a magical pond by his mother. She held himby the heel, which was not immersed, and later died by an arrowwound in his heel. Although injuries to this areamust have been known for more than 2,000 years, it was firstreported in the medical literature by Ambroise Par? only 400years ago.

"...the biggest contributor to chronic achilles tendonitis is ignoring pain."

The Achilles tendon joins three muscles: the two heads of thegastrocnemius and the soleus. The gastrocnemius heads arise fromthe posterior portions of the femoral condyles. The soleus arisesfrom the posterior aspect of the tibia and fibula.

The gastrocnemius is a muscle that crosses three joints: theknee, the ankle, and the subtalar joint. The functioning of thesejoints and influence of other muscles on these joints has a significanteffect on the tension that occurs within the achilles tendon.As an example tight hamstrings impact the functioning of theankle joint, the subtalar joint, and increase tension in theachilles tendon. The soleus does not cross the knee and is abiarticualar muscle.

The plantaris is a nearby muscle that has its separate tendon.It arises from the lateral condyle of the femur. It has a thintendon that passes between the gastrocnemius and soleus and insertsinto the calcaneus. When this musclculotendinous structure isinjured it is frequently felt as a "pellet shot" inthe back of the leg. The tear is usually about eight inches belowthe knee joint.

The bulk of the achilles tendon inserts into the posterior superiorthird of the calcaneus. Some fibers course distally and continueto where portions of the plantar fascia insert into the plantaraspect of the calcaneus.

The achilles tendon does not have a rich blood supply. The bloodsupply has been found to be weakest at a point between 2 and6 cm above its insertion into the calcaneus. (Although Astromfound with Doppler flow measurements the least vascularity atthe insertion.) It is not invested within a true tendon sheath.A paratenon composed of other soft tissue surround it. The outerlayer is a portion of the deep fascia, the middle layer is calledthe mesotenon and the inner layer is contiguous with a thin layersurrounding the tendon itself (epitenon). The blood supply tothe proximal portion of the tendon comes from the branches ofthe muscles themselves. The distal portion is supplied by branchesfrom the tendon-bone interface. The mesotenon supplies the majorblood supply to the Achilles tendon.

Contributing Factors
There are several factors that can contribute to achillestendonitis. First, you should know that the biggest contributorto chronic achilles tendonitis is ignoring pain in your achillestendon and running through the pain of early achilles tendonitis.If your achilles tendon is getting sore it is time to pay attentionto it, immediately.

Sudden increases in training can contribute to achillestendonitis. Excessive hill running or a sudden additionof hills and speed work can also contribute to this problem.Two sole construction flaws can also aggravate achilles tendonitis.The first is a sole that is too stiff, especially at theball of the foot. (In case you are having difficulty locatingthe "ball" of your foot, I mean the part where thetoes join the foot and at which the foot bends) If this areais stiff than the "lever arm" of the foot is longerand the achilles tendon will be under increased tension and thecalf muscles must work harder to lift the heel off the ground.

The second contributing shoe design factor which may lead tocontinuing achilles tendon problem is excessive heel cushioning.Air filled heels, while supposedly are now more resistant todeformation and leaks are not good for a sore achilles tendon.The reason for this is quite simple. If you are wearing a shoethat is designed to give great heel shock absorption what frequentlyhappens is that after heel contact, the heel continues to sinklower while the shoe is absorbing the shock. This further stretchesthe achilles tendon, at a time when the leg and body are movingforward over the foot. Change your shoes to one without this "feature".

Of course another major factor is excessive tightness of theposterior leg muscles, the calf muscles and the hamstrings maycontribute to prolonged achilles tendonitis. Gentle calf stretchingshould be performed preventatively. During a bout of acute achillestendonitis, however, overly exuberant stretching should not beperformed.

Treatment
The first thing to do is to cut back your training. If you areworking out twice a day, change to once a day and take one ortwo days off per week. If you are working out every day cut backto every other day and decrease your mileage.Training modificationis essential to treatment of this potentially long lasting problem.You should also cut back on hill work andspeed work. Post running ice may also help. Be sure to avoidexcessive stretching. The first phase of healing should be accompaniedby relative rest, which doesn't necessarily mean stopping running,but as I am emphasizing, a cut back in training. If this doesnot help quickly, consider the use of a 1/4 inch heel lift canalso help. Do not start worrying if you will become dependenton this, concentrate on getting rid of the pain. Don't walk barefootaround your house, avoid excessively flat shoes, such as "sneakers",tennis shoes, cross trainers, etc.

"...Training modification is essential."

In office treatment would initially consist of the use of thephysical therapy modalities of electrical stimulation, (HVGS,high voltage galvanic stimulation), and ultrasound. Your sportsmedicine physician should also carefully check your shoes. Aheel lift can also be used and control of excessive pronationby taping can also be incorporated into a program of achillestendonitis rehabilitation therapy. Orthotics with a small heellift are often helpful.

Exercises to Avoid
Excessive stretching is not good for your achilles tendon. Thestretch that I most often recommend is the "wall stretch".I do not recommend the "stair stretch", the "inclinestretch", or the "put a towel around your feet andpull up until it hurts stretch". If any of these are workingfor you, that's great, you don't need any advice. In most cases,for the patients I see, these stretches put too much tensionon the already tender achilles tendon. Contracting the musclewhen it is in a stretched position, as initial therapy of aninjured achilles tendon is not a good thing.

Treatment Outline:Relative rest (see above)Cut back mileageLower intensityAvoid hills, speedwork, plyometricsAvoid over-stretchingGentle stretch after warm-upStart with Straight leg calf stretch, build up muchlater to bent leg, consider eccentric stretch later.Ice Massage10 to 20 minutes after exerciseNSAIDsAlleve, Motrin, etc. 10 - 14 days.Check Running ShoesReplace if heel is wornReplace if excessive heel shock absorption (soft airsole cushion, excessive gel shock absorption)Replace if shoe is excessively stiff at the "breakpoint" (ball of foot).Physical Therapy ModalitiesHVGS (electrical stimulation)UltrasoundExercise instruction: Strength and flexibility
Current Concepts
While Achilles tendon problems are widespread, the terminologyused to describe them is often inaccurate and is undergoing asignificant transition. First to be precise we must considerwhere along the course of the tendon does the problem exist.This may be in one of three main areas:
InsertionMusculo-tendinous JunctureNon-insertional (main body of tendon)
While the term that most people use and that most individualswill search for on the web is "tendonitis", most Achillestendon problems could better be called a tendinopathy and morespecifically a tendinosis and are a non-inflammatory problemof the tendon. Inflammatory cells are not found on microscopicexamination.

Clinically there may be two differing entities in acute achillestendinopathy:
PeritendonitisInflammation in the tissue surrounding the tendonOften 2 - 6 cm above insertionPossible crepitus with long standing injury (paratenonwith fibrin exudate)In chronic tendinopathy approximately 20% of the injuredperitendinous area are scar forming myofibroblast cells.TendinosisImpairment of circulation with resulting damage totendon structureFocal areas of tendon degeneration
Future Research and Solutions
Much future research and better understanding of these injuriesis needed. In spite of the vagaries of scientific understandingof these entities a successful approach using training modification,stretching, strengthening and appropriate return to exercisemay be undertaken. At this time there are few significant clinicalstudies with valid results for treatment. There is often disagreementon approach and much is likely to be changed in the future. Atthis point treatment and treatment recommendations for this problemremain an art practiced with varying degrees of success. Whenevaluating new research, it is hard to recommend major paradigmchanges in thought and recommendations based on studies of fewerthen 20 cases or even 50 cases.

Stretching Demonstration
As anyone knows who has spent time on my web site, I am not a fan of excessive stretching for this problem. In individuals who are experiencing pain, I advise against the stair stretch, particularly if you've been trying it already for 6 weeks or more and found only more pain, and no improvement. In early cases of pain, I like to restrict stretching, thangraduate to the wall stretch, and then the wall stretch with a bent knee.

Roxanne Darling of Beachwalks with Rox does an excellent job of demonstrating a variety of stretches from the hard to the easy. For those without pain, you may carefully follow Rox's example of the stair stretch if you'd like. If you have pain, skip the stair stretch fornow. Start with the straight leg, wall stretch and about 3 weeks - 4 weeks later add the bent knee variation. Read this article in its entirety. In the meantime, if you need a little downtime and some chilling, visit Beachwalks With Rox for words of wisdom, thought and relaxation.

Visit: Rox's Stretching demonstration

Beachwalks With Rox

Achilles Tendon Ruptures
The achilles tendon is the connection between the heel and themost powerful muscle group in the body. This has long been knownas a site prone to disabling injury. It is named after Achilles,who according to myth was protected from wounds by being dippedin a magical pond by his mother. She held him by the heel, whichwas not immersed, and later died by an arrow wound in his heel.Although obviously, injuries to this area must have been knownfor more than 2,000 years, it was first reported in the medicalliterature by Ambroise Par? only 400 years ago.

The achilles tendon joins three muscles: the two heads of thegastrocnemius and the soleus. The gastrocnemius heads arise fromthe posterior portions of the femoral condyles. The soleus arisesfrom the posterior aspect of the tibia and fibula.

The gastrocnemius is a muscle that crosses three joints: theknee, the ankle, and the subtalar joint. The functioning of thesejoints and influence of other muscles on these joints has a significanteffect on the tension that occurs within the achilles tendon.As an example tight hamstrings impact the functioning of theankle joint, the subtalar joint, and increase tension in theachilles tendon. The soleus does not cross the knee and is abiarticualar muscle.

The plantaris is a nearby muscle that has its separate tendon.It arises from the lateral condyle of the femur. It has a thintendon that passes between the gastrocnemius and soleus and insertsinto the calcaneus. When this musclculotendinous structure isinjured it is frequently felt as a "pellet shot" inthe back of the leg. The tear is usually about eight inches belowthe knee joint.

The bulk of the achilles tendon inserts into the posterior superiorthird of the calcaneus. Some fibers course distally and continueto where portions of the plantar fascia insert into the plantaraspect of the calcaneus.

The achilles tendon does not have a rich blood supply. It isnot invested within a true tendon sheath. A paratenon composedof other soft tissue surround it. The outer layer is a portionof the deep fascia, the middle layer is called the mesotenonand the inner layer is a thin layer. The blood supply to theproximal portion of the tendon comes from the branches of themuscles themselves. The distal portion is supplied by branchesfrom the tendon-bone interface. The mesotenon supplies the majorblood supply to the Achilles tendon.

The actual cause of rupture of the Achilles tendon is not known.The mechanism of injury is a force that increases the tensileforce in the tendon beyond its tensile strength. This may bevisualized as a dorsiflexion force at the foot or concomitantlya forward motion of the tibia over the foot while the calf musclesare contracting. As stated the force must exceed the tensilestrength of the tendon. A forceful stretch of the tendon or acontraction of the muscles may create this force. Most oftenit is a combination of the two forces. Many researchers feelthat some degeneration is present in the tendon prior to rupture.The usual site of rupture is approximately 2 to 6 centimetersproximal to the insertion in the calcaneus. This is also theportion of the tendon that has the poorest blood supply. Occasionallyruptures occur at the tendon-bone interface or musculo-tendinousjunction. Since vascularity decreases with age, this frequentlyoccurs in the ageing athlete. A weakening of the Achilles tendonhas been observed following intra- tendinous steroid injection.Therefore, injections of steroids are not recommended at thislocation. Diseases associated with a possibly increased incidenceof tendon rupture include gout, systemic lupus erythematosis,rheumatoid arthritis and tuberculosis.

Diagnosis
Physical examination of the site of a recent rupture may reveala palpable gap at the site of the rupture. Swelling will be seen.The most frequently described clinical test is called the Thompsontest. With the patient lying prone (on his stomach) the calfis squeezed. The foot will plantarflex in a patient who doesnot have a completely torn Achilles tendon. The foot will notplantar flex when the Achilles tendon is completely torn. AnMRI will accurately reveal the extent of the tear. Diagnosticultrasound is also used to assist in the diagnosis of a tornAchilles tendon.

AnMRI image of a partially torn Achilles Tendon is availableon line at the site of The Graduate Hospital Imaging Center.

Treatment
Complete tears of the Achilles tendon, in the athlete, are usuallytreated with surgical repair followed with up to 12 weeks ina series of casts. Partial tears are sometimes treated with castingfor up to 12 weeks alone, and sometimes are treated as are thecomplete tears, with surgery and casting. A heel lift is usuallyused for 6 months to one year following removal of the cast.Rehabilitation to regain flexibility and then to regain musclestrength are also instituted following removal of the cast.

Additional Resources:
The Science of Tendinopathy. Stephen M. Pribut, DPM. Web. Accessed May 22, 2011.

Mechanotransduction and Overuse Injuries. Stephen M. Pribut, DPM. Web. Accessed May 22, 2011

Overuse Injuries: All The Small Things - (PDF)Stephen M. Pribut.Podiatry Management Magazine, October 2010.

Blog: PRP Disappoints in Study Stephen M. Pribut. Blog. January 14, 2010.

Runner's Achilles Heel - Running Times Magazine. Mackenzie Lobby. Accessed April 15, 2011

Selected References:Current Concepts Review: Achilles Tendinopathy. Paavolaet. al. JBJS 84-A: 2062-2076. November 2002.In vivo measurements of Achilles Tendon Forces In Man. Komiet. al. Med Sci Sports Exer 1984; 16:165-6.Biomechanical Loading Of Achilles tendon during normal locomotion.Clin Sports Med. 1992;11:521-531.Ruptured Achilles Tendons are more degenerated then TendinopathicTendons. Tallon et. al. Med Sci Sports Exer 2001; 33:1983-1990.Blood Flow in the Human Achilles Tendon. Astrom M. et. WestlinN.. J. Orthop Res. 1994;12:246-252.Classification of Achilles Tendon Disease. Puddu G. et. al..Am J Sports Med. 1976; 4:145-150.Paavola M: Long-term prognosis of patients with Achillestendinopathy. Am J Sports Med 2000, 28:634-641Treatment of Acute Achilles Tendon Ruptures A SystematicOverview and Metaanalysis. Bhandari, M; Guyatt, G, et.al. ClinicalOrthopedics and Related Research (400) July 2002 pp 190-200


About Dr. Pribut:Dr. Pribut is a member of the Advisory Board of Runner's World magazine. He is a past presidentof the American Academyof Podiatric Sports Medicine (AAPSM). He served as chair of the AAPSM Athletic Shoe Committee for 5 years and has served on the Education Committee, the Research Committee, the Public Relations Committee and the Annual Meeting Committee. He is a co-Editor of the current AAPSM Student's Manual. Dr. Pribut is a past president of the District of Columbia Podiatric Medical Association, serving in that post for 4 years. Dr. Pribut currently is a member of the American Podiatric Medical Association's Clinical Practice Advisory Committee. Dr. Pribut is a Clinical Assistant Professor of Surgery at the George Washington University Medical Center.

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