Achilles Tendon Injury Exercises

Overview
The Achilles is a large tendon that connects two major calf muscles to the back of the heel bone. If this tendon is overworked and tightens, the collagen fibres of the tendon may break, causing inflammation and pain. This can result in scar tissue formation, a type of tissue that does not have the flexibility of tendon tissue. Four types of Achilles injuries exist, 1) Paratendonitis - involves a crackly or crepitus feeling in the tissues surrounding the Achilles tendon. 2) Proliferative Tendinitis - the Achilles tendon thickens as a result of high tension placed on it. 3) Degenerative Tendinitis - a chronic condition where the Achilles tendon is permanently damaged and does not regain its structure. 4) Enthesis - an inflammation at the point where the Achilles tendon inserts into the heel bone.

Causes
The Achilles tendon is a strong band of connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel, producing movement. The Achilles tendon moves through a protective sheath and is made up of thousands of tiny fibres. It is thought that Achilles tendonitis develops when overuse of the tendon causes the tiny fibres that make up the tendon to tear. This causes inflammation, pain and swelling. As the tendon swells it can begin to rub against the sheath surrounding it, irritating the sheath and causing it too to become inflamed and swollen. It has a poor blood supply, which can make it susceptible to injury and can make recovery from injury slow. Factors that can lead to the development of Achilles tendonitis include, tight or weak calf muscles, rapidly increasing the amount or intensity of exercise. Hill climbing or stair climbing exercises. Changes in footwear, particularly changing from wearing high-heeled shoes to wearing flat shoes. Wearing inadequate or inappropriate shoes for the sporting activity being undertaken. Not adequately warming up and stretching prior to exercise. A sudden sharp movement that causes the calf muscles to contract and the stress on the Achilles tendon to be increased. This can cause the tendon fibres to tear.

Symptoms
Patients with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute, severe pain. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, which may result in an inability to ambulate further. A patient with Achilles tendon rupture will be unable to stand on his or her toes on the affected side. Tendinosis is often pain free. Typically, the only sign of the condition may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through its range of motion (ROM). Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion. Paratenonitis with tendinosis. This is diagnosed in patients with activity-related pain, as well as swelling of the tendon sheath and tendon nodularity.

Diagnosis
A podiatrist can usually make the diagnosis by clinical history and physical examination alone. Pain with touching or stretching the tendon is typical. There may also be a visible swelling to the tendon. The patient frequently has difficulty plantarflexing (pushing down the ball of the foot and toes, like one would press on a gas pedal), particularly against resistance. In most cases X-rays don't show much, as they tend to show bone more than soft tissues. But X-rays may show associated degeneration of the heel bone that is common with Achilles Tendon problems. For example, heel spurs, calcification within the tendon, avulsion fractures, periostitis (a bruising of the outer covering of the bone) may all be seen on X-ray. In cases where we are uncertain as to the extent of the damage to the tendon, though, an MRI scan may be necessary, which images the soft tissues better than X-rays. When the tendon is simply inflamed and not severely damaged, the problem may or may not be visible on MRI. It depends upon the severity of the condition.

Nonsurgical Treatment
In order to treat achilles tendinitis effectively, it is important to complete a thorough examination of the entire lower extremity. Once the true cause is identified, a comprehensive treatment program can be initiated to reduce inflammation and improve any faulty lower extremity biomechanics. Treatment options may include biomechanical analysis of gait. Splinting/bracing to alleviate the strain on the tendon. Soft tissue mobilization/manual therapy to decrease inflammation and promote healing of the tendon. Strengthening/flexibility and proprioceptive exercises. Home exercise program. Modalities for pain and inflammation (i.e. ultrasound, iontophoresis, electrical stimulation, ice). Methods to alter faulty mechanics (i.e taping, orthotics). Education about lifestyle changes (i.e. proper shoes, activity modification).



Surgical Treatment
There are three common procedures that doctor preform in order help heal the tendinitis depending on the location of the tendinitis and amount of damage to the tendon, including: Gastrocnemius recession - With this surgery doctors lengthen the calf muscles because the tight muscles increases stress on the Achilles tendon. The procedure is typically done on people who have difficulty flexing their feet even with constant stretching. Debridement and Repair - When there is less than 50% damage in the tendon, it is possible for doctors to remove the injured parts and repair the healthy portions. This surgery is most done for patients who are suffering from bone spurs or arthritis. To repair the tendon doctors may use metal or plastic anchors to help hold the Achilles tendon in place. Patients have to wear a boot or cast for 2 weeks or more, depending and the damage done to the tendon. Debridement with Tendon Transfer - When there is more the 50% damage done to the Achilles tendon, and Achilles tendon transfer is preformed because the remain healthy tissue is not strong enough. The tendon that helps the big toe move is attached to give added strength to the damaged Achilles. After surgery, most patients don?t notice any difference when they walk or run.

Prevention
A 2014 study looked at the effect of using foot orthotics on the Achilles tendon. The researchers found that running with foot orthotics resulted in a significant decrease in Achilles tendon load compared to running without orthotics. This study indicates that foot orthoses may act to reduce the incidence of chronic Achilles tendon pathologies in runners by reducing stress on the Achilles tendon1. Orthotics seem to reduce load on the Achilles tendon by reducing excessive pronation,