Resolving Achilles Tendonitis

Common Injuries to the Achilles Tendon

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.

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 Gastrocnemius and Soleus can cause abnormal pronation during the stance phase of the normal gait cycle.

Consider the Kinetic Chain Structures

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 illustration below 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.

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.

Avoiding 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.

Using ART to Treat Achilles Tendonitis

Active Release Techniques (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 muscles 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.