We were lucky to able to invite Seth O’Neil to speak to us about management of tendonopathies, namely Achilles tendonopathies. Seth is a Physiotherapist, lecturer and researcher at the University of Leicester. He has written a number of articles on Achilles tendonopathy management, blogs which are freely available on line (here) and is also on twitter @Seth0Neill
Achilles tendon pain is a common problem that affects most runners and a problem that we speak to people a lot about through PhysioLine.
Most lower limb tendon problems that are non-traumatic occur through overuse or overload; sudden spikes in running distances, increases in training volume, running pace or running frequency or changes in training type hill training, sprint training or plyometrics training or running to soon after leg session in the gym. Other factors including previous injury, increasing age, gender, genetic predisposition, diabetes, increased BMI and/or adiposity, medication and lower limb biomechanics also should be considered, particularly if the patient isn’t responding to treatment. Therefore the key to accurately diagnosing Achilles Tendonopathy is a good subjective that can pick out the above factors. Followed by an objective assessment that includes painful arc testing, pain on palpation, passive stretch over a step, double single heel raise, hop or jump testing.
Tendon fibres are comprised of collagen, elastin and proteoglycans (sugars), arranged in densely packed, regular shaped bundles, encased in irregular tendon sheaths. When we suffer a tendonopathy the collagen fibres become disorganized and start to break down. The image below shows a cross section and plan view of a “normal” tendon (left side images) and a “pathological” tendon (right side images).
Over training can result in a tendonopathy because of how collagen responds to load and rest. After exercise we see a degradation process; collagen changes shape and organization (see above images on the right). This response can last up to 36 hours. This response is then followed by a period of synthesis; formation or reorganization of collagen tissue. Because of this response it is vital that when training we allow for appropriate rest times before performing the same activity. Too short a rest period between runs or repeated loading sessions may lead to an overuse injury.
In someone who trains regularly it may take a large spike in training to cause a tendonopathic response, as their tendons and soft tissue is used to exercise and load and has the capacity and robustness to perform exercise. In a sedentary individual it takes a lot less stress to generate a tendonopathy response or a soft tissue tear; attempting to run across the road or a one off game of 5 a side may be enough to lead to injury.
Management of tendonopathies varies with patients often advised to rest, stretch, foam roll or use other soft tissue release techniques. In clinic treatments may include acupuncture, electrotherapy, massage or taping. In most cases these approaches have limited effect. They may help reduce symptoms but they don’t treat the root cause of the problem, weakness of the Soleus and gastrocnemius muscles. Strengthening the tendon and muscle groups has been shown to reduce pain and improve capacity of structures to tolerate activity (return to running).
As well as a loading programme we also have to include activity modification, particularly if the patient has a very reactive tendon; a tendon that is irritable with very little input. With most people who run asking them to take a break from running is like asking them to cut a leg off! So it may be that we find a compromise and if there is a distance they are able to run that doesn’t irritate symptoms then keep them running at this distance but no more or reducing how regularly the patient runs, if symptoms stay painful then they should take a break from it, but, with the reassurance from the physio that this will only be a short term break whilst they continue with rehab. Or, they swap running for another exercise, swimming or cycling.
Loading (strengthening) works by increasing tendon tissue thickness and length, this allows the tendon to absorb and produce greater forces. As the tendon grows there is vascular and nueral growth, more blood vessles means greater blood supply to the soft tissue, neural growth improves the ability of the muscle to recruit fibres to produce force; when you first start a single leg squat you can’t squat very deep and you wobble all over the place. As you practice it more regularly, eventually you stop wobbling and can squat deeper.
As well as loading we have to aim to get the patient back to the distances and pace they were running before injury and this is done through graded exposure; gradually increasing running distances, pace and training frequency. This part of rehab can be tricky as we don’t know what will happen when the patient starts to run.
How do we load the achilles?
The achilles tendon is made up of the gastrocnemius tendon and soleus tendon. To specifically tartget these two muscles we can use two simple exercises; bent knee calf raises and straight knee calf raises. Bent Knee calf raises target the soleus more than straight leg calf raises which predominantly engage the gastrocnemius.
Seated Calf raises (Physiotec.ca)
Straight leg Calf raises (Physiotec.ca)
Bent Knee Calf raises (Physiotec.ca)
The exercises can be performed in a variety of sets and repetitions depending on what affect you are aiming to achieve. Once the patient can achieve them with body weight then weight should be introduced, if the patient is hoping to return to running then the load has to be heavy (70% 1 rep max) or close to body weight, due to the forces generated when running.
There are other exercises that we can use and if the patient attends the gym then it is easier to incorporate load in their rehab. If they don’t have access to a gym them simple things like a back pack filled with weight can be just as effective as a bar or dumbbell.
The key things I took from the day were to ensure that I took a good subjective and objective to ensure accurate diagnosis, to encourage the patient to load the Achilles despite pain and reassure them that this is safe to do. Advise the patient that it will probably be a slow process but that with persistence and a progressive loading and return to running programme they will recover.
For further information:
Physioedge podcasts Jill Cook, Peter Malliaras, Alison Grimaldi, Jeremy Lewis, Bill Vincenzino,
BJSM podcasts Jill cook, Jonathan Rees, Alison Grimaldi
PhysioMatters podcasts (me)
Images reproduced with kind permission from Seth O’Neil & Physiotec.ca