Achilles Tendon Injuries

1. Achilles Tendon Injuries Michael LaBella

2. Objectives • To be able to identify the difference between Achilles Tendinitis and an Achilles Rupture. • How a coach could evaluate an Achilles injury. • Post surgery rehabilitation programs to be able to return to play after the rupture of an Achilles. • Exercises and stretches to help prevent the chances of Achilles injuries. • The different causes that associate with Achilles injuries and how people come to suffer these injuries.

3. Anatomy of the Achilles Tendon The Achilles tendon is the tendon that connects the calf muscle (gastrocnemius) to the heel bone (calcaneus). This is the tendon that is just below the skin at the back of the ankle. As with most tendon injuries, this tendon may be injured.

4. Function • When the gastrocnemius muscle (in the calf) contracts (shortens), the tendon which is attached from the muscle to the heel bone (calcaneus) moves. As the muscle shortens, the tendon moves to point the foot downwards. This is the action that allows a person to stand on one's toes, to run, to jump, to walk normally, and to go up and down stairs.

5. Achilles Tendonitis • Soreness and stiffness that comes on gradually and continues to worsen until treated. • Often starts with stiffness and creaking when first getting out of bed in the morning. • Common injury among middle and long distance runners.

6. Achilles Tendon Rupture • Partial or complete tear of the achilles tendon. • Comes on suddenly, sometimes with a popping sound, and is debilitating. • Most likely to occur in sports requiring sudden eccentric stretching, such as sprinting, and racquet sports. • Most likely to occur in middle aged athletes who have not been training or who have been doing relatively little training.

7. Achilles Tendonitis Achilles Tendonitis Video

8. Achilles Tendon Rupture Achilles tendon Rupture video

9. Causes of Injury • Overuse • Too fast of an increase in athletic activities such as: • Running or walking longer • Running or walking faster • Running or walking up and down more or steeper hills or stairs • More or more powerful “explosive” movements such as lunges, jumps, or push off’s. • Misalignment • Unequal leg length, • Over or under pronation, • Short or tight Achilles tendons or calf muscles, • Disproportionably weak calf muscles, and • Misshapen heel or other foot bones.

10. Causes of Injury • Improper Footwear • Shoes or sports shoes with too much or too little: • Arch support, • Cushioning, • Motion control, and/or • Heel support; • High heels; and • Worn out shoes or sports shoes. • Accidents • Crushed in a car or work accident; or • Cut (lacerated) by a lawn mower or in a work accident.

11. Signs and Symptoms • Rupture • Pain, possibly severe, and swelling near your heel • An inability to bend your foot downward or walk normally • An inability to rise on your toes on the injured leg, if you've ruptured the tendon completely • Often people report hearing a popping or snapping sound when the injury occurs. With a partial rupture, you may still be able to move your foot, and you may experience only minor pain and swelling.

12. Signs and Symptoms • Tendonitis • Mild pain after exercise or running that gradually worsens • A noticeable sense of sluggishness in your leg • Episodes of diffuse or localized pain, sometimes severe, along the tendon during or a few hours after running • Morning tenderness about an inch an a half above the point where the Achilles tendon is attached to the heel bone • Stiffness that generally diminishes as the tendon warms up with use • Some swelling

13. Coach’s Evaluation • Checking for tendonitis or partial rupture • Feeling with fingers along lower leg for tenderness, swelling, nodules, warmth, and decrease in mass. Signs and Symptoms Video • A Thompson test could be performed by a doctor to detect if there is a rupture. • A coach should never try and perform a Thompson test.

14. Treatment • Rupture • Surgery is a common treatment for a complete rupture of the Achilles tendon. The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons.

15. Treatment • Tendonitis- treatment varies depending on amount of pain. • If heel pain, tenderness, swelling, or discomfort in the back of the lower leg occurs, physical activity that produces the symptoms should be discontinued. • If damage to the tendon is minor, the injury may respond to a simple course of treatment known as RICE (rest, ice, compression, elevation).

16. Rehabilitation • Physical Therapy • Stretching and flexibility exercise are key to helping your tendon heal without shortening and becoming chronically painful. • Ultrasound heat therapy improves blood circulation, which may aid the healing process. • Transcutaneous electrical nerve stimulation (TENS) is sometimes used and may provide pain relief for some people. • Massage helps you increase flexibility and blood circulation in the lower leg and can help prevent further injury. • Wearing a night brace keeps your leg flexed and prevents your Achilles tendon from tightening while you sleep. An Achilles tendon that chronically tightens at night is not able to heal properly.

17. Post Surgery Rehabilitation • Phase I- PWB(partial weight bearing) beginning 4 weeks post-op • Gait training (wean from heel lift after 2 weeks if applicable)Soft tissue massage and/or modalities as neededExercises: • Towel calf stretch (without pain)Theraband exercises – dorsi and plantar flexion, inversion, eversionSitting calf raisesStraight leg raisesBAPS in sittingBike light if ROM (range of motion) allowsMay perform pool ex’s also • The patient may do this mainly as an independent program if appropriate • Progress to Phase II when: • -tolerates all Phase I without pain or significant increase in swelling-ambulates FWB (full weight bearing) without device-ROM for plantar flexion, inversion and eversion are normal-dorsi flexion is at approximately neutral

18. Post Surgery Rehab • Phase II (6-8 weeks post op) • Gait trainingSoft tissue work and/or modalities as neededExercises: • Standing gastroc and soleus stretchesBike light to moderate resistance as toleratedLeg press: • quads bilateral to unilateral • calf raises (sub-maximal bilateral to unilateral) • Sitting calf raises to standing at (generally 8-10 weeks)BAPS board standing (with support as needed)Step upsStep downsUnilateral stance; balance activities with challenges if appropriate (such as ground clock)Mini-squats – bilateral to unilateralStairmaster – short steps 4", no greater than level 4 if no pain or inflammationMay continue pool if appropriate • May be 2X/wk or to independent as appropriate • Progress to Phase III when: • -cleared by physician-can do each of Phase II activities without pain or swelling-ROM equal bilaterally-able to do bilateral calf raise without difficulty and weight equal bilaterally-unilateral stance balance equal bilaterally

19. Post Surgery Rehab • Phase III (generally not before 10-12 weeks) • Frequency at discretion of therapistGait normal without deviceStanding calf raises to unilateral (generally 16 weeks)Outdoor bikingFull/maximal one leg PRE's [progressive resistance exercises] (generally at 16 weeks)Agility drills (generally not before 16-20 weeks. Should be discussed with physician first.)     - jogging to running when pain-free    -sport-specific; cutting, side shuffles, jumping, hopping

20. Return To Play • After surgery an athlete should not return to play until they meet the criteria for progression to Phase III. • Even after completing Phase III the athlete should return at the discretion of their doctor and/or physical therapist.

21. Prevention • Avoid activities that place excessive stress on your heel cords, such as hill-running and jumping activities (especially if done consistently). • If you notice pain during exercise, rest. • If one exercise or activity causes you persistent pain, try another. • Alternate high-impact sports, such as running, with low-impact sports, such as walking, biking or swimming. • Maintain a healthy weight. • Wear well-fitting athletic shoes with proper cushioning in the heels.

22. Prevention • To avoid reoccurrence of an Achilles tendon injury: • Use warm-up and cool down exercises and calf-strengthening exercises. • Apply ice to your Achilles tendon after exercise. • Alternate high-impact sports with low impact sports, so as not to overwork your Achilles tendons.

23. References • http://www.mayoclinic.com/health/achilles-tendon-rupture/DS00160/DSECTION=7 • http://www.achillestendon.com/ • http://www.arthroscopy.com/sp09009.htm • http://www.emedicinehealth.com/achilles_tendon_rupture/article_em.htm • Schepsis, Anthony. (2002). Achilles tendon disorders in athletes. (Current Concepts). The American Journal of Sports Medicine.