Named for the bloke that took the poison arrow to the back of his leg in Greek mythology the Achilles tendon has always been a difficult area to manage. They’re very common in runner’s and they can be difficult to manage.
They can be very painful during activities like running or stair climbing because they transmit all the power from your calf through your ankle to your foot. In the last 10 years it’s treatment emphasis has slid away from surgery towards a more conservative, rehab based, approach. Even so, finding an exercise programme that will work for an individual presents challenges. There are a range of possible diagnoses for this kind of problem and they may include one or more of the following.
Complete rupture – this is what it sounds sounds like, the entire tendon has broken into two distinct part and can no longer transmit force toward the ground or point the foot and toes.
Midportion Tendinopathy – the classic achilles tendon degenerative process. It usually involves shortening and weakening of the tendon itself, it may involve smaller tears or changes in the type and shape of cells making up the tendon. Often small nodules of scar tissue can be demonstrated.
Paratendinosis – The paratenon is the support structure of achilles tendon. It can become diseased in isolation with little change in the tendon itself and in the diseased state we see a lot more blood vessel and nerve formation in it’s tissues which are thought to transmit the heightened pain experience.
Insertional Tendinopathy – this is more a disease of the structure close to the ankle bones and involves less or the actual fibrous tendon itself. There may be inflammation of the small bursa’s where the fibrous tendon attaches to the bone and these can be very painful, especially during traditional rehab and will likely require a bit of a balancing act between exercises.
The best evidence currently exists for exercise programmes, often initially eccentric training, though heavy slow weight training has been gaining ground in the last 2 years particularly. The biggest challenge is always in loading up the degenerated tendon to a degree where we stimulate repair without triggering the already sensitive inflammatory process.
Challenges to the approach might include a patient where heavy slow weight training is out of the question due to a recent shoulder surgery, eccentric exercises could cause an inflamed ligament insertion point to flare up and seated resistance band exercises aggravate an anterior ganglion cyst. A working compromise in this situation could involve half depth one legged squats, the doubled body weight could be just enough to stimulate the growth required to get strength back while the range of motion would be shallow enough not to stress out any of the other local injuries.
Another kind of presentation where a good rehab program at a local physiotherapy practise had been successfully completed might just find some instrument assisted soft tissue manipulation helpful in regaining the last degree’s of joint range of motion even when everything else is going well.
If you have a painful achilles tendon that won’t come right then see your chiropractor, there are many facets to consider when planning a treatment approach to an achilles tendon and one size will not fit all!