Home Sports Injuries Achilles Tendinitis, Tendinosis or Rupture

Achilles Tendinitis, Tendinosis or Rupture

by Gary Vitti
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As of November 20th Rotoworld reported there were five NBA players sidelined with Achilles injuries. I have no direct knowledge of the specifics of each of these players but Achilles disorders generally fall into three categories: tendinitis, tendinosis or rupture. Over the course of my career I treated many Achilles issues including ruptures, most notably to Kobe Bryant.

The Achilles tendon was named after the mythological Greek hero Achilles because it was the only vulnerable spot on his body after his mother dipped him into the river Styx. It is formed by the confluence of the gastrocnemius and soleus calf muscles. It is the longest and strongest tendon in the body, connecting the calf muscles to the heel bone (calcaneus).  Achilles tendon injuries are common to both athletes and non-athletes. The function of the Achilles is to generate force from the foot to the calf for walking, running and jumping but it also functions to absorb external forces which puts tremendous loads on the tendon. To absorb these loads the tendon must have strength, flexibility and elasticity.

Achilles injuries can be sustained from acute overload or chronic overuse. Studies have reported acute load to the Achilles tendon can be as high as 12.5% body weight. Injuries due to chronic overload can be caused from intrinsic, extrinsic and unknown factors. Intrinsic factors can be blood flow to the tendon, age, weight, height, foot mechanics, mobility and ankle instability. Extrinsic factors may be poor training techniques, previous injury, footwear and/or training surfaces that lead to tendon degeneration. Please refer to my blog on stress reactions to understand adaptation to tendon overload and the difference between tendinitis and

tendinosis.

The main symptom of an Achilles injury is pain but in my experience most Achilles ruptures occur to athletes that have never experienced the pain associated with Achilles tendinitis. Studies have shown that chronically painful Achilles tendons show no inflammation and some Achilles tendons show clear defects on MRI or diagnostic ultra-sound but are pain free. Pain may occur where the tendon attaches to the calcaneus but it usually occurs in the belly of the tendon an inch or two above its attachment. There’s approximately a 6 cm area that has a poor blood flow resulting in poor cell adaptation to the loads put upon the tendon.

Most athletes reaction to Achilles tendinitis is to stretch it. In my experience, stretching a painful Achilles tendon will make it worse. When the athlete is pain free they can return to gentle Achilles stretching exercises both with the knee straight and the knee flexed. Cryotherapy (ice) seems to always help followed by contrast treatment (ice & heat) as the pain symptoms subside. In the acute phase I always put an orthopedic felt heel lift in the athletes shoes which can be found on line. I always use footmanagement.com. This will raise the floor and take the stretch out of the Achilles. I put one in both shoes even though most Achilles issues are unilateral. This will prevent the athlete from listing to one side causing other postural dysfunction issues. The heel lift should be limited to a 1/4 to a 1/2 inch so as not to change the relationship of the foot to the shoe and should be changed often as body weight and gravity will reduce the width of the lift. Oral anti-inflammatories should help but in my 32 years as the head athletic trainer for the Los Angeles Lakers I never saw a cortisone shot in an Achilles tendon and do not recommend it. I’m also not a big fan of immobilization but sometimes in extremely stubborn cases it cannot be avoided.

After treating the symptoms the practitioner must identify whether the pain is the result of a structural issue or a mechanical issue.  Structural is partial tearing or rupture of the Achilles which will require surgery or prolonged immobilization. Mechanical issues can be corrected with physical therapy and/or orthotic control.

There are many mechanical complications that can cause Achilles issues. Two of the most common mechanical issues include overpronation from a flat foot (pes planus) or underpronation (supination) from a high arched foot (pes cavus). How the foot pronates begins with the action at the subtalar joint also known as the rear foot. The subtalar joint/rear foot is formed by the two largest bones of the foot. The ankle bone (talus) that sits on top of the heel bone (calcaneus). The rear foot allows the foot to roll side to side causing pronation or supination. How the rear foot functions will determine how the  loads of running and jumping are distributed up the kinetic chain. High speed cinematography has shown that excessive pronation causes the tibia to excessively rotate internally creates a whipping action or bowstring effect on the Achilles causing microtears in the tendon.

Athletes that tend to underpronate present themselves with tight calf muscles and a tight

iliotibial band. They also tend to develop calluses and bunions on the outside of the foot and are more susceptible to ankle sprains.

A visit to a good foot specialist and a good physical therapist or athletic trainer can help identify the bio-mechanical deviations and provide corrective techniques. High speed cameras and high speed sensor technology can also give a 100% objective evaluation of ones foot mechanics.

Achilles ruptures occur in about 1 per 10,000 people per year. They are more common in males than females at a ratio of 20 to 1 and are most common between the ages of 30 and 50. Every athlete that I know that experienced an Achilles rupture, including Kobe Bryant told me the same thing: “it felt like someone kicked me from behind, I turned around and no one was there”. The difference between them and the Mamba was Kobe told me he reached back and tried to pull it down.  I’m not sure what he meant by that because it’s not like the ruptured tendon rolls up your leg. Most athletes know immediately they have a severe injury and they are out of action. Kobe asked me if I could tape it so he could finish the game. By his description of the injury I assumed he ruptured his Achilles but it became clear when I got him into the training room and he had a positive Thompson test.

The Thompson test also called the Simmonds’ test, Simmonds-Thompson test or calf squeeze test requires the athlete to lie face down with the foot hanging off of the treatment table.  The practitioner then squeezes the corresponding calf. If there is no movement of the foot, the test is positive. This test is extremely accurate for detection of an Achilles rupture but is unable to distinguish between a partial tear or complete tear. Definitive diagnosis requires an MRI scan.

The surgeon will discuss different options for repair of the tendon depending on the amount and type of tendon damage. A ruptured tendon could be sewn back together. A degenerated tendon may have the damaged part of the tendon removed and that part repaired and a

severely damaged tendon may be replaced with a tendon transfer from another part of your body. There are two options for surgical repair of the Achilles depending on several factors including age and activity level. The open repair requires a single large incision in the back of the leg. The second option is a percutaneous surgery where the surgeon makes several small incisions instead of one large incision.

Post op requires immobilization in a cast, boot or similar device for 6 to 12 weeks. The foot will be positioned with the toes pointing down (plantar flexion). This will allow the tendon to heel in a shortened position. The worse thing is to take the foot out of this position too early. Taking the foot out of the planter flexed position too early will cause healing in a lengthened position which will lose the Achilles mechanical advantage to generate force.

Depending on the repair, there are different protocols that the surgeon will decide on with the physical therapist.  As healing continues, the immobilization position will gradually be adjusted to bring the foot back to a neutral position and eventually to full range of motion. The current trend to full return of strength, power and endurance is 6 to 8 months. But it could take up to a year for a fully healed and remodeled Achilles tendon to endure the loads of an NBA game.

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