Achilles Tendinopathy

Achilles tendinopathy is a relatively common injury in athletes. The injury involves damage to the fibres of the Achilles tendon, often at the narrow point of the tendon just above the heel. This area is most at risk as it has a poor blood supply and so is less able to repair itself.

The best treatment for this problem is an eccentric strengthening program. These exercises are usually quite painful. This does not mean that you are damaging the tendon further.

Exercises can be performed on the floor (without a step) or using a stair or step as shown in the above picture.

1. Standing on both feet, raise up onto toes
2. Lift unaffected foot from the floor
3. Slowly lower the affected foot to the ground - this is the 'eccentric' treatment part of the exercise
4. "Up with two down with one"

If these are too painful to begin with support some of you body weight with your arms - lean over a table or bannister

Ideally you should aim for 90 repetitions (45 with the knee straight and 45 with the knee bent) twice a day. This needs to be done for a period of 3 months.

After each set of exercises try to ice the painful area. This will improve pain and limit inflammation. In addition to strengthening it is important to identify activities which may be contributing to your pain and to aim for a reduction in overall loading. It is best to discuss this with your lead provider.

Achilles Tendon Rupture

Achilles tendon rupture are common. Most athletes describe a sudden acute event with an associated popping sensation and pain in the Achilles tendon. They often think that they have been kicked or struck in the calf. It is important to get prompt treatment and to be placed in an equinous cast (a cast with the foot in a pointed position). More definitive treatment options can be discussed after this has occurred.

There are a number of treatment options available for patients with Achilles ruptures. In general these involve surgical repair of the tendon followed by casting or immobilisation of the tendon with the ends opposed (in an equinous position). There is often a lot of discussion about which is best. In reality there is no best solution for everyone and treatment decisions are made on an individual basis with the patient. The most important thing is to get the tendon to heal and for it to heal at its normal length. How this occurs is less important.

Mr Bruce Twaddle, one of the UniSports Orthopaedic Surgeons, has developed an accelerated non-operative treatment program for managing this injury. We have had good success with this regime in both recreational and elite athletes. This protocol uses a moonboot rather than with the plaster of paris cast which is generally used. The advantage of this protocol is that it allows you to do some basic ankle and foot exercises to limit muscle wasting and joint stiffness. In the later stages we are also happy for you to remove the boot for sleep.

If you would like to consider using this protocol ask your primary care provider to refer you to one of the Sports Physicians to see whether this might be appropriate for you.

Achilles Ruptures – Sports Physicians' Protocol

• Equinous cast immediately for two weeks.
• Window cast or remove and check that there is no palpable gap in the tendon.
• Non-Weight Bearing (NWB) 30° equinous AAFO boot for one week
• During this time the boot can be removed for range of motion (ROM) exercise for five minutes an hour. It is important that you do no stretching and that the foot is not flexed up beyond neutral. If you are unsure about this discuss this with your doctor.
• NWB 20° equinous boot for 1 week – still wearing this at night and still no stretching.
• NWB 10° equinous boot for 1 week – still wearing this at night and still no stretching.
• NWB 0° equinous boot for 1 week – still wearing this at night and still no stretching.
• From six weeks post-injury you can weight bear in the boot. Can remove the boot in bed at night. By eight weeks the goal is to be weight bearing fully in the boot.
• From eight weeks you can come out of the boot and start a strengthening program. When you can support your weight on one leg your strengthening program can be more aggressive. Be very cautious with stretching, start slowly after 8 weeks.
• If the Achilles appears to have healed long we will arrange for you to have a heel raise for your shoe.
• A review and clinical check with your doctor at each stage of the protocol is needed to make sure that the tendon is healing normally.
• Whichever protocol you use to treat your Achilles tendon rupture you are likely to require some form of immobilisation for about eight weeks. It is likely to be a minimum of six months before you are back to playing sport.

Plantar Fascia Pain

Plantar Fascia pain or Plantar Fasciitis is a painful condition that affects the heel. Patients often notice pain when they put their heel down first thing in the morning. The exact nature of the injury is not known. The condition can be frustrating so requires a multi-faceted approach.

1. Podiatry – a special orthotic (insert) can be made to alter the tension on the plantar fascia
2. Ice massage – using a frozen coke bottle or golf ball under the heel 10mins each evening can help alleviate symptoms
3. Calf stretching – tight calves mean the heel leaves the ground earlier during walking – increasing the load on the plantar fascia. Stretch your calves holding for 30 seconds at least 4 times a day.
4. Intrinsic foot muscle strengthening – the muscles of the foot itself can often be neglected and training these muscles helps support foot architecture. These can be exercised in a number of ways
1. Try and pick up marbles or pegs with your toes
2. Lay a towel out on the kitchen or bathroom floor and use your toes to scrunch the towel up.
3. Put marbles between your toes and try to spread your toes wide to let the marbles fall from between them

Sever's Disease

Sever’s disease is repetitive micro trauma or overuse of the heel in young athletes. Sever’s is caused by overloading the insertion of the Achilles tendon onto the calcaneus and the apophyseal growth plate. Active Children (7 to 15 years), particularly during the pubertal growth spurt or at the beginning of a sport season (e.g. gymnasts, basketball and football players), often suffer from this condition.

Contributing factors to the development of Sever’s disease

There are several factors which may increase the likelihood of developing this condition. These need to be assessed and corrected with direction from a physiotherapist to ensure an optimal outcome. Some of these factors include:

• Inappropriate footwear
• Calf tightness and/or weakness
• Joint stiffness (particularly the foot and ankle)
• Poor lower limb biomechanics
• Inappropriate or excessive training
• Inadequate recovery periods from training or activity
• Inappropriate training surfaces
• Inadequate warm up
• Poor core stability
• A lack of lower limb strength and stability
• Poor proprioception or balance
• Rapid growth and age

Treatment of Sever’s disease

Consulting with a physiotherapist to confirm the diagnosis is important. Physiotherapist’s will advise on a management plan, usually consisting of activity modification (a reduction in playing and training) and addressing the contributing factors as outlined above. Treatment may include:

• Relative rest/modified rest or cessation of sports
• Biomechanical correction
• The use of heel wedges
• Soft tissue massage
• Joint mobilisation
• Education
• Icing
• Taping
• Exercises addressing flexibility, strength or balance issues
• Footwear assessment and advice
• A gradual return to activity program

Examples of treatment: calf stretches, ice massage protocol