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A few weeks ago it was my pleasure to attend a talk by Physiotherapist Seth O’Neill in Manchester. Seth gets really excited about Achilles tendons! Even more so than me. His talk struck the perfect balance between looking at the local tissues and current research and the “je ne sais quois” of Achilles problems. His talk has inspired me to share with you the updates in Physiotherapy research and what they mean in real terms to anyone with an Achilles tendon problem or anyone looking to avoid one in the future.
Before We Start
As is now traditional, I’d like to get a little something off my chest! Just because you have pain somewhere near your Achilles it does not necessarily mean you have an Achilles problem! Please, please, please, don’t panic if you start getting an awareness of sensation or pain in the Achilles region. Come and see us, we’ll properly assess where the problem is really coming from and you’ll avoid any kind of lay off.
The pain in the Achilles region can be caused by calf muscles (gastrconemius, soleus and plantaris), nerves which run through the area (tibial, peroneal, sural and femoral), muscles which run behind the Achilles tendon (tibialis posterior, flexor hallucis longus, flexor digitorum longus) limitation of the ankle joints (talo-crural and talo-calcaneal) and that’s before I even get started.
So How Do You Know If You Have An Achilles Problem?
Well you don’t! Even if you have pain in the Achilles! Allow me to explain…
One of the key indicators Sports Therapists and Physiotherapists use to assess the injury is to feel the Achilles to see it there are any local changes. Is it thickened is the biggest question. As a rule of thumb if we can feel localised thickening (particularly when compared to the other side) then we have an indication there are local changes without the need for MRI scans. However, what we have noticed is that this is in no way an indication of how much pain someone will feel.
The latest Physiotherapy research Seth presented agrees with his. Localised tissue changes are in no way related to the pain you feel – this has been confirmed by scanning lots and lots of Achilles and scoring the pain and incapacity levels of their owners. However, conversely, if there are changes in the tissues you are more likely to have pain.
This is worth repeating in very simple English because it really is quite confusing. So if you have a ‘thickened’ Achilles you are more likely to get pain from it at some point. But, if you are in pain, the thickening of the Achilles is not an indicator of the amount of pain that you feel!
This needs us nicely back to our previous post on The 50 Shades Of Pain. Where we look at the different factors that can affect our pain levels.
As we spoke about in our previous post pain comes both from the local tissues and our well being. Let’s have a look more locally at what the current research is telling us.
More recently with improvements in the quality of MRI imaging we are starting to see that the three calf muscles are all represented within the Achilles tendon. We are also seeing that it is usually the soleus portion of the Achilles tendon where most of the changes in the physiology of the tendon take place. Equally there seems to be an involvement from the fat pad which sits between the soleus part of the Achilles and the ankle bone (calcaneum).
With Achilles problems there also seems to be drop off in calf muscles strength. This could be the pain inhibiting function or perhaps the weakness in the muscles is a precursor to problems. (See What Can I Do To Avoid It below). This also seems to hold true for research carried out on patella tendon issues. The quadricep muscles are inhibited and thereby affect changes in the tendon.
Ok, so we’ve identified the local tissue problems but what else can affect the Achilles region?
If we look from a myofascial perspective (how muscles are joined up) then we can see there is a whole host of factors that can lead to pain in the Achilles. Running up from the plantar fascia, the calf muscles as we’ve spoken about, the hamstrings, into the glutes the erector muscles in your back all the way to the base of you skull. See here for a picture of this Superficial Back Line.
If we start adding nerves to the mix, which seems sensible as it is these structures that give us sensation, this further complicates the picture. So you can see if we’re looking at a neuro-myo-facial picture then things start getting very complex. Trying to understand which part of this is the most important part for each individual is where we really work hard for our money! Each case is truly unique.
Lets Clear Things Up
I’m hoping I haven’t lost you just yet! I fear that last section may have been a bit techie. But lets bring it back to earth with a nice real life case study.
Mr X, a 69 year old gentleman, popped into our clinic about 18 months ago complaining of Achilles pain. On inspection his Achilles was very thickened and even seemed swollen – this is particularly interesting seeing as Achilles Tendinopathy is thought not to be inflammatory in this enlightened age.
With a gentleman of this age and with such a mess (that’s a technical term!) of an Achilles even I had my reservations. However, sure enough, 4 sessions treatment on the factors affecting the tension in calves, Achilles, nerves and fascia and Mr X was reporting no pain and playing some good golf to boot. Had his swelling gone down, yes. Had we changed the make up of his Achilles tendon, probably not – though I’d like to have seen a before and after MRI scan!
A nice story with a nice outcome. It not only demonstrates what is possible it highlights that not all pain comes from the local, apparently damaged, structures.
Stretching? Probably not, at least not the calf muscles. When you stretch the calf muscles it pushes the fat pad and Achilles tendon onto the calcaneum (one of the bones in the ankle). Potentially this can cause irritation of these structures and actually lead to the development of Achilles issues.
That said, I would suggest stretching other structures which can lead to tension on the calf muscle. Primarily the hamstrings and glutes. Again you still have to ask yourself why the hamstring and glutes are tighter than they should be but there’s only so much I can write in one blog!
Barring coming to see us your best bet is to do some strength training as shown in this paper from the British Journal Of Sports Medicine. This will allow gradual adaptation of the calf muscles to the load placed on it.
Equally, the classic presentation we see is when people have done “too much too soon.” Either a good runner upping their mileage too soon for a big event or marathon. Or someone who hasn’t run for a while starting to do too much training from scratch.
So What Should I Do To Get It Fixed?
Firstly, of course, come and see us and we’ll remove all those pre-disposing factors call 01273 921831 if you’d like to discuss this or any other injury. About 90% of issues can be solved within a few sessions. If you’re one of the unlucky ones we’ll need to do some good old school strengthening to try to change the physiology of the Achilles tendon.
Previously it was thought that eccentric contractions (that’s the bit on the way down from a calf raise) were the way to go. However, recent research suggests that the load going through the Achilles tendon does not vary on concentric (on the way) or eccentric (on the way down). It does however within the muscle belly.
What does than mean in real terms? Just do calf raises. Lots of them. But maybe not every day. It appears that collagen takes 24-36 hours to replenish. Collagen is the stuff that helps tendons fix and makes them robust. If you train, whether that’s simple calf raises or a speed set running, and the following morning it’s a bit worse and stiff you’ve probably over done it, leave it 24 hours to recover and train again with less intensity.
Balance is another predisposing factor so practice standing on one leg – with your eyes closed if that’s too easy. Try varying your training too. If you do a lot of off road, to some on road and vice versa. Challenge your body to do new things rather than the same old thing over and over again.
Whatever You Do Don’t Stretch! As mention above we want contractile tendons not loose ones and we certainly don’t want to be wedging any tender structures up against the back of your heel bone!
Achilles tendon problems may seem like a mystery wrapped in an enigma but most can be easily treated with some biomechanical correction treatment. In fact I’d say 90% of the pain we see is nothing to do with the Achilles! Of those remaining “true” Achilles problems 50% can be sorted with removal of predisposing factors. The remaining 50%, I make that 5 out of 100, a bit of rehab some activity modification and a little bit of patience and you’ll be there too.
If you’d like us to have a look at your Achilles (or any other problem for that matter) to see how quickly and easily it can be eased then call us now on 01273 921831 or mail us at info@BrightonSportsTherapy.co.uk.
If you’d like to check out Seth’s website which has all the latest research on all things Achilles then click the link here: Achilles Tendon Research. There’s some more interesting reviews from the inventor of the eccentric heel drop protocol Dr Hakan Alfredson here. Be warned it’s quite technical and very localised in it’s outlook.