Treatment of Achilles Tendonitis
The first thing to do is to cut back your training. If you are working out twice a day, change to once a day and take one or two days off per week. If you are working out every day cut back to every other day and decrease your mileage. Training modification is essential to treatment of this potentially long lasting problem. You should also cut back on hill work and speed work. Post running ice may also help. Be sure to avoid excessive stretching. The first phase of healing should be accompanied by relative rest, which doesn't necessarily mean stopping running, but as I am emphasizing, a cut back in training. If this does not help quickly, consider the use of a 1/4 inch heel lift can also help. Do not start worrying if you will become dependent on this, concentrate on getting rid of the pain. Don't walk barefoot around your house, avoid excessively flat shoes, such as "sneakers", tennis shoes, cross trainers, etc.
In office treatment would initially consist of the use of the physical therapy modalities of electrical stimulation, (HVGS, high voltage galvanic stimulation), and ultrasound. Your sports medicine physician should also carefully check your shoes. A heel lift can also be used and control of excessive pronation by taping can also be incorporated into a program of achilles tendonitis rehabilitation therapy. Orthotics with a small heel lift are often helpful.
The achilles tendon is the connection between the heel and the most powerful muscle group in the body. This has long been known as a site prone to disabling injury. It is named after Achilles, who according to myth was protected from wounds by being dipped in a magical pond by his mother. She held him by the heel, which was not immersed, and later died by an arrow wound in his heel. Although obviously, injuries to this area must have been known for more than 2,000 years, it was first reported in the medical literature by Ambroise Paré only 400 years ago.
The achilles tendon joins three muscles: the two heads of the gastrocnemius and the soleus. The gastrocnemius heads arise from the posterior portions of the femoral condyles. The soleus arises from the posterior aspect of the tibia and fibula.
The gastrocnemius is a muscle that crosses three joints: the knee, the ankle, and the subtalar joint. The functioning of these joints and influence of other muscles on these joints has a significant effect on the tension that occurs within the achilles tendon. As an example tight hamstrings impact the functioning of the ankle joint, the subtalar joint, and increase tension in the achilles tendon. The soleus does not cross the knee and is a biarticualar muscle.
The plantaris is a nearby muscle that has its separate tendon. It arises from the lateral condyle of the femur. It has a thin tendon that passes between the gastrocnemius and soleus and inserts into the calcaneus. When this musclculotendinous structure is injured it is frequently felt as a "pellet shot" in the back of the leg. The tear is usually about eight inches below the knee joint.
The bulk of the achilles tendon inserts into the posterior superior third of the calcaneus. Some fibers course distally and continue to where portions of the plantar fascia insert into the plantar aspect of the calcaneus.
The achilles tendon does not have a rich blood supply. It is not invested within a true tendon sheath. A paratenon composed of other soft tissue surround it. The outer layer is a portion of the deep fascia, the middle layer is called the mesotenon and the inner layer is a thin layer. The blood supply to the proximal portion of the tendon comes from the branches of the muscles themselves. The distal portion is supplied by branches from the tendon-bone interface. The mesotenon supplies the major blood supply to the Achilles tendon.
The actual cause of rupture of the Achilles tendon is not known. The mechanism of injury is a force that increases the tensile force in the tendon beyond its tensile strength. This may be visualized as a dorsiflexion force at the foot or concomitantly a forward motion of the tibia over the foot while the calf muscles are contracting. As stated the force must exceed the tensile strength of the tendon. A forceful stretch of the tendon or a contraction of the muscles may create this force. Most often it is a combination of the two forces. Many researchers feel that some degeneration is present in the tendon prior to rupture. The usual site of rupture is approximately 2 to 6 centimeters proximal to the insertion in the calcaneus. This is also the portion of the tendon that has the poorest blood supply. Occasionally ruptures occur at the tendon-bone interface or musculo-tendinous junction. Since vascularity decreases with age, this frequently occurs in the ageing athlete. A weakening of the Achilles tendon has been observed following intra- tendinous steroid injection. Therefore, injections of steroids are not recommended at this location. Diseases associated with a possibly increased incidence of tendon rupture include gout, systemic lupus erythematosis, rheumatoid arthritis and tuberculosis.
Treatment for a Ruptured Achilles Tendon Complete tears of the Achilles tendon, in the athlete, are usually treated with surgical repair followed with up to 12 weeks in a series of casts. Partial tears are sometimes treated with casting for up to 12 weeks alone, and sometimes are treated as are the complete tears, with surgery and casting. A heel lift is usually used for 6 months to one year following removal of the cast. Rehabilitation to regain flexibility and then to regain muscle strength are also instituted following removal of the cast.
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