Achilles Tendinopathy

ACHILLES TENDINOPATHY

The Achilles tendon is the largest and strongest tendon in the lower body.  Located in the back of the lower leg it connects the powerful calf muscles to the heel bone.  Achilles tendinopathy is the inflammation and gradual degeneration of the Achilles tendon that results in damage to the collagen.  Damage to the collagen increases the development of tissue adhesions and scar tissue formation, which may limit muscle, tendon and joint mobility.  Tendinopathy can develop gradually over time or immediately, due to a one-time trauma.  Achilles tendinopathy should not be left untreated as tendons and ligaments have low metabolic rates and poor circulation which contribute to slow healing, potential tearing and lengthy recovery. 

WHAT CAUSES ACHILLES TENDINOPATHY?

There are several contributing factors that cause Achilles tendinopathy.  The most general cause is physiological demands placed on the tendon exceeding its capabilities:

•         Activities that involve sudden starts and stops or repetitive jumping (i.e basketball, running)
•         A sudden increase in activity level
•         Decreased recovery time between exercise sessions
•        Training on changing surfaces (i.e. running on trails vs. concrete sidewalks)
•         Poor footwear selection (i.e. high heels, sandals)
•        Over-pronation of the foot (when the feet roll inward too much)
•         Limited ankle range of motion
•        Calf muscle weakness and inflexibility

SIGNS AND SYMPTOMS

The symptoms of Achilles tendinopathy usually develop over time, however in some cases they can be a direct result of trauma to the Achilles tendon.  Repetitive stress on an already torn Achilles tendon may lead to a complete tear.  Signs of Achilles tendinopathy include:

•          Pain and stiffness in the back of the lower leg just above the heel during or after exercise
•         Swelling and redness over the Achilles tendon
•        Tenderness with palpation along the inside/outside of the Achilles tendon
•          Reduced strength and mobility in the lower leg
•         Severe pain in the morning

SELF MANAGEMENT

There are several ways that you can prevent the development or recurrence of Achilles tendinopathy including:

•       Post activity foam rolling or trigger point ball therapy through the calf, glutes, hamstrings and quads
•       Wear appropriate footwear with heel support
•        Avoid activities that place a constant strain on the Achilles
•        Eccentric stretching and warm-up prior to activity 
•    Eccentric heel drops 
•    Theraband resistance pointing the foot downwards

MANAGEMENT

Consultation with a healthcare professional is recommended. It might be necessary to modify or minimize the activity that causes pain.  Your healthcare professional may recommend any of the following treatment regimens to rehabilitate the tendon and increase its capabilities:

•         Modify activity that reduce stress on the tendon (i.e. cycle, elliptical machine, swimming)
•         Active Release Techniques^© (ART) and/or Graston Technique^© to help elongate the tissue and breakdown any scar tissue or adhesion formation
•       Functional Rehabilitation to strengthen the kinetic chain
•       Joint mobilization to improve ankle and tarsal (bones of the foot) mobility
•      Gait analysis and gait training
•         Passive modalities (i.e. low volt therapy, ultrasound)
•         Wear appropriate footwear
•          Heel lifts inserted in the shoes
•         Foot orthotics (over the counter or custom)
•         Night splints/Kinesio Taping^©

You may find that resting from activity may decrease the pain, however when you return to activity the pain remains unchanged.  This is due to adhesion formation and/or shortening of the tissues that never changed.

The intent of this article is to provide a brief overview of Achilles tendinopathy.  In no way does it describe all causes or treatment options or intended for self-diagnosis.  If you are questioning your pain please follow-up with a licensed health care provider.

PLANTAR FASCIITIS

Plantar fasciitis is characterized by stiffness, inflammation and gradual degeneration of the plantar fascia (fibrous connective tissue) on the plantar (bottom) aspect of the foot.  A less common cause is associated with a bone spur of the heel. 

WHAT CAUSES PLANTAR FASCIITIS?

•  There are a number of factors that can contribute to plantar fasciitis including:
•  Repetitive impact resulting in micro trauma or stress to the heel tissues that may cause inflammation or calcification of the fascia
•  Inflexibility of the calf muscles
•  Flat (planus) or high (cavus) arched feet
•  Unhealthy foot pronation
•  Limited ankle range of motion
•  Excessive body weight
•  Poor footwear
•  Irritation of the small nerve that runs under the foot where the fascia attaches to the heel bone

In our office we most commonly have patients with repetitive micro trauma to the plantar fascia resulting in adhesion and scar tissue formation.

SIGNS AND SYMPTOMS:

This injury can manifest in several ways.  The most common signs and symptoms include:

•  Pain and tenderness on the sole of the foot usually localized at the heel bone when standing or walking
• Pain following your activity
• Pain associated with the first few steps taken in the morning when getting out of bed or after prolonged sitting

DIFFERENTIAL DIAGNOSIS:

Many conditions can resemble and can coexist along with plantar fasciitis, such as:

• Strain of the Flexor hallucis longus
• Achilles tendonopathy (inflammation and gradual degeneration of the Achilles tendon)
•  Ankle sprains (damage to the ankle ligaments)
• Referred nerve pain from the low back

SELF MANAGEMENT:

There are several ways that you can prevent development and recurrence of plantar fasciitis including:

•   Stretch and warm-up prior to activity (including foam rolling/lacrosse ball)
•   Use a frozen water bottle to roll along the base of your foot
•  Maintain appropriate strength/conditioning (glute and lower extremity)
• Maintain healthy body weight
• Avoid activities that put a constant strain on the foot
•  Wear appropriate footwear
•  Night splints
• Correction of gait abnormalities

CONSERVATIVE MANAGEMENT:

Similar to any foot-related injury, treatment interventions will vary based on the individual and are commonly multifaceted.  More complicated cases may require several of the following interventions in order to achieve positive clinical outcomes:

• Active Release Techniques©(ART) and/or Graston Technique^© to help elongate the tissue and breakdown any scar tissue or adhesion formation
• Functional Rehabilitation to strengthen the kinetic chain
• Joint mobilization to improve ankle and tarsal (bones of the foot) mobility
•  Passive modalities (low volt therapy, ultrasound)
• Night splints/Kinesio Taping^©
•  Orthotics (custom/over the counter)
• Gait analysis and gait training
• Appropriate footwear

Plantar fasciitis can quickly become a chronic condition if ignored for too long.  If you are experiencing symptoms of plantar fasciitis for greater than 1-2 weeks and self-management does not change your symptoms, you should have your condition evaluated.  The longer you wait, the longer it takes to resolve.   If a condition does not resolve with self-management and conservative care, higher intervention therapies may be necessary.  

The intent of this article is to provide a brief overview of plantar fasciitis.  In no way does it describe all causes or treatment options or intended for self-diagnosis.  If you are questioning your pain, please follow-up a licensed health care provider.

LOW BACK PAIN (LBP)

     Let’s start our journey of LBP by understanding the anatomy of the spine.  The low back is comprised of vertebrae, ligaments, muscles, blood vessels, nerves and discs.  The vertebrae are the bones that make up the spine.  The ligaments help to hold the bones and other structures in place.  Muscles attach to the bones and help produce functional movements.  Blood vessels run throughout the body and deliver nutrients to tissues.  Nerves run throughout the spinal column to send and receive information.  The most notable part of the nervous system found in the spine is the spinal cord.  Lastly the most notorious anatomical structure in regards to LBP, are the intervertebral discs.  Discs are fibrous and gelatinous structures that sit between the vertebrae and provides cushion for weight bearing activities and movement.  Together these structures unite to form the low back, each having the ability to produce LBP.

The causes of LBP can be organized in 4 basic classifications, somatic, radicular, central and visceral.

  1) Somatic pain arises from musculoskeletal structures such as intervertebral discs, ligaments, muscles and joint capsules etc.  This type of pain can be felt locally, which is noticed by more superficial structures and as referred pain which is most commonly associated with deeper structure of the body.   Most somatic pain is referred pain.  Referred pain can be described by the brains inability to localize a structure because of neurons converging together from many different areas.  One of the most common types of referred pain we see in our office is discogenic.  Discogenic pain arises from irritation of the disc which can present locally (ie: in the center of the back) or distally (ie: in the glute, hamstring, knee or foot etc.).  The disc itself has nervous innervation, which means it can perceive pain.  When the disc is stressed, for example with the fault of low back flexion during deadlifts, it will tell you with a pain response. 

     Somatic pain can present as constant, intermittent, sharp, dull, vague, radiating, and localized or any other descriptor you may think of when you think LBP.  Biomechanics of the body also play an important role in how somatic structures are affected.  For instance poor posture or bending and twisting places undue stress on musculoskeletal structures creating pain and dysfunction.

  2) Radicular pain can be the result of nerve irritation from the pressure on a neurological structure.  This exists when the disc protrudes/bulges or when other anatomical structures place pressure on the nerve root creating radiating pain.  99% of the time, pressure on a nerve root produces shooting radiating pain, numbness, tingling and/or motor weakness.  It can be excruciating and is comprised of both a mechanical and chemical source.  Chemical sources mean inflammation and mechanical sources mean pressure on the nerve root.  Radicular and somatic pain CAN occur together.

  3) Visceral pain arises from organs.  Examples of this are cardiac pains felt in the jaw and down the left arm, or gallbladder pain felt between the shoulder blades.

  4) Central pain arises from cells in the central nervous system.  For example, herpetic neuralgia or phantom limb pain.

Presentations of LBP and relevancy of severity:

     LBP can present in a number of ways, below I will discuss the most common.  The most concerning forms of injury is when there are shooting pains, numbness, tingling and/or motor weakness and mechanical deformation, meaning stuck in one position or blocked motion.  Central low back pain or intermittent pain activated by poor mechanics is usually not as painful as the above examples of pain, however still concerning.

The most common questions we receive as docs are, “when do I know it is bad pain? And should I follow up with a doctor?”  Honestly, all back pain is bad, especially the shooting, radiating kind, but only you can make the determination whether it requires a doctor visit.  For all intents and purposes, if it is causing pain, don’t ignore it.  Pain signifies injury and it’s your body’s way of telling you something is wrong.  Prolonging correction of a problem can make the injury more severe than the initial onset.

The RED FLAGS that will require an immediate visit to the emergency room are any one or all of the follow symptoms: loss of bowel/bladder control, numbness along the inner thighs and uncontrollable pain.

What can you do to prevent LBP?

     Be diligent with your low back stabilization exercises and core exercises.  Including these exercises into a daily routine is the staple for LBP prevention and rehabilitation.  Make sure to talk to a licensed provider prior to starting and exercise or rehabilitation program to make sure it is designed right for you.

Key takeaway points for LBP prevention:

             1)  Avoid any type of flexion and rotation of the low back – it creates a sheering force on the discs

             2)  Avoid low back flexion with heavy weights

             3)  Watch your posture.  Sitting is not a natural position and continually places stress on the discs and tissues.  Reduce bad form and limit stress caused by sitting for multiple hours per day. 

This article was intended to give a brief overview of low back pain.  In no way does it describe all causes or types of low back pain or is the information intended for use of self-diagnosis.  Many times low back pain can be caused by biomechanical dysfunction of the musculoskeletal system.  This is why it is essential for you to follow up with a health care practitioner if you are experiencing low back pain, to determine the appropriate cause of the pain.

Physicians Plus Voted Best Rehab in Midwest

 Physicians Plus Chiropractic and Sports Rehabilitation has been voted 2011’s Best Sports Rehab Clinic in the Midwest by the readers of Competitor Magazine!  Each year Competitor invites the public to vote for their favorite products, events, and services throughout the nation and we are proud to make the list.  We will continue to provide the highest standard of care to all of our patients and athletes, to keep you healthy and pain-free day after day. 

We would also like to give a shout out to our friends at CrossFit Chicago for being voted 2011’s Best Gym in the Midwest.  CrossFit Chicago continues to show excellence in fitness training, coaching and community support, so it no wonder why they were voted the Best Gym in the Midwest.  Physicians Plus is proud to work with such an amazing group of people.