Achilles Tendon

Question 1

Achilles Tendon Tendinopathy and Rupture - Anatomy Review

Answer 1

• Achilles tendon is the insertional tendon for the gastrocnemius (originates above knee joint) and Soleus (orginates distal from knee joint).
  
  • Gastrocnemius has two heads. Major role in plantarflexion, especially when knee is in an extended position.
  • Soleus plays major role in plantarflexion, especially when knee is in a flexed position. When running, soleus is crucial because we run in a slightly flexed knee position.
  • Plantaris muscle sometimes attaches to the Achilles tendon, but not always.
  • Achilles tendon is very long and inserts into the supero-posterior aspect of calcaneus.
    Can be mid-substance tear or injury or insertional tear or injury.

Question 2

How do tendon injuries happen? Risk factors (10)

Answer 2

• Age (as we get older, tendons become more degenerative, and therefore less capable of coping with high loads and more vulnerable to rupture)
  
  • Genetic factors and predisposition of family
  • Rheumatological conditions
  • Muscle strength (if weaker muscles, the tendon is less capable of dealing with the loads placed on muscle)
  • Deconditioning and/or previous injury (especially if unable to regain previous muscle strength)
  • Metabolic influence: smoking, diabetes, kidney function (affects healing of tendons. Smokers = nutrients find it more difficult to get to tendon because of arthroscleporiss, fatty plaques in blood vessels, oxygen levels. Similar principles with diabetes and poor kidney function. Kidney is main waste controller in body so has major role in making sure we have right level of nutrients in body)
  • Obesity: increase tendon fibre diameter leading to stiffness (obesity increases general level of inflammation in body, so joints have naturally higher state of inflammation. Tend to have thicker tendon fibres, leading to more stiffening as they become less elastic)
  • Females and menopause (hormonal changes can influence tendons)
  • Certain drugs: anabolic steroids and fluroquinolones
    Activity levels: too little and too much (if do too little, tendons are less adept at managing loads as not had conditioning. If too much without letting settle, can increase risk.

Question 3

Compared to other tissue, tendons are …

Answer 3

• Less tolerant of stretching and quicker, sharper forces, and quick changes in direction particularly with large forces, as muscles have a much higher component of elastic tissue so more adept at reacting to quick contract-stretch mechanisms than tendons. Relevant to both ruptures and tendinopathies.
• Higher recurrence rate
• Less tolerance of varied loads
• Tendon injuries often take longer to respond than other soft tissue injuries.
• Myofascial injuries which occur at the level of the skin has the quickest healing time.
• Musculotendinous injuries (involves element of tendon and the muscle) the healing time increases a little bit.
• Injuries which are purely tendinous, healing time is much longer.

Question 4

How do tendinopathies happen?

Answer 4

• Tendinopathy is a misbalance of the rate or wear and repair.
• When we have a tendinopathy, tendon heals by laying down collagen fibres.
• One of the key principles of tendon healing is that immature (disorganised type 3 collagen gets converted into mature (organised) type 1 collagen during the remodelling stage.
• Tendinopathy patients can re-injure or re-irritate their tendons before the remodelling process can begin.
• During the remodelling stage of tendon healing, the body converts type 3 collagen to type 1 collagen which is much stronger.
• If we don’t allow the body time to get into the remodelling phase, we get a tendinopathy because the tendon has to try function in its immature, disorganised state.
• This leads to a higher presence of immature collagen remaining in an irritated tendinopathic tendon
• Loading is good as it allows collagen to be laid down.
• Repeated overloading without adequate rest means type 3 collagen cannot be converted into type 1.
• Type 3 collagen is more vulnerable and less adept at coping with load.
• By not reducing loads and keep irritating tendon, we keep creating an inflammatory reactive state in tendon, meaning the body thinks we need to keep laying down type 3 collagen and the body cant cope with the loads a type 1 tendon could cope with.

Question 5

Does the tendon healing process matter to Achilles tendon ruptures as well?

Answer 5

• Absolutely!
  
  • If a tendon has a much higher content of immature type 3 collagen, it responds more poorly to load and excess quick-stretch.
  • This can make it more vulnerable to further injury, perhaps in the form of an Achilles tendon rupture.
    This is even more relevant to very degenerative tendons.

Question 6

How do ruptures happen?

Answer 6

• The Achilles tendon is the most frequently ruptured tendon in the body.
  
  • Injury video analysis of 60 footballers with Achilles rupture.
  • 50 (83%) were classified as non-contact and 10 (17%) as indirect contact.
  • Occur during accelerations in 3 main situations
    1. Forward acceleration from standing (42%)
    2. Crossover cutting (legs crossing over) (25%)
    3. Vertical jumping (18%)
  • Often multi-planar (but predominantly sagittal plane) with slightly flexed trunk, extended hip, early flexed knee and end range dorsiflexion (40degrees)
    Deconditioned tendon as patient hasn’t played a sport in a while, and then suddenly goes back to playing.
    After the age of 35, our tendons start becoming more degenerative.

Question 7

Tendinopathy - Subjective Assessment

Answer 7

• PMH - previous Achilles injuries? Previous rheumatology? Drug history?
  
  • SH - hobbies, activities, any influence?
  • HPC - When? How? How long? Better/same/worse? Listening for story of overload.
  • Body chart - pain at the Achilles specifically - mid portion or insertional? Aching but could be sharp with sudden increases in activity, not expecting widespread added symptoms (like pins and needles, numbness, global pain)
  • Aggravating factors - related to loading / activity (running, jumping, stairs, walking)
  • 24 hour pattern (more activity dependent but possibly worse next day?)
    Not expecting red flags, distinct night pain.

Question 8

Tendinopathy - Questions for Runners?

Answer 8

• How long have you been running?
  
  • How long have you been running regularly?
  • What was your key reason for starting running? Important for management.
  • Did you do any strength work prior to starting running? Looking to see how conditioned and strong is the tendon.
  • Tell me about what you do each week? (load vs rest)
  • How did you progress your training? Looking at periodic overload. Was it a progressive overload or a quick progression of overload.
  • How long into your run does it start to hurt? Looking at how capable they are. Important for load management.
    How sore/debilitated are you after? For how long? Looking at how much rest they need between each run to prevent overload.

Question 9

Tendinopathy - Objective Assessment

Answer 9

• Pain and ? Swelling on palpation of the Achilles tendon. Sometimes in more degenerative tendons, you get a widening or thickening of tendon where it is irritable.
  
  • Range of movement testing (pain with non-weight bearing dorsiflexion is not consistent with tendinopathy, but significant increase (pushing tendon to elastic limit) or decrease (any stretching/elongation is causing irritation) in dorsiflexion could be a risk factor)
  • Weak calf = risk factor for tendinopathy. Test plantarflexion strength.
  • Straight leg raise: SID (sural, inversion, dorsiflexion) for Sural nerve, TED (tibial, eversion, dorsiflexion) for tibial nerve. Not expecting neural signs with tendinopathy.
  • London hospital test (patient laid in supine. push on painful part of tendon, then passively dorsiflex the ankle and push on tendon. Dorsiflexion seems to reduce pain. ) Eased pain in dorsiflexion position is positive result for tendinopathy.
    Establishing if your patient has a mid-portion or insertional tendinopathy is important for rehab.

Question 10

Achilles Rupture - Assessment - Diagnosis

Answer 10

• • Trauma, think of mechanism of injury. Could be position of dorsiflexion or push off position.
  • Felt or heard ‘pop’
  • Consider risk factors e.g., anabolic steroids, fluroquinolones.
  • Altered tendon on palpation. If can’t palpate it, could be ruptured.
  • Change in strength of plantarflexion.
  • Thompson’s (squeeze) test. (Patient in prone, knee on bed, ankle off bed. Squeeze calf muscle. Should plantarflex the foot. If it doesn’t, could be due to Achilles tendon rupture because the connection has been sethered).
  • Matles’ test. (patient in prone, flex both knees to 90 degrees, hold onto tibia so knees stay in that position. Sole of the foot should be horizontal because tension in Achilles tendon should hold the foot up. If no tension in Achilles, the foot might drop into dorsiflexion. That is positive sign of Achilles rupture).
    If required, ultrasound or MRI. Sometimes done for partial ruptures.

Question 11

Achilles Rupture - Treatment Planning

Answer 11

• What has the management been? Surgical vs conservative. How long in plaster? NWB? Did they stick to it? Sometimes patient’s who don’t stick to it, don’t regain as much strength.
  
  • Aims and goals that they want to get back to? (high level sports = plyometrics, end range dorsiflexion position, push-off exercises)
  • Active range of movement
  • Strength of plantar flexors and rest of lower limb chain.
  • Weight bearing status and ability.
    Proprioception.

Question 12

Rehab - Achilles Rupture - Management Options

Answer 12

• Throughout the literature, there is no consensus regarding the optimal treatment protocol.
  
  • Achilles tendon ruptures can be treated surgically or conservatively.
  • Elite athletes tend to be referred for surgical intervention as it might be suggested that they have a quicker recovery.
    However, there is more complications associated with surgical intervention as well.

Question 13

Heel Raises Progressions in Achilles Tendon Treatment:

Answer 13

Heel Raises Progressions in Achilles Tendon Treatment:
- Low level = single leg seated heel raises (could put weight)
- Double leg heel raise to neutral (off a step - not into dorsiflexion)
- Double leg heel raise with dorsiflexion
- Double leg heel raise with one sided bias
- Single leg eccentric heel raise (concentric on one leg, eccentric on other leg - good if got irritable tendon which doesn’t leg eccentric movement)
Single leg heel raise (concentric and eccentric on same side)

Question 14

Achilles Tendon Rehab - Plyometrics:

Answer 14

• Squat jump
  
  • Lunge jump
  • Single / triple leg hop
  • Box jumps
    Drop jumps
• push off from sprint box

Question 15

Rehab: Achilles Rupture - Management Options?

Answer 15

Throughout the literature, there is no consensus regarding the optimal treatment protocol.
- Achilles tendon ruptures can be treated surgically or conservatively.
- Elite athletes tend to be referred for surgical intervention as it might be suggested that they have a quicker recovery.
- However, there is more complications associated with surgical intervention as well.
- Conservative management is more common for “normal” non-elite athlete population

Question 16

Rehab - Achilles Rupture - How are they managed conservatively?

Answer 16

• Immediate immobilisation after diagnosis in Equinus cast (30degrees plantarflexion)
  
  • Subsequent referral to fracture clinic for orthopaedic boot.
  • Progression from plantarflexed position towards neutral (plantargarde) using heel pads, and gradual removal of these.
  • Weight bearing (look at local guidelines)
  • The LAMP protocol as below, is an example of an established regime used for the management of conservative Achilles tendon ruptures. Alternative protocols may focus on similar guidelines with a clear period of immobilisation with gradual progression of dorsiflexion.
  • Leicester Achilles Management Protocol (LAMP):
  • 0-4 weeks - locked in 30degrees plantarflexion.
  • 4-6 weeks - dynamised 15-30degrees plantarflexion
  • 6-8 weeks - dynamised 0-30 degrees plantarflexion
  • Remove boot at 8 weeks.
  • Able to fully weight-bear throughout.
  • Physio 2 weeks after boot removal.
  • Re-ruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury.
  • Physio key concerns - re-rupture, tendon elongation, DVT. Re-emphasise important of wearing the boot.
  • Do not force dorsiflexion. During the immobilisation stage, theres a focus on preventing excessive dorsiflexion because if the tendon is overly stretched in those early stages and that tendon gets elongated it loses strength and tensile strength. If we try and get dorsiflexion back by doing aggressive forceful stretches, we simply elongate the tendon so it loses its tensile strength.
  • The gradual progression of dorsiflexion is crucial to prevent over stretching of the tendon, as this leads to tendon elongation meaning that tensile strength is reduced.
  • As a result, we must continue this concept in our rehab by not offering forceful dorsiflexion stretching. Simply offer active range of movement exercises such as ankle circles which restore dorsiflexion in a slower more controlled manner. “let it come naturally”.

Question 17

Rehab - Achilles Rupture - Phases of Rehab?

Answer 17

• Phase 1 - Re-establish plantarflexion activity and re-educate towards FWB with no boot (8-12 weeks) = plantarflexion isometrics, general ankle ROM e.g., ankle circles, writing name with foot, progression of gait once boot removed from 2 crutches to FWB.
  
  • Phase 2 - Concentric plantarflexion with natural eccentric movement (12-20 weeks) = sitting heel raises: progress with double leg to single leg. Theraband plantarflexion; consider starting with knee flexion and progress to knee extension, ensure fully weight bearing with no concerns and no limp, start working on single leg proprioception, end with double leg standing heel raises, and walking agility, glutes, quads, and hamstrings as well. Don’t do heel raises that go into dorsiflexion.
  • Phase 3 - Progress to weight bearing strengthening and build single leg strength (20-30 weeks) = standing heel raises; progress from double leg to single leg. Higher level strengthening: squats, lunges, dead lifts, single leg press, single leg calf press, retro-walking on a treadmill, start agility training with consideration of low-level running when able to complete 20 single leg heel raises. End of phase; consider DL heel raises with element of DF. 90% single leg heel raises compared to other side?
    Phase 4 - Heavier contractions, plyometrics, dorsiflexion tolerance, plan for return to sport (30+ weeks) = heavy resistance / loading with single leg heel raises, single leg heel raises with DF component, plyometrics = box jumps, lunge jumps, hopping and landing; consider position of injury (PF in end range DF with trunk flexion), achieving return to sport criteria.

Question 18

Rehab - Achilles Rupture - Return to Sport Criteria?

Answer 18

• Achilles tendon total rupture score (considered need to achieve 95/100 for return to sport)
  
  • 95% LSI with single leg heel raises.
  • Y Balance test / star excursion balance test: 95%
    95% LSI on hop tests (single leg hop, triple leg hop, triple leg crossover hop)

Question 19

Return to Sport Rates

Answer 19

• Sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention (LaPrade et al, 2022)
  
  • NFL players: The overall RTP rate was 61.3% (Wang et al, 2019)
  • NBA players: significant decrease in playing time and performance, with 39% of players never returning to play (Amin et al, 2013)
  • Non-operative Mx: Assessed by Tegner Activity Scale. Patients with a high preinjury activity level = 67% Return to play. Patients with a low pre-injury activity level = >90% (Lerch et al, 2020).
  • As sport gets more difficult, its more difficult to return to sport.
    Professional level, the mean time to RTP is 11 months, nearly double the estimated 6-month recovery for RTP in the general population (Johns et al, 2020).

Question 20

Rehab - Tendinopathy - Patient Education

Answer 20

• How it started? Want to point out that it started by doing too much / not enough preperation and if we continue this, it will happen again.
  
  • Key principles in load management - why - collagen? Instead … what is their role? Need them to know they need to be disciplined in their load management. Explain the tendon healing process so they understand their role in load managament and how important it is.
  • Pain levels during exercise (2-5/10 pain, definitely do not go above 5/10 pain during exercise)
  • Repetition diary (see correlation between repetitions and symptoms)
  • Advice for if it gets irritable
  • Manage flare up expectations (increase rest, reduce intensity of exercise)
    Manage prognosis expectations

Question 21

Rehab - Tendinopathy - Can I Keep Running?

Answer 21

• “I can’t remember many times when I told someone to stop running”
  
  • Psychological effect but also physical effect on tendon. (can affect people psychologically especially if running for mental healthy. Physical effect on tendon as it loses strength, tensile activity between plantarflexion and dorsiflexion).
  • May have to really reduce, but better than stopping.
  • A little burn after is ok, as long as it calms quickly.
  • What distance can they run which is tolerable?
  • Walk-run: could be good to build up. (speed can create more issues than distance. Running further is easier than running faster on the Achilles tendon).
  • Keep speed constant: speed can create more issue than distance.
    Track distances, keep diary.

Question 22

Rehab - Tendinopathy - Heel Raises

Answer 22

• Cannot do an Achilles tendinopathy rehab plan without heel raises.
  
  • Heel raises (seated, double leg, double leg bias, eccentric, single leg, plyometric)
  • Other heel raises strategies (progress if patient able to do 15 reps comfortably, need combination of knee flexion and extension: running needs flexion! Height control (0-100-25-75-50-100-0); heavy - aim for additional 50% body weight as an external load)
    For insertional Achilles tendinopathy, we may choose not to give heel raises which move into DF as this puts a compressive load through the tendon insertion which can make it more irritable. Tendons need to be able to cope. So we may do this in latter stages of an insertional tendinopathy once more substantial recovery has occurred.

Question 23

Rehab - Achilles Tendinopathy - Isometrics

Answer 23

• Using the recommended approach of a heavy 45-seconds isometric contractions did not offer a meaningful acute benefit for sensory or motor output for subjects with Achilles tendinopathy”.
  
  • In conclusion, isometric plantarflexion holds gave an approximately 50% immediate reduction in Achilles tendon pain with a functional load test.
    Ultimately, the evidence currently does not fully support the use of isometrics in practice for Achilles tendinopathy.

Question 24

Rehab - Achilles Tendinopathy - Silbernagel Protocol

Question 25

Rehab - Tendinopathy - Heavy-slow resistance

Answer 25

- Basic principle is very heavy weight, very slowly. - Initially done with patella tendinopathies. - Rep max progression: 1. Week 1: 15 rep max 2. Week 2-3 : 12 rep max 3. Week 4-5: 10 rep max 4. Week 6-8: 8 rep max 5. Week 9-12: 6 rep max - 4 sets / sessions, 3 times a week, for 12 weeks - 6 seconds per rep (3 concentric, 3 eccentric) - The Heavy-Slow resistance model shows a gradual progression in the intensity of heel raises, as the level of Rep Max progresses as the weeks go by. The key focus here is that with each repetition there is a 6-second period (3 seconds concentric and 3 seconds eccentric). This model has also been shown to be effective in the research. "The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks".

Question 26

Rehab - Tendinopathy - Plyometrics

Answer 26

- Plyometrics: force + speed = power - Muscle actively stretches before shortening - Vital for improving long term tolerance - Lunges, lunge jumps, squat jumps, jump and land, push offs (think MOI) Plyometric training is essential for those who have high aspirations of going back to high level sport or activity following their tendinopathy, to ensure that the tendon has the highest level of tolerance. Think about mechanism of injuries and ensuring that this position is a part of our plyometric training too, perhaps with an exercise like sprint push-offs.

Question 27

Rehab - Tendinopathy - Adjuncts

Answer 27

Taping and heel pads can be beneficial, but only in early stages to settle tendon down

Question 28

Rehab - Tendinopathy - do we focus on glutes too?

Answer 28

- Yes, it can be useful to strengthen the hip extensors. - But don't overly rely on this. The Achilles tendon still needs really good loading too.

Question 29

Rehab - Tendinopathy - Extracoporeal Shockwave Therapy

Answer 29

- ESWT is an effective intervention and should be considered for GTPS, Patella tendinopathy , and Achilles tendinopathy particularly when other non-operative treatments have failed. - ESWT produces immediate conditioned pain modulation effect when applied to Achilles tendon in healthy populations. - Evidence for using shockwave for Achilles tendinopathy is emerging and progressing. NICE guidelines not completely convinced about shockwave therapy.