Achilles tendonitis is an inflammatory condition that involves the Achilles tendon and/or its tendon sheath. Achilles tendonitis is the most common overuse injuries reported in distance runners. 16 Although Achilles tendonitis is generally a chronic condition, acute injury may also occur. Typically, the athlete will suffer from gradual pain and stiffness about the Achilles tendon region, 2 to 6 cm proximal to the calcaneal insertion. The pain will increase after running hills, stairs, or an increased amount of sprints (running on toes). Upon evaluation, the gastrocnemius and soleus muscle testing may be normal however, flexibility will be reduced. Having the patient perform toe raises to fatigue will show a deficit compared to the uninvolved limb. Inspection of the area may feel warm to the touch and pain, tenderness and crepitus may be felt with palpation. The tendon may appear thickened indicating a chronic condition.
Healing of Achilles tendonitis is a slow process due to the lack of vascularity to the tendon. Initially, patients will feel comfortable by placing less stress to the area by wearing a heel cup. Resting and activity modification is important during the initially healing stages. The clinician needs to emphasize the importance of allowing the tendon to heal. During this time, cross friction massage can be started to the area to break down adhesions and promote blood flow to the area.
Stretching and strengthening of the gastrocnemious-soleus complex should be incorporated as tolerated by the patient. Towel stretching and slant board stretching should be done throughout the day. As range of motion is restored, the heel cup should be removed to reduce the chances of adaptive shortening of the muscles and tendon. Progressive strengthening including toe raises and resistive tubing should be incorporated at the beginning of rehabilitation. Sets should start low with low reps and gradually increase to low sets high reps for endurance as tolerated by the athlete. As pain and inflammation decreases, machine weights, lunges, and sport specific exercises can be added. Eccentric exercises for the triceps surae often have beneficial results in athletes with Achilles tendonitis.
The patient’s foot structure and gait mechanics should be evaluated for possible orthotic benefits. Often Achilles tendonitis is a result of overpronation, an abnormality that can be addressed with foot orthoses. 18 Once range of motion, strength and endurance has returned, athletes should slowly progress into walking and jogging program. Workouts should be done on a flat surface when possible. The walking and jogging program should start out with slow mini-bursts of speed. The program is to increase the amount of stress the Achilles tendon can tolerate; it is not to improve overall endurance. As tolerated by the patient, running and sprinting can be increased.
Criteria for full competition
Athletes should be allowed to compete when full range of motion and strength has returned. The athlete should have regained endurance in the involved limb and be capable of completing a full practice without pain. Depending on the sport, some athletes may be able to compete while suffering from Achilles tendonitis. However, patients should be educated in the fact that the condition will not go away without proper rest and treatment.
Patients need to be educated with the risks of Achilles tendonitis, specifically hill running, lack of proper shoes, lack of rest, and flexibility. Hill workouts increase the stress and strain to the gastrocnemius-soleus complex and Achilles tendon. Hill workouts should be done at a maximum once a week to allow the body time to heal. Similar to any chronic injury to the feet, shoes must be evaluated. Athletes need to learn and understand their foot type and the proper shoes for their foot type. Also, shoes should be replaced every 500 miles are a maximum 2 years. Running on old worn shoes will alter biomechanics and cause stress and strain to the body. Finally, the lack of flexibility is often the main culprit in Achilles tendonitis. The importance of stretching and stretching often should be emphasized.
Initially, heel cups will reduce the tension and stress placed on the Achilles tendon. As flexibility is regained, the heel cup should be gradually reduced to reduce the chances of an adaptive shortening of the tendon. Athletes may find comfort in a special tape job that will reduce the stress placed on the Achilles tendon as well. The patient’s foot type and gait mechanics should be evaluated for possible use of custom orthotics. Achilles tendonitis can often be attributed to over pronation during gait. A custom orthotic will be able to adjust the athlete’s gait to reduce this abnormality.