Pilates For Achilles Tendinitis

June 3rd is National Running Day and many running organizations from across join forces in an effort to promote running as an easy, healthy, affordable form of exercise. Unfortunately, runners are susceptible to foot problems, including heel pain, tendinitis, ankle sprains, stress fractures and blisters. Proper shoe fit and training are two of the easiest ways to prevent foot and ankle injuries while running. This article review the top 5 foot problems in runners and simple tips for treatment and prevention. 1. Heel Pain and Plantar Fasciitis: Plantar fasciitis is caused by excess stress on the ligament-type structure within the arch of the foot. The tearing causes inflammation and the inflammation causes pain, most commonly at the inside of the heel. Over million runners develop plantar fasciitis each year. Although classic plantar fasciitis pain occurs at the heel upon stepping down first thing in the morning, this is not always true for runners. Many runners experience pain on the bottom of the heel and through the arch during the first 10-15 minutes of a run. In most cases, it works itself out as the run progresses, but returns at the end of the run, or later in the day. To prevent the development of plantar fasciitis when running or to help avoid re-injury, pay special attention to your shoes. Check your shoes for support and make sure they do not fold in the middle. Take the heel of the shoes and press the toe of the shoe into the floor. If the foot collapses under this pressure, it is much too flexible. A short run in an old pair of shoes can cause plantar fasciitis to development. Throw out old shoes when they are worn out and test all new shoes with this simple test. make sure your shoe is supportive. Just one run in that old, worn out pair of shoes can cause enough stress on the plantar fascia to start the process. If you are prone to developing arch pain or plantar fasciitis, stretch the arch before you run for at least one minute. Place one foot on the opposite knee while seated and grab the toes. Pull both the ankle and toes back. This will stretch the arch and you should be able to palpate the plantar fascia. Perform this stretch after the run as well. Calf stretching will also be beneficial, but if not done appropriately, can lead to Achilles problems. Warm up first, then perform calf stretches. Repeat the stretches when you are finished. Slowly progress with training by adding in distance and hills gradually and increasing pace and stride gradually. 2. Achilles Tendinitis: Achilles tendinitis and calf related injuries are the most common injuries experienced by runners. Pain may gradually develop at the back of the heel or calf, or come on suddenly as a sharp pain. Pain at the beginning of a run is common as well as pain and stiffness when first stepping down in the morning. Improper training, over training and poor footwear are the three most common reasons for development. A sudden increase in distance or pace or additional of steep hill climbs can strain the muscles and tendons in the foot and ankle causing microtears within these structures, resulting in pain and inflammation. Prevention for Achilles tendinitis and calf problems is similar to that of plantar fasciitis. Appropriate shoes and training are the most important. Calf stretching should be done after a 5-10 minutes warm up and it’s important to note that improper stretching or over-stretching can cause injury. 3. Stress fractures: A stress fracture is an incomplete break in the bone. In the foot, the long bones (metatarsals) are the most commonly affected. A sudden onset of pain and swelling on the top of the foot is an indication of a stress fracture. Stress fractures are generally not associated with blunt trauma or a specific injury, but are more often linked to unsupportive shoes in combination with overuse. Individuals with flatfeet, overpronation, hypermobility and tight calves are at the greatest risk. Those with very flexible feet tend to overstress the ball of their foot because the great toe joint tends to rise (hypermobility) during the push off phase of walking. The great toe joint does not take it’s fair share of weight and a greater force is placed on the smaller metatarsal bones. Individuals with tight calf muscles have a heel that lifts earlier than normal when walking. This also places excess stress on the ball of the foot and lesser metatarsals. Hypermobility and tight calves are linked to overpronation and this triad of abnormal foot mechanics, in combination with poor quality shoes and overuse can lead to stress fractures. Supportive shoes, heel lifts, orthotics (if necessary), proper training and stretching are the keys to avoiding stress fractures. 4. Ankle Sprains: Ankle sprains are a common injury experienced by runners. The most common injury is called an inversion ankle sprain and involves the ankle rolling out while the foot turns in. This causes a partial tearing of one or more of the ligaments on the outside of the ankle. Most ankle sprains are mild to moderate in severity, but some may be severe and involve complete tearing of the ligaments. Rest, ice, compression, elevation and early range of motion are the keys to treating most ankle sprains. Mild ankle sprains will need 2-6 weeks of rest and support, while moderate ankle sprains may take 6-12 weeks to heal. Severe ankle sprains will take 12 weeks to a year to heal and some involve surgery. An evaluation by a physician may be important to rule out a fracture or complete ligament tear. 5. Blisters: Almost all runners have experienced blisters and although they may not be as limiting as other running injuries, they are annoying at best. Blisters develop as a result of friction and shearing forces on the skin. Abnormal motion in the foot, such as pronation, excess moisture on the feet or within the socks, ill fitting shoes and foot deformities all increase the chance of blisters forming. The body’s natural defense mechanism to excess rub, irritation and shearing forces on the skin is to develop fluid between the outer layers of the skin. This provides a cushion and protects the under layers, allowing for a new layer of skin to grow. Blisters can be prevented with proper fitting shoes and appropriate socks. Finding the right combination of shoes and socks can be a challenge. Socks should be made of a wicking material which facilitate the transfer of moisture from your feet to the outer layer of the sock, so it can evaporate. Cotton socks absorb moisture like a sponge and should be avoided. The American Academy of Podiatric Sports Medicine recommends socks made with CoolMax. Shoes with mesh fabric allow for breathability and help with moisture evaporation. Supportive shoes with proper fit are important to avoid excess movement in the shoe. If you have orthotics, make sure you run with them, as excess pronation and abnormal foot motion are also factors causes friction, shearing on the skin and contribute to blister formation.

Heel pain can occur at either of two places: the bottom of the heel or the back of the heel. The heel bone, the calcaneus, is the largest bone of the foot and bears our full weight during part of each stride. The painful heel, in almost all instances, is caused by excessive strain on one of the two major ligaments, and the pain occurs where these ligaments attach to the bone.

First, the Achilles tendon attaches at the back of the heel. This is the strongest tendon in the body and connects the muscles on the back of the calf to the heel. The force of contraction of the calf muscles enables us to stand on tiptoe and gives an extra thrust as we walk. Damage to this tendon attachment is called Achilles tendinitis. Frequently, there will also be tears in the tendon itself or in the lower part of the muscle.

Second, the heel spur syndrome affects the bottom of the heel. This is where the ligaments that make up the arch of the foot attach to the heel bone. These ligaments function like a bowstring to arch the foot, so they are under pressure every time we stand or step. If a problem at the bottom of the heel persists, calcium may develop in the inflamed area where the ligaments attach. The presence of the calcium spur may or may not cause additional pain. Many people have pain without visible spurs on X-ray, while others have spurs but no pain.

Usually heel pain is a simple result of a minor and forgotten injury. Unfortunately, since we strain the injured part every time we walk or stand, these problems can become a vicious cycle in which there is more injury, more inflammation, more injury, and so forth.

Rest, avoidance of further injury, and gradual resumption of activity as the pain subsides are indicated. Non-weight-bearing activities like swimming can be continued full tilt.

For Achilles tendinitis, rest the foot or feet. Use a shoe with a high heel wedge and a lot of padding, since this limits the stretch on the tendon. Warm up and stretch carefully for 10 to 15 minutes before exercise. Exercises such as tennis or walking uphill are not good; these stress the tendon. Remember that tight muscles on the back of the leg put extra strain on this tendon, so warm up with gentle toe touching or other stretching exercises for the calf muscles.

For the heel spur syndrome the activities to avoid are ones that cause pounding on the bottom of the heel. Heel padding will help, but support for the arch is even more important since this takes tension off the ligaments whose job it is to hold the arch. A strap around the foot at the level of the top eyelets on a shoe, secured firmly but not tightly by Velcro, can give good relief. Commercially made running shoes are sometimes very helpful. In most of these shoes the cushioning air cells break down after a few months, so you should change shoes even before they appear worn out. Don’t worry about wearing a silly-looking shoe; forget fashion and concentrate on getting well. This kind of problem can take a year or more to resolve, or it may go away quickly. Keep trying.

Achilles was the Trojan war Hero made famous by Greek Mythology. He was dipped into the river Styx by his mother, in an attempt to protect him in battle and make him immortal. Unfortunately he was struck by an arrow in the one spot at the back of his heel that she missed when she dipped him in the magical river. The Achilles tendon, which connects the powerful calf muscle to the back of the heel, now bears his name. Runners, athletes and Achilles are all similar in the vulnerability in this area. Without this tendon (which happens to be the largest and strongest in the body) running, jumping and athletic activities would be severely hampered. Anyone can develop Achilles tendonitis. It is a common, but preventable (and treatable) overuse injury of the tendon.
If you are out running hills and feel a sharp pain or dull ache in the back of the leg down near the heel, this could be Achilles tendonitis. If you feel along the course of the tendon (where it is mobile just above your heel bone) and you have tenderness, this is most likely Achilles tendonitis. Don’t ignore this. Ice the area and decrease your activity level. Avoid hills or speedwork until it subsides. If it doesn’t quickly get better, see your podiatrist. Otherwise you might end up sidelined for four to six weeks.
One of the most effective ways to prevent injury to the Achilles tendon is through a good warm-up and stretching routine prior to long runs, hill repeats and speed workouts. This keeps the tendon pliable, preventing micro-tears. Stretching can improve blood flow, enabling a speedy recovery if you do become injured. Stretch after a short warm-up; you should avoid aggressive Achilles stretches when your muscles are cold.
Patients with Achilles tendinitis often report a sense of sluggishness in the leg, diffuse pain around the Achilles tendon, or mild pain either during or after exercise that usually worsens as they run. Other symptoms can be swelling, morning tenderness in the Achilles tendon, or stiffness at the back of the leg that generally diminishes as the tendon warms up with use.
The severity of the injury to the Achilles tendon will help determine the treatment. But in most cases, rest is part of the treatment. It might be necessary to stop running and other high impact exercise, although often you can cross-train and cycle, as long as there is no pain or stress to the healing tendon. Treatment can also include non-steroidal anti-inflammatory medication or orthoses, which are devices designed to help support the muscle and relieve stress on the tendon, such as a heel pad or shoe insert.
Other treatments are bandages specifically designed to restrict motion of the tendon, stretching, physical therapy, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors that work against the Achilles tendon. If the tendonitis is mild, simple modifications of activities may help. Decreasing mileage, running on flats instead of hills, and backing off the activity level until there is no pain with exercise can allow the tendon to heal. In general, ice is much better than heat for tendonitis.
Some medications can increase the risk of Achilles tendon ruptures (complete tear). Whenever taking medications such as oral steroids or antibiotics (prednisone, Cipro, Levaquin, etc.) you should not exercise unless you have discussed this with your treating doctor. You may have seen in the news where the FDA recently posted a strong “Black Box” warning about these antibiotics and the associated risk of tendon ruptures.
A torn Achilles tendon is serious. Interestingly, it is not always painful. However, there is usually significant weakness and difficulty standing up on the toes if this has occurred. Any suspected torn tendon can be serious and should be evaluated by a podiatrist. In rare cases surgery may be needed to repair the tendon.
If you happen to be a marathon runner in training for battle on the course; warm up before you stretch, but most of all, don’t deviate from your training program. Do not run through the pain if you think you have Achilles tendonitis. If you are a Trojan War hero in battle, and you see any arrows coming your way, stay low and keep moving!

Achilles tendon injuries are an extremely common injury amongst runners.

What causes Achilles tendonitis?

There are multiple causes of this problem. Sometimes it is a simple case of overload: too much, too soon.

Sometimes there is a dramatic change in training – maybe changing from flat running to hills or from slow paced running to sprints. It is very important to make sure that enough time is allowed for adaptation to the muscles and tendons to occur.

What exactly is Achilles tendinitis?

Achilles injuries may result in inflammation of the tendon. Continued wear and tear to the tendon causes degenerative changes in the tendon. Sometimes long standing injuries the tendon may have calcification within it.

What are the symptoms of Achilles tendinitis?

Most people report to the clinic with the following symptoms;

            Tenderness in the Achilles tendon

            Stiffness, especially when getting up in the morning

            A general ache throughout the day which may ease when warming up

            Reduced range of movement in the ankle joint

            A thickening of the tendon

What is the best treatment for Achilles tendinitis?

It is important to understand the pathology of the injury. Some patients that we see have been told to rest. This approach very rarely works. Yes, rest will stop it getting worse but will not cause it to heal.

It is important to look at the biomechanics of the ankle when running. Sometimes the runner over pronates at heel strike thereby placing excessive lateral forces on the Achilles tendon. This can be fixed either with orthotics or with awareness of the problem and re training the runner’s gait.  

Along side gait retraining is specific strengthening exercises, deep tissue massage techniques and ankle mobilizations to ensure there is no ankle joint restrictions.

The time is takes to fix the problem depends how long the runner has had it and what state the tendon is in. if they are seen early in the process 3-4 weeks will be enough to heal the damage. However if the runner has been running through the problem  for months or years “hoping it would go away”, treatment is likely to take months.

Achilles Tendonitis:  Tampa Dr. Nelson Mane provides treatment with High Power Laser

Achilles Tendonitis is generally a condition which affects weekend warriors and athletes over 30.  These individuals are participating in sports which typically include running and jumping.  A tendon connects muscle to a bone.  The Achilles tendon is located in the lower leg and connects the gastrocnemius and soleus to the heel.  These are very powerful muscles in the calf.   “Itis” is a suffix which means inflammation of.  So in Achilles tendonitis we have an inflammation of the tendon which attaches the major calf muscles (gastrocnemius and soleus) to the heel.  The Achilles tendon is located posteriorly or on the back side of the lower leg. 

In my practice the most difficult aspect associated with treating a patient suffering from Achilles tendonitis is that the patient (runner, soccer player, basketball player) doesn’t want to stop playing his particular sport or activity and wants to return to his chosen form of exercise and recreation immediately.  Standard treatments for tendonitis include rest (to reduce inflammation), anti-inflammatory, Motrin, Aleve, (to reduce inflammation), ice, (to reduce inflammation) custom made orthotics may be used in order to reduce biomechanical stress on the Achilles tendon.

Physical therapies such as ultra sound and electric muscle stimulation may be used.  Rehabilitation may include strengthening and stretching exercises.

High Power Laser Therapy is a little used but highly effective treatment in the treatment of Achilles tendonitis.  Laser Therapy has been shown to increase bone and cartilage repair, accelerated healing, increase circulation, reduce inflammation and scar tissue as well as reduce pain.  High Power Laser Therapy as a tool in the treatment of Achilles tendonitis that allows a properly trained physician with experience and training regarding treatment of biomechanical injuries to the lower extremity (leg) and High Power Laser Therapy can accelerate the athletes repair and return to their chosen activity.  High Power Laser Therapy can also reduce the possibility of further injury by reducing the formation of scar tissue (a weaker grade of tissue) and repairing the Achilles tendon injury.   Most doctors are not aware that High Power Laser Therapy exist and therefore cannot use this to help treat these patients.  Below are a couple of articles from the scientific literature specifically dealing with Achilles tendonitis with laser therapy.

BACKGROUND: Eccentric exercises (EEs) are recommended for the treatment of Achilles tendinopathy, but the clinical effect from EE has a slow onset. HYPOTHESIS: The addition of low-level laser therapy (LLLT) to EE may cause more rapid clinical improvement. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 52 recreational athletes with chronic Achilles tendinopathy symptoms were randomized to groups receiving either EE + LLLT or EE + placebo LLLT over 8 weeks in a blinded manner. Low-level laser therapy (lambda = 820 nm) was administered in 12 sessions by irradiating 6 points along the Achilles tendon with a power density of 60 mW/cm(2) and a total dose of 5.4 J per session. RESULTS: The results of the intention-to-treat analysis for the primary outcome, pain intensity during physical activity on the 100-mm visual analog scale, were significantly lower in the LLLT group than in the placebo LLLT group, with 53.6 mm versus 71.5 mm (P = .0003) at 4 weeks, 37.3 mm versus 62.8 mm (P = .0002) at 8 weeks, and 33.0 mm versus 53.0 mm (P = .007) at 12 weeks after randomization. Secondary outcomes of morning stiffness, active dorsiflexion, palpation tenderness, and crepitation showed the same pattern in favor of the LLLT group. CONCLUSION: Low-level laser therapy, with the parameters used in this study, accelerates clinical recovery from chronic Achilles tendinopathy when added to an EE regimen. For the LLLT group, the results at 4 weeks were similar to the placebo LLLT group results after 12 weeks.

PMID: 18272794 [PubMed - indexed for MEDLINE]

Physiotherapy Science, University of Bergen, Bergen, Norway. jmbjor@broadpark.no

BACKGROUND: Low level laser therapy (LLLT) has gained increasing popularity in the management of tendinopathy and arthritis. Results from in vitro and in vivo studies have suggested that inflammatory modulation is one of several possible biological mechanisms of LLLT action. OBJECTIVE: To investigate in situ if LLLT has an anti-inflammatory effect on activated tendinitis of the human Achilles tendon. SUBJECTS: Seven patients with bilateral Achilles tendinitis (14 tendons) who had aggravated symptoms produced by pain inducing activity immediately before the study. METHOD: Infrared (904 nm wavelength) LLLT (5.4 J per point, power density 20 mW/cm2) and placebo LLLT (0 J) were administered to both Achilles tendons in random blinded order. RESULTS: Ultrasonography Doppler measurements at baseline showed minor inflammation through increased intratendinous blood flow in all 14 tendons and measurable resistive index in eight tendons of 0.91 (95% confidence interval 0.87 to 0.95). Prostaglandin E2 concentrations were significantly reduced 75, 90, and 105 minutes after active LLLT compared with concentrations before treatment (p = 0.026) and after placebo LLLT (p = 0.009). Pressure pain threshold had increased significantly (p = 0.012) after active LLLT compared with placebo LLLT: the mean difference in the change between the groups was 0.40 kg/cm2 (95% confidence interval 0.10 to 0.70). CONCLUSION: LLLT at a dose of 5.4 J per point can reduce inflammation and pain in activated Achilles tendinitis. LLLT may therefore have potential in the management of diseases with an inflammatory component.

PMID: 16371497 [PubMed - indexed for MEDLINE]

PMCID: PMC2491942

The advantage of High Power Laser Therapy over low level or cold laser is its power.  In laser physics power equals penetration.  The increase power allows the treating doctor to reach and   saturate the deeper target tissues with the light energy which creates the healing effect.

Dr. Mane is a board certified chiropractic orthopedist and neurologist.

For more information about the treatment of Achilles tendonitis with High Power Laser Therapy or about Dr. Nelson Mane D.C. please visit our website at http://www.manecenter.com/neuropathy.htm. 

Dr. Mane offers one on one consultation for Achilles tendonitis Sufferers.  If you are interested in scheduling a consultation please call 813-935-4744.