SOFT-TISSUE REHABILITATION FOCUS

MANAGEMENTOF ACHILLES TENDINOPATHY

By Dylan Morrissey, MCSP

Achilles tendinosis is a condition com- mon in many sports and especially in runners and describes degeneration of the achilles tendon.

The majority of these injuries occur in men, with most patients being middle-aged. It typically affects the middle third of the tendon and may be accompanied by an inflammation of the tendon sheath. Cystic degeneration and microtearing that heals poorly results in a thickened, swollen, painful tendon which causes pain during and after exercise. There may be evidence of ongoing inflammation, for example morning stiffness.

Successful management of achilles tendi- nosis relies on accurate diagnosis, multi- factorial clinical assessment of contributo- ry factors and completion of a progressive rehabilitation programme that addresses these aspects.

These principles apply to management of all repetitive use tendon injuries and there is good evidence for the efficacy of conser- vative management of chronic persistent achilles tendinosis.

The core element of this approach is a graduated eccentric retraining of the tri- ceps surae complex (the proximal inser- tions of gastrocnemius and soleus and the joined distal insertion of the Achilles ten- don), complemented by assessment-based intervention to address contributory fac- tors.

Diagnosis Accurate diagnosis is essential. This pro- vides a diagnostic label which must be accompanied by a detailed description of contributory factors.

Useful local diagnostic tests 1. The London Hospital sign The hypertrophic area is palpated both when the muscle is relaxed and during sta-

tensioned tendon prevents the same degree of palpation compressing the lesion

Figure 11b: Resisted contraction

2. Tendon sheath differentiation The painful area is palpated with a pincer grip and the ankle passively plantar and dorsi-flexed (Fig.12). If the primary source of the pain is the tendon sheath then the pain will not vary with move- ment as the sheath stays still. A primarily sore tendon will cause pain that is worst when the cystic area of tendon is moved to between the palpating fingers.

palpation pressure no contraction

tic resisted contraction (Figs. 11a & 11b). An intra-tendon cyst will be less painful when the muscle is contracted. A tendon sheath problem is likely to be more sore.

no contraction palpation pressure lesion

3. Posterior impingement differen- tiation

This test compares the pain produced dur- ing a static, resisted contraction in midrange plantar flexion which loads the achilles tendon, to the pain evoked during passive over-pressure of plantar flexion which compresses the back of the talo- crural joint (Figs. 13a & 13b).

contraction

achilles tendon in crimped lax state so palpation can compress lesion

Figure 11a: Relaxed state contraction palpation pressure Figure 13a: Static resisted contraction no contraction

achilles tendon lesion

passive pressure applied to back of joint

Figure 13b: Application of passive pressure

Role of eccentric retraining Eccentric muscle work is difficult for the body to control as it requires sophisticated central neural control and local tissue integrity that allows the muscle to ‘pay out’ as it is generating force in relation to an external load ie. gravity multiplied by body mass.

passive plantar and dorsiflexion Figure 12: Tendon sheath differentiation

Eccentric work generates high force in both the contractile and non-contractile compo- nents of the muscle complex. This type of muscle work is very energy efficient. The energy is primarily supplied by the effects of gravity and the concentric cross-bridge cycle is reversed minimising the use of ATP. Additionally, some of the potential energy is stored in the series and parallel

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