The Achilles tendon holds the distinction of being both the largest and strongest tendon in the human body, capable of enduring up to 1,100 pounds of force (Kannus, 2000). This remarkable structure serves as the conduit for transmitting the force generated by the calf muscles, enabling essential motions such as walking, running, and jumping. Despite its mythological namesake, Achilles, who was nearly invincible, the Achilles tendon has its own vulnerability—namely, a limited blood supply that predisposes it to injury (Maffulli et al., 2010).
Article Index
Anatomy & Biomechanics
Examination & Diagnosis
Motion Specific Release
Exercise & ADL
Conclusion & References
Introduction
Data from a study by Owens et al. (2018) underscores this vulnerability, revealing that over a third of NFL players suffering from Achilles tendon injuries never returned to the field. Among those who did, there was a significant 50% reduction in their performance metrics. While surgery isn't always a necessity for recovery—physical therapy can be effective in many cases (Khan et al., 2005)—it remains imperative to adopt preventive strategies to avert the potentially crippling impact of Achilles tendon injuries.
The Achilles Tendon: A Key Player in Running Mechanics
The Achilles tendon plays an indispensable role in the kinetic chain of a runner, orchestrating several vital tasks throughout the running gait. Research indicates that the tendon acts as an energy-storing spring during the gait cycle, thereby decreasing the metabolic toll on the body's muscular framework (Butler et al., 2013). Specifically, the energy harbored in the Achilles tendon during the midstance phase facilitates the initiation of the propulsion phase, propelling the knee and hip in an upward and forward direction (Farris et al., 2016).
In addition to these roles, studies reveal that the tendon's action substantially alleviates the workload on hip flexors like the iliopsoas and rectus femoris, as well as the hamstring muscles (Farris et al., 2016). This biomechanical advantage not only serves as a preventive measure against injuries but also optimizes running efficiency.
Anatomy & Biomechanics
Anatomical Framework
The Achilles Tendon is a co-joined tendon that bridges the calf muscles—the gastrocnemius and soleus—to the calcaneus, also known as the heel bone (Kerssemakers et al., 2021). Innervation for these muscles is supplied by the tibial nerve, highlighting their pivotal role in the tendon's overall functionality.
Particularly vulnerable is the watershed region, located 2 to 6 cm above the tendon's insertion point into the calcaneus. Characterized by chronic tension and limited blood supply, this area is a hotbed for injuries and notoriously slow to heal (Maffulli et al., 2010). Thus, meticulous care and preventive strategies are essential for preserving the integrity of this critical tendon.
Myofascial Network and the Achilles Tendon
From a myofascial standpoint, the Achilles Tendon forms a complex interplay of connections that become particularly crucial when addressing injuries to the tendon (Kerssemakers et al., 2021). Notably, the Achilles doesn't merely anchor the calf muscles to the heel bone; it also maintains fascial continuity with the plantar fascia and the foot's fat pad (Stecco et al., 2013). This integrated relationship implies that undue stretching or tightness in the Achilles could exacerbate issues like plantar fasciitis and gait disturbances.
Additionally, the Achilles Tendon is interconnected with the hamstring muscle group—consisting of the biceps femoris, semitendinosus, and semimembranosus—and shares direct fascial links with the gastrocnemius muscles (Stecco et al., 2013). Consequently, tension in the hamstrings has a direct line of transmission to the Achilles Tendon.
Of interest is the finding that hamstring tension can be a sign of inadequate gluteal activation (Distefano et al., 2009). Given that the gluteal muscles primarily facilitate hip extension, a lack of activation here redirects force to the hamstrings, which serve as secondary hip extenders. This further emphasizes the need for a comprehensive understanding of the myofascial connections when diagnosing and treating Achilles Tendon injuries.
The Intricate Role of the Plantaris Muscle in Achilles Health
The plantaris muscle, while relatively feeble in function, presents an intriguing relationship with the Achilles tendon (Babinski et al., 2014). Originating from the lateral supracondylar ridge of the femur, just above the knee, the plantaris muscle courses between the gastrocnemius and soleus—two major calf muscles—before integrating into the inner part of the Achilles tendon (Kerssemakers et al., 2021). This muscle is under the control of the tibial nerve.
Interestingly, trigger points or adhesions can develop within the plantaris muscle, causing localized discomfort or a radiating pain along the inner Achilles tendon (Dommerholt & Gerwin, 2015). This often leads to a misdiagnosis where the pain is attributed solely to the Achilles tendon rather than its actual source, the plantaris muscle.
Moreover, in cases of Achilles tendon injuries like tears, the plantaris muscle may partially compensate for the damaged tendon, thereby obscuring some of the classical symptoms one would expect (Maffulli et al., 2010). This compensation adds a layer of complexity in correctly identifying Achilles tendon issues.
Types of Injuries
Injury Nomenclature Clarification
In this article, I opt for the term 'Achilles tendon injuries' rather than the commonly used 'Achilles tendinitis.' The reason for this specific terminology lies in the histopathological evidence, which frequently reveals an absence of inflammation in such injuries. Therefore, using 'tendinitis' can be misleading and may not accurately reflect the underlying pathology.
Inflammatory and Degenerative Conditions
When inflammation is present, it is often termed as 'paratenonitis' (Edama et al., 2014). The paratenon serves as a protective sheath around the Achilles tendon, facilitating its smooth movement amid adjoining tissues (Edama et al., 2014). This inflammatory condition frequently stems from overuse or sustained strain and is commonly observed among triathletes and runners (Gatz, 2017).
Another distinct condition affecting the Achilles tendon is 'tendinosis,' characterized by tendon degeneration often triggered by prior injury (Magnusson et al., 2003). A distinguishing feature is a palpable lump near the heel, indicative of scar tissue accumulation (Kannus & Józsa, 1991).
Tears of the Achilles Tendon
A tear of the Achilles tendon is a common clinical diagnosis that involves the separation or tearing of the Achilles tendon from its attachment to the calcaneus, or heel bone (Khan et al., 2005). Remarkably, even though the Achilles tendon is the strongest and largest tendon in the human body, it ranks as the second most frequently ruptured tendon (Maffulli et al., 2010). The severity of these tears varies and can be classified through a grading system, which is crucial for selecting the appropriate treatment:
Grade 1: Minor tears with mild pain and tenderness, featuring minimal loss of function.
Grade 2: Moderate tearing that significantly impairs function, accompanied by pronounced pain and swelling.
Grade 3: Complete rupture, characterized by severe pain and a total loss of movement in the affected limb.
Treatment pathways depend on the grade of the tear:
Grades 1 and 2: For these less severe cases, manual therapy techniques, such as Motion Specific Release, can be part of a comprehensive rehabilitation strategy to enhance healing and restore function.
Grade 3: A complete rupture typically results from untreated or inadequately managed conditions like paratenonitis and tendinosis (Maffulli et al., 2010). In such instances, surgical intervention becomes necessary, as no form of manual therapy can rectify a fully separated tendon (Khan et al., 2005).
PHYSICAL EXAMINATION
The videos provided below showcase commonly used orthopedic, neurological, and vascular procedures during the assessment of an Achilles injury.
Effective Ankle and Foot Examination
This instructional video employs orthopedic tests to conduct a thorough evaluation of prevalent conditions affecting the ankle and foot in clinical settings. Highlighted among these conditions is Achilles Tendon Injuries, an area requiring particular scrutiny due to its susceptibility to various forms of impairment. Additional conditions covered in the video include Ankle Sprains (specifically, inversion sprains), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fractures, Syndesmosis Damage, Morton's Neuroma, 2nd Metatarsal Stress Fractures, Plantar Fasciitis, and Bunions (Abelson, 2018).
Lower Limb Neuro Examination
The lower limb neurological examination serves as a vital component within the broader neurological assessment process. This examination aims to scrutinize the motor and sensory neurons supplying the lower limbs, thereby aiding in identifying any nervous system impairments. This is particularly crucial when evaluating cases involving Achilles Tendon Injuries. Utilized both as a screening and diagnostic instrument, the lower limb neurological examination can offer invaluable insights into the neuromuscular integrity of the affected area, thereby informing more targeted treatment strategies (Abelson, 2018).
Peripheral Vascular Examination - Key Points
The peripheral vascular examination serves as an indispensable diagnostic tool for identifying vascular-related pathologies and is critical in everyday clinical practice. Its ability to detect and help treat Peripheral Vascular Disease (PVD) can be instrumental in minimizing cardiovascular and cerebrovascular risks. Notably, this examination holds significant relevance when managing Achilles Tendon Injuries. It provides crucial data on blood flow to the affected area, which can impact both the healing process and the outcome of various treatment modalities (Abelson, 2018).
Manual Therapy
Managing both soft-tissue and joint limitations is critical, not just for the Achilles tendon but for the whole kinetic chain, extending from the foot to the hip. In the accompanying videos, Dr. Abelson, the originator of Motion Specific Release, showcases various techniques effective for alleviating restrictions in both soft tissues and joints when dealing with Achilles tendon injuries.
Calf Pain No More - Release Tom, Dick, and Harry
In this video, Dr. Brian Abelson, the creator of Motion Specific Release, demonstrates potent MSR techniques aimed at re-establishing the relative movement between tissue layers. This can not only mitigate calf pain but also serves as a vital component in the comprehensive approach to treating Achilles injuries. (Abelson, 2018)
7-Point Ankle & Foot Mobilization: A Key to Achilles Tendon Recovery
Enhancing joint mobility is paramount, especially when focusing on comprehensive treatment for Achilles tendon injuries. Ignoring joint mobility constraints would significantly diminish the efficacy of any myofascial treatment, given that these issues are intrinsic components of the body's kinetic chain. (Abelson, 2018)
Treatment Frequency
The frequency of manual treatment is tailored to the severity of ligamentous injury. Mild injuries often require less intensive therapy, allowing for an early transition to self-managed care. Moderate injuries demand a more structured approach to navigate through healing phases and initiate rehabilitation. Severe, especially post-surgical injuries, necessitate intensive, prolonged therapy to ensure optimal recovery, manage scar tissue, and restore function while preventing secondary complications. Each injury grade thus dictates a distinct therapy approach and frequency, aligning with individualized therapeutic needs for optimal healing and functionality restoration.
Grade 1 Tear (Mild):
Initial: 2 times per week
Duration: 1-2 weeks, transitioning to home exercises and self-management
Approximate Total Appointments: A total of 3 to 6 appointments, followed by 1 or 2 follow-up appointments, depending on patient response.
Grade 2 Tear (Moderate):
Initial: Weekly to bi-weekly visits
Duration: 2-4 weeks, then tapering off as symptoms improve and home exercises progress
Approximate Total Appointments: 3 to 8 appointments, comprising weekly to bi-weekly visits over a span of 2-4 weeks, followed by 1 or 2 follow-up appointments, depending on patient response.
Grade 3 Tear (Severe - Requires Surgery):
When surgery is required, post-operative rehabilitation begins with managing pain and swelling, and immobilizing the ankle. Early rehabilitation introduces weight-bearing and basic exercises. Intermediate rehabilitation advances strengthening and normalizes walking. Late rehabilitation intensifies strength training and introduces sport-specific exercises. Finally, a gradual return to full activities usually within 4 to 6 months.
Exercises
Incorporating the right blend of exercises and soft-tissue therapy is imperative for addressing Achilles tendinopathy, largely due to key physiological processes that must be considered.
A prime factor is tissue remodeling, a process where bodily tissues adapt based on the stresses placed upon them. Achieving full recovery from Achilles tendinopathy necessitates a well-rounded regimen comprising stretching, strengthening, and proprioceptive exercises.
The exercises presented herein serve as potential options for those managing Achilles tendinopathy. Nonetheless, the actual exercises prescribed will be tailored to meet the specific needs of each individual case.
Stretching Your Calf Muscles
Stretching the calf muscles—including both the gastrocnemius and soleus—is an essential component for enhancing lower limb flexibility. Minor adjustments in technique can yield significant gains in flexibility, but the key lies in a balanced approach that avoids overstretching. A warm-up involving walking for a few minutes can prepare your muscles for stretching and reduce the risk of injury.
While you may stretch 3 to 4 times per day, the focus should be on the quality of each stretch session. Adopt a gradual approach to reach the full extent of each stretch, holding it for approximately 15 to 30 seconds not longer. Pay close attention to your body's signals; never stretch to the point of pain, as this is a clear indicator that you may be overstretching. Exercise caution and take note of your body's limitations, ensuring each stretching session is both effective and safe.
Calf Muscle Release - Lacrosse Ball & Foam Roller
The gastrocnemius and soleus muscles play pivotal roles as the main plantar-flexors of the ankle joint and as powerful knee flexors. These muscles converge to form the Achilles tendon, making them integral to its health. Effective calf muscle release through self-myofascial techniques, like using a lacrosse ball or foam roller, can help mitigate Achilles injuries and promote joint flexibility.
Calf Strengthening - Eccentric Calf Raises & Pulsations
Strengthening the gastrocnemius and soleus muscles is crucial for the rehabilitation and prevention of Achilles tendon injuries. Eccentric Calf Raises offer a safe and effective method to build muscle strength without exacerbating existing conditions. However, it's important to note that calf pulsations, although excellent for enhancing sports performance and power, should be avoided by individuals with ongoing Achilles issues until they have fully recovered. Prioritize mastering the standard Eccentric Calf Raises before progressing to more advanced exercises.
Improve Your Balance - Exercises for Beginners
Balance exercises hold a significant place in both rehabilitation and sports performance training, and their importance cannot be overstated, especially in the context of Achilles tendon injuries. Improving your balance through targeted exercises not only enhances overall athleticism but also serves to stabilize the ankle joint, thereby reducing undue strain on the Achilles tendon. By following our methodical progression techniques, you can engage in these exercises safely, minimizing the risk of further injury.
Activities of Daily Living (ADL)
Ice Massage for Achilles Tendon
Ice massage is a practical, evidence-based approach for immediate relief from Achilles Tendon discomfort. Cold therapy can minimize swelling and serve as an analgesic by numbing the sore tissue (Hubbard, et al., 2004).
How to Do It
Freeze Water in a Cup: Fill a disposable cup with water and freeze it.
Peel Back the Cup: Once frozen, peel back the top layer of the cup to expose the ice.
Apply to Achilles Tendon: Gently massage the ice in a circular motion on your Achilles Tendon for 5–10 minutes.
Note: The ice massage can be done multiple times a day, but it's crucial to wait at least one hour between sessions to prevent frostbite.
Footwear and Achilles Tendon Care
Wearing shoes, even when at home, can provide the necessary heel elevation to relieve strain on the Achilles Tendon. Footwear should have a good arch support and a slightly elevated heel to minimize stress on the tendon (Malliaras et al., 2013).
Guidelines
In-Home Footwear: Opt for footwear that offers support, even if you are just at home.
Avoid Going Barefoot: Walking barefoot, especially on hard surfaces, can stress your Achilles Tendon and can be a precursor to injuries.
Conclusion
In summary, the Achilles tendon is an awe-inspiring yet vulnerable marvel of human biomechanics. As the largest and strongest tendon in the body, it serves as a critical link in the kinetic chain, facilitating essential movements like walking, running, and jumping. However, its strength is counterbalanced by a predisposition to injury, due largely to limited blood supply and a complex myofascial network that interconnects with various other structures like the plantar fascia and hamstring muscles. Research underscores the importance of adopting preventive measures and carefully considered treatment plans, be it manual therapy techniques such as Motion Specific Release for minor tears or surgical intervention for complete ruptures (Kannus, 2000; Maffulli et al., 2010; Abelson, 2018).
Understanding the Achilles tendon is not just a matter of anatomy but a venture into a nuanced orchestration of biomechanical and myofascial interrelationships. This intricacy extends from its role in the gait cycle to its susceptibility to different kinds of injuries, which can range from inflammatory conditions like paratenonitis to degenerative states such as tendinosis. Given the high stakes—evidenced by career-impacting statistics among athletes and significant implications for the general population—it's clear that further interdisciplinary research is vital for both preventive and treatment modalities. Hence, as we continue to peel back the layers of complexity surrounding the Achilles tendon, our overarching goal should remain anchored in science-backed strategies to minimize risk and optimize function.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References
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