What can I expect following treatment?
Nonsurgical Rehabilitation
Tendocalcaneal Bursitis/Paratendonitis
When you begin Physical Therapy at Excel Rehabilitation Services, LLC the type of treatment you will receive will depend on the particular problem you have present.
If there is a true inflammatory process present with your injury (i.e.: tendocalcaneal bursitis or paratendonitis) your initial treatment at Excel Rehabilitation Services, LLC will aim to decrease excessive inflammation and pain. Our Physical Therapists can assess when anti-inflammatory treatment is necessary and for how long this treatment should continue. Simply icing your Achilles can often relieve a lot of the acute pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and inflammation. Massage for the calf may also be helpful. In addition, a heel lift placed in your shoe can help take the tension off of a painful tendon. In order to not affect alignment, a lift is also placed in the other shoe. Some taping or strapping techniques we use at Excel Rehabilitation Services, LLC can also be useful to decrease the pain caused by an Achilles tendon injury and allow healing to occur. Limiting, but not eliminating, inflammation is the goal. If inflammation is present, the injury should respond quite quickly to any anti-inflammatory treatments used.
Once the initial pain and inflammation has calmed down, your Physical Therapist in Gonzales will focus on improving the flexibility, strength, and alignment around the ankle joint and entire lower extremity. Static stretches for the calf will be prescribed by your Physical Therapist early on in your treatment to improve flexibility and put gentle stress on the healing tissues which encourages them to properly align. Gentle stretching can also help with relieving pain. As mentioned above, any tightness in the muscles or tissues in the lower extremity can change the alignment and force put through the Achilles tendon therefore your Physical Therapist will prescribe stretches for any of the muscles in the lower extremity that have been determined to be affecting your alignment. This may include stretches for the back or your thighs (hamstrings) or even your hips. Dynamic stretching (rapid motions that stretch the tissues quickly) will also be taught and will be incorporated into your rehabilitation exercise routine as part of your warm-up once you return to doing more aggressive physical activity. Dynamic stretches are used to prepare the tissues for activity whereas static stretches focus more on gaining flexibility.
Strength imbalances will also affect the alignment around the ankle and can cause muscles to tighten. Your Physical Therapist will determine which muscles in your individual case require increased strengthening. Appropriate strength in areas above the ankle, in particular the hip, which controls the position of the rest of the lower extremity, is very important. In the repetitive motion of walking, running or jumping the Achilles tendon is placed under tremendous load. In order to prepare the healing tendon to take this load, your Physical Therapist will first prescribe ‘concentric’ muscle strengthening. Concentric contractions occur when the muscle shortens as it contracts. For example, when you rise up on your toes, your calf muscles are concentrically contracting and pulling on the Achilles tendon. Exercises such as calf raises will provide the appropriate stress to the tissues of the healing tendon to begin to prepare them for the forces of everyday activities. These exercises will first be done using both legs and when ready, we will progress you to doing them on one leg at a time in order to fully load the tendon with your body weight.
Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch. Landing from a jump is an example of an eccentric contraction. As soon as appropriate, your Physical Therapist will prescribe eccentric exercises for your Achilles injury. These contractions encourage the tendon to adapt to the more aggressive force that will eventually be needed to return to regular physical activity. Exercises such as raising up onto your toes on a step and then lowering down so that your heel is below the step is an eccentric calf exercise. Again, as appropriate, your Physical Therapist will progress you to do this on just the injured side, and they will increase the speed of the lowering portion of the exercise to add even more force. They may also add weights to even further advance the force of the exercise. Repetitive jumping from a height and rebounding once you land is another advanced exercise that loads the tendon eccentrically. All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon. Maintaining proper alignment of your entire lower extremity is paramount to decreasing the overall stress that is placed on your Achilles tendon so your Physical Therapist will stress the use of proper technique and maintaining this alignment during all or your rehabilitation exercises.
In addition to strengthening and stretching, foot orthotics may be useful to correct your foot position, which in turn then encourages proper alignment up the lower extremity chain and decreases the stress on the Achilles tendon. Your Physical Therapist can advise you on whether orthotics would be useful for you, and also on where to purchase them. We may try taping or strapping the bottom of the foot before encouraging you to purchase orthotics. This type of taping can give us a good indication if orthotics will be useful in decreasing your pain or changing your alignment before you actual purchase a permanent insert.
A critical part of our treatment for Achilles tendon problems at Excel Rehabilitation Services, LLC includes education on returning to your full normal physical activity, whether that be a daily walking routine or a competitive level sport. The Achilles tendon takes stress during each step you take so an Achilles tendon that is recovering from injury can easily be aggravated. Returning to your normal physical activity at a graduated pace is crucial to avoid repetitive tendon pain or a chronic injury. Your Physical Therapist at Excel Rehabilitation Services, LLC will advise you on the acceptable level of activity at each stage of your rehabilitation process and assist you in returning to your activities as quickly but as safely as possible. With a well-planned rehabilitation program and adherence to suggested levels of rest and activity modification, most patients are able to return to their previous level of activity without recurring symptoms.
Tendonosis/Tendinopathy
If your Achilles problem is one of tendon tissue degeneration, healing and recovery may take longer and the injury will not respond to treatment designed to reduce inflammation. Two to three months or more of Physical Therapy may be necessary. Correct treatment of tendonosis involves fostering new collagen tissue growth and improving the strength of the tendon.
Most importantly, a chronically injured tendon needs some relative rest while new collagen growth is encouraged. Limiting activities such as walking allows for a relative rest. Activities such as swimming or cycling can be substituted to allow a cardiovascular workout as long as they can be done in a fashion that doesn’t cause increased discomfort. Modalities for pain may also be used, such as ice or heat, but it should be remembered that their aim is to assist with local pain rather than inflammation. Your Physical Therapist may use acupuncture or dry needling to encourage new collagen tissue growth of the chronically injured tendon. If available, your Physical Therapist may also refer you to a doctor who performs injections of the blood to assist healing.
Autologous blood injections (ABI) and platelet-rich plasma injections are fairly new treatment techniques for chronic tendon problems and are still undergoing research regarding their efficacy. In ABI blood it taken from a patient and then injected right back into the injured tendon (under ultrasound guidance.) Platelet-rich plasma injections are similar but once the blood is withdrawn, only portions of the blood that are thought to be the most important for healing are injected into the tendon. These portions of the blood are highly active in creating new collagen growth of the tissues. (See Patient Guide Platelet-Rich Plasma Treatment.) Several injections may be done over a period of time depending on your doctor’s opinion and experience. A small rest period is usually encouraged while the tendon initially begins the healing process but then Physical Therapy as described below is encouraged.
As your chronic tendon injury heals, your Physical Therapist will prescribe similar stretching and strengthening exercises as described above under tendocalcaneal bursitis/paratendonitis. New collagen requires a controlled amount of stretching and strengthening to encourage the fibers to slowly adapt to the stresses of regular physical activity. If the appropriate controlled stress is not put through the tendon, a recurrence of symptoms will occur. Your Physical Therapist at Excel Rehabilitation Services, LLC will ensure you are not putting too much stress through your healing tendon, while also ensuring you can return to your regular activities as soon as possible.
Another form of therapy, called low-energy shock wave therapy, has been used successfully for chronic tendinopathy. This procedure causes high energy vibrations produced by the energy waves and is applied to areas of tenderness while the affected foot and ankle are gently moved in all directions. Shock wave therapy works by turning off nerves responsible for pain without affecting motor function. The procedure does not require anesthesia but it may take several treatment sessions before a difference is felt. This form of therapy also stimulates soft-tissue healing by increasing blood supply to the area treated. Newer treatments, such as blood and plasma-rich injections, as described above, are now more often being used rather than low-energy shock therapy.
Tendon Rupture
The success of nonsurgical treatment for an Achilles tendon rupture is under constant review. It is clear that treatment with a cast will allow the vast majority of tendon ruptures to heal, but it is not clear whether the incidence of re-rupture is significantly increased in those patients treated with casting for eight weeks when compared with those undergoing surgery. For this reasons many orthopedists still feel that Achilles tendon ruptures in younger active patients should be surgically repaired. Undergoing surgery, however, presents a wealth of other potential complications so the non-surgical treatment option, even with a potential for increased re-rupture, is currently being used as a viable treatment option for patients of all ages while ongoing research into the two treatment options occurs.
Non-surgical repair of an Achilles tendon rupture is often the recommended choice in all instances of the aging adult who has an inactive lifestyle. Nonsurgical treatment in this case allows the patient to heal while avoiding the potential complications of surgery. The patient’s foot and ankle are placed in a cast that holds the foot in a slightly pointed position for eight weeks. This position brings the torn ends of the Achilles tendon together and holds them until scar tissue joins the damaged ends. A large heel lift is worn in the shoe for another six to eight weeks after the cast is taken off. Rehabilitation at Excel Rehabilitation Services, LLC begins once the surgeon feels it is appropriate. Aggressive rehabilitation is avoided as not to re-rupture the tendon or stretch it out too much. Your Physical Therapist will closely liaise with your surgeon regarding the appropriate time frames for stretching and strengthening the injury. Similar rehabilitation principles as listed above in tendocalcaneal bursitis/paratendonitis section will be followed.
Where is the Achilles tendon, and what does it do?
A violent strain can cause trauma to the calf muscles or the Achilles tendon. This injury can happen during a strong contraction of the muscle, as when running or sprinting. Landing on the ground after a jump can force the foot upward, also causing injury. The strain can affect different portions of the calf muscles or Achilles tendon. For instance, the strain may occur in the center of the muscle, or it may happen where the muscles join the Achilles tendon (called the musculotendinous junction). This strain leads to an inflammatory process around the tendon. Initially, it is the irritation of the outer covering of the tendon, called the paratenon, affected by inflammation, which causes paratendonitis. Paratendonitis is simply inflammation in the lining around the tendon. An increase in activity or the commencement of a new activity which the body is not used to can also cause the outer covering to become inflamed. Sometimes even the use of new footwear leads to added strain on the tendon leading to inflammation.
It's not entirely clear why these problems develop in some people but not in others. Changes in the normal alignment of the foot and leg are often a large contributing factor. For instance, if your feet are flat or your knees naturally knock together, the alignment of your lower extremities in relation to the pull of gravity downwards will not be anatomically perfect. In these cases the stresses put through your legs and into your foot and heel can lead to excess stress on the Achilles tendon of one or both legs. A similar alignment issue can occur if you have had a previous injury to one leg (i.e.: ankle sprain, bone fracture, hip or back injury.) Previous injuries will often cause you to use your legs differently during everyday activities as the injury heals and you are dealing with pain or decreased range of motion. If the injury is not fully rehabilitated by regaining maximum range of motion, strength, and normal functional movement then muscle imbalances can occur. These muscle imbalances of the hip and leg will then affect your alignment of the forces down your leg and into your foot and heel in everyday activities such as walking, running, jumping, or stair climbing. This can then lead to excessive stress at the Achilles tendon. Tight calf muscles can cause similar problems. Feet that are too rigid can also cause extra stress on the tendon due to poor shock absorption. Anyone with one leg shorter than the other or chronic ligament laxity in the ankle is also at an increased risk of Achilles tendon problems due again to the alignment issue these problems create.
Sudden increases in training intensity can also be a key factor in the development of an overuse Achilles tendon injury. Runners may have recently added on miles or have engaged in excessive hill training. Non-athletes may develop problems if they engage in an unusual amount of walking compared to their normal activity level (i.e.: a day of sightseeing.) Training regularly on cambered surfaces or hard surfaces can also lead to Achilles tendon problems. Other risk factors include obesity or an increase in weight (pregnancy,) diabetes (or other endocrine disorders), exposure to steroids, and taking fluoroquinolones (antibiotics). Shoes that rub on the heel, have inflexible soles, poor support, lack of shock absorption, or that are excessively worn or do not fit well (adding pressure to the heel) can also initiate an Achilles tendon irritation.
In some cases of persistent tendonitis or tendonosis a procedure called debridement of the Achilles tendon may be suggested to help treat the problem. This procedure is usually done through an incision on the back of the ankle near the Achilles tendon. The tendon is identified, and any inflamed paratenon tissue (the covering of the tendon) is removed. In the case of tendonosis the tendon is then split, and the degenerative portion of the tendon is removed. The split tendon is then repaired and allowed to heal. It is unclear why, but removing the degenerative portion of the tendon seems to stimulate repair of the tendon to a more normal state.