Posts in achilles tendinopathy
Return to Play after Achilles Tendon Rupture

Achilles tendon ruptures mainly occurs in middle aged adults, males > females, participating in sports with high levels of jumping or high force activity.  The repair and recovery time of these tendon ruptures is lengthy due to the post operative immobilization, weight bearing, and exercise restrictions.  Prior research has shown only 1 in 2 athletes returns to play at 1 year post op.  Among these athletes who do not return some may either choose not to return to their previous sport due to fear of reinjury while others have placed themselves at greater risk of injury due to not restoring their leg's strength, balance, agility, and coordination to pre injury levels.  

A recent article in the British Journal of Sports Medicine reviewed the available evidence to determine an athlete's ability to return to play after achilles tendon repair.  (Zellers et al. 2016).  The authors reviewed 108 studies of over 6500 patients and found on average 80% of athletes return to play at pre injury levels.  The average time to return to sport after a course of Physical Therapy was 6 months.

Athletes are encouraged to use Physical Therapy following an Achilles Tendon injury to accelerate their healing and improve their chances of recovery.  

Ankle Mobility and Achilles Tendon Injury

The achilles tendon is a strong, durable structure capable of absorbing and producing large loads as we walk, hike, and run.  When the tendon is overloaded without adequate recovery periods this structure is prone to painful and limiting conditions such as achilles tendonitis and tendinopathy.  One of the important risk factors for achilles injury among athletes and patients is a lack of ankle mobility.  If the ankle is unable to bend adequately during functional movements the achilles is placed under increased load leading to tendon injury.  In our Boulder Physical Therapy practice, we commonly see a loss of ankle mobility among patients with achilles tendon injury.

During our Physical Therapy examination we often see a loss of rear foot or ankle mobility and a compensatory increase in motion at the mid foot or arch (pronation).  A recent study in the journal Clinical Biomechanics confirmed our observations (Chimenti, R. et al. 2016).  The authors assessed individuals with and without achilles tendinopathy to determine their ability to bend their ankle as well as which areas of the ankle and foot where contributing to this movement.  The group with achilles tendinopathy had significantly less ankle mobility than the control group.  Importantly, this group compensated during testing with increased mobility of their arch instead due to an inability to move through the rearfoot.

This study highlights the importance of treating the ankle in patients with achilles tendon injury.  To learn more about how to safely and effectively treat this condition contact your local PT.

Increased Achilles Tendon Loading In Treadmill Running

The treadmill remains a necessary evil when completing run training allowing athletes to escape inclement weather to complete their workouts.  Thankfully, in Boulder we have few inclement days as we move through the Spring and Summer months allowing athletes to train outside.  Prior research has noted significant bio-mechanical differences in treadmill vs. ground running including athletes adopting a shorter stride length on the treadmill.  This reduction in stride length is accompanied by an increased in step frequency to maintain a given speed.  These changes will impact the rate and magnitude of loading across the leg during landing.  Recently, a Physical Therapy article examined the biomechanical impact of treadmill and over ground running on the knee and ankle structures. 

Willy and colleagues studied 18 healthy runners (9 female) who were running at least 10 km per week over the last 6 months and were free of injury over the previous 3 months (JOSPT. 2016).  Runners were analyzed in a Physical Therapy biomechanics laboratory while running on a treadmill and overground both at a previously self selected gait speed.  

Similar to prior research, runners selected a shorter stride length when using the treadmill compared to level ground.  The authors did not find differences in knee mechanics or loading between the two conditions.  Conversely, the authors noted greater achilles tendon loading and calf muscle contraction during treadmill running.  They attributed these changes to increased peak tendon forces during the treadmill run.  

This article was performed in healthy individuals but may have implications for those returning to running from achilles injury or those using the treadmill for the majority of their training runs.  


Marathon Running Injuries

Marathon running is a challenging event requiring substantial amounts of endurance and strength training for optimal performance and injury prevention.  The race distance of 26.2 miles requires high mileage training, often >75-100 miles per week at the elite level, placing the athlete at risk of a running related injury (Saragiotto et al. 2014).  In addition to training volume, athletes with training errors (too much volume too quickly), muscle imbalances, and gait deviations place themselves at greater risk of future injury and lost performance.    

A recent study in the International Journal of Sports Physical Therapy (Carvalho et al. 2016) sought to document the frequency, severity, and location of running related injuries among elite marathoners.  The athletes all met the following criteria: sub 2:35 and 3:00 marathon for men and women, respectively, as well as, enrollment in the "elite" racing category.  The 199 enrolled athletes were asked to assess their prevalence of running injuries over the previous 12 months.  Even at the elite level, 3 out of 4 runners reported a running related injury most commonly experienced in the leg (19%), knee (15%), and achilles (15%).  Among the injured runners close to 40% described at least two different injuries over the last year.  

Athletes preparing for an upcoming marathon are encouraged to work with a local Physical Therapist to reduce modifiable risk factors for running related injuries. 

Ankle Mobility Techniques

Ankle mobility is essential for both daily walking tasks as well as higher level athletics and sports participation.  In our Physical Therapy practice in Boulder we see a loss of dorsiflexion, bending, among athletes with lower extremity injuries and conditions.  A lack of ankle bend, dorsiflexion, has been associated with many conditions including heel pain, plantar fasciitis, ankle sprains, stress fractures, achilles tendonitis, and ACL injuries.  An example of the impact of ankle mobility on performance can be found with a squat test.  Try to squat as deeply as you can keeping your heels on the ground, then repeat the squat with your heels lifted on a weight plate.  If the latter is easier you may not have the 10-20 degrees of bend required during many athletic tasks, stair climbing, or walking.  

One of the most effective ways of restoring ankle dorsiflexion in our physical therapy practice involves the use of manual therapy.  These interventions allow a Physical Therapist to passive mobilize the areas of restriction decreasing your sensations of tightness and improving your ability to move through a more full range of motion.  Often the squat test is dramatically improved after mobilizing the joints of the foot and ankle to improve ankle bending.  

boulder physical therapy ankle mobility treatments

In our experience, ankle mobility is more quickly restored when these manual therapy techniques are followed by home exercises designed to move through the newly acquired range of motion.  A recent study examined the impact of two exercises designed to restore ankle bending in individuals who lacked the normal amount of motion in their ankle.  Jeon et al. randomized 32 individuals to either a static stretching group or a group performing a similar stretch using a band (J Athletic Training. 2015).  Individuals underwent the stretching protocol (15 reps x 20 second holds) 5 days a week x 3 weeks under the supervision of a Physical Therapist. 

boulder physical therapy ankle mobility with strap

The authors reported both groups improved their ankle range of motion after 3 weeks, but greater improvements were noted in the group utilizing the strap.  The strap may help localize the movement to the area of joint restriction making the exercise more specific to the individual.  To learn more about the examination and treatment of your ankle mobility contact your local Physical Therapist. 

Foot Orthotics and Overuse Injury

Customized foot orthotics based off a clinical examination, plaster or foam cast have been utilized for decades in order to treat overuse injuries of the foot, ankle, knee, hip and even spine.  These orthotics are usually not covered by insurance and usually run into the hundreds of dollars compared to an off the shelf model.  Many businesses have opened up lately specializing in the prescription and fabrication of orthotics for these conditions claiming correction of the foot and ankle can change the mechanics up the kinetic chain.  Up to this point, with a few patient exceptions, customized orthotics have not been proven more effective than cheaper off the shelf orthotics.  

This blog has previously posted on many aspects of achilles tendinopathy.  A recent article examined in the British Journal of Sports Medicine randomized 140 patients with achilles tendinopathy to either a sham orthotic or a customized orthotic (Munteanu et al. 2015).  In addition, both groups were given eccentric calf strengthening exercises.  The patients were followed over a total of 12 months.  Authors noted improvement in both groups, but no difference between groups at either short or long term functional or clinical outcomes.    It appears the orthotic did not improve symptoms or function above or beyond improvements noted with the eccentric exercise.  

In short, consistent with prior research, customized orthotics are not more effective than other interventions for overuse injuries of the lower extremity.  Future research should attempt to identify any individual factors that may indicate a need for an orthotic intervention.