Robert Blizzard III, DPT
Achilles Tendon Injury
Eric is a 55 year-old man, who recently started training for marathon. He used to play tennis. He believed that he would be an excellent marathon runner. He got up around 5AM, run about 2 hours, then went to work. He runs about 5 to 6 days per week. Recently, he had a slight fall during training, he heard pop sound, and immediately felt pain and swelling on right back of the ankle. The pain was sharp, he was unable to walk. He called his PCP right away. He was referred to orthopedic physician. By careful examination, he was suspected to have Achilles tendon tear. MRI was done, which showed right Achilles partial tear. He was advised to stop marathon training, and ice was put at the right Achilles tendon. He was instructed to have rest for one month, wait and see, in the mean time, using ice massage three times a day for 10 min of each, if the tendon is not healed, he might need surgery to repair the tendon.
After two months of the incident, the patient came to me and reported his right ankle is still painful and mild swelling. He was told by his orthopedic doctor that his Achilles tendon is healing, it is not necessary to have surgery. However, he still felt a lot of pain, he only could walk for one block without pain. He tried ice massage and rest another month, he still felt severe pain at right back of the ankle. Therefore, he came to me for eval and treatment.
By physical examination, I saw a swelling and tender Achilles tendon at right with some floating fluid inside. I palpated the ankle, there was some kind of tenderness and the patient was unable to make a full range of motion at right ankle. I believed that the patient was suffering Achilles Tendonitis.
Achilles tendon is the tendon located at back of the ankle that connects calf muscles at the back of the lower leg to the heel bone. Achilles tendon is the thickest and strongest tendon in the body. The Leg muscles are the most powerful muscle group in the body. The contraction of calf muscles pulls the Achilles tendon upward, which pushes the foot downward and gives the power of standing on the toes, walking, running, and jumping. Each Achilles tendon sustains a person’s entire body weight with each step. Depending upon speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subject to up to 3-12 times a person’s body weight during a sprint or push off.
Qualitative and quantitative histological analyses in one study showed that the Achilles tendon has a poor blood supply throughout its length, as determined by the small number of blood vessels per cross-sectional area, which do not in general vary significantly along its length. In light of these findings, it is suggested that poor vascularity may prevent adequate tissue repair following trauma, leading to further weakening of the tendon.
(J Orthop Res. 1998 Sep;16(5):591-6. Blood supply of the Achilles tendon.
Mechanism of injury:
1. Achilles tendonitis is inflammation of the Achilles tendon. Repetitive eccentric overload causing inflammation and microtears of the tendon. However, recently some researches discovered that most people with Achilles injury besides Achilles tendon rupture have Achilles teninosis, rather than Achilles tendonitis because there is no evidence of inflammation at Achilles tendon, the cells at the Achilles tendon are disorganized, degenerated and scarred. But most people in medical field still call it Achilles tendonitis.
Achilles tendonitis is often a running injury or other sport-related injury resulting from overuse, intense exercise, jumping, or other activities that strain the tendon and calf muscles. People, who suffer Achilles tendonitis usually are lack of flexibility and do not warm up the Achilles tendon before their activities.
2. Achilles tendon rupture
Inflammatory: inflammation and degeneration causing a series of microruptures of breakdown in the collagen fibers.
Poor nutrition: Inadequate vascularization 2-6 proximal to the insertion of the tendon.
Mechanical: Sudden push-off with the foot in the extension position, such as landing from a jump
Gradual pain and the pain worsens over time at back of the ankle is the most common sign of Achilles tendonitis. Signs and symptoms of Achilles tendonitis include:
- Mild pain at the back of the ankle after running and other sports activities.
- The pain is getting worse after prolonged running, tennis, stair climbing and jumping, or other activities. The patient has difficulty walking, stiffness, especially in the morning.
- If partial tear, swelling and/or bump might show on the Achilles tendon, a crackling or creaking sound might be heard when touching or moving the Achilles tendon.
- Acute Achilles tendonitis:
Pressure: apply pressure on Achilles tendon with ice bag for 15 to 30 min
Rest: stop lower extremities sports such as running, biking, etc. for at least 2 to 4 weeks. You may continue upper extremities exercises, such as bench weight lift, etc.
Ice: as above
Compression: apply pressure on Achilles tendon with Ace bandage
Elevation: elevate the foot to avoid fluid retention
B: Avoid Anti-inflammation Medication such as Tylenol, Advil, etc. and pain killer, because Tylenol, Advil will not help heal the inflammation and pain killer may mask the pain and you may not be able to feel the pain and may injure your Achilles tendon more
C: Avoid steroid injection at Achilles tendon because steroid injection might cause further rupture of the Achilles tendon.
- Chronic Achilles tendonitis:
A: Physical Therapy: Stretching both the gastrocnemius and soleus needs to be addressed as pictured below with both the leg straight and slighty bent in each position for one minute.
Stretches for the Achilles can be performed on a specific device called ProStretch or off any sturdy step and held for a minute each.
Acupuncture treatment can bring blood flow to Achilles tendon and help the healing. The main acupuncture points are as follows,
Local Points: UB 60 Kun Lun, UB 61 Pu Shen, Ki 13 Tai Xi, Ki 14 Da Zhong, Ki 15, Shui Quan
Distal points: Sp 9 Yin Ling Quan, GB 34 Yang Ling Quan, LI 4 He Gu, LI 11 Qu Chi,
|1||Kun Lun||UB 60||In the depression between the external malleolus and archillus tendon||Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and heel pain, difficult labor, epilepsy|
|2||Pu Shen||UB 61||In the depression directly below the external malleolus||Epilepsy, mania, headache, dizziness, insomnia, backache, aching of the leg|
|3||Tai Xi||Ki 3||In the depression between the medial malleolus and tendo calcaneus at the level with the tip of the medial malleolus||Sore throat, toothache, deafness, tinnitus, dizziness, spitting of blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, low back pain|
|4||Da Zhong||Ki 4||Posterior and inferior to the medial malleolus, in the depression medial to the attachment of tendo calcaneus||Spitting of blood, asthma, stiffness and pain of the lower back, dysuria, constipation, pain in the heel, dementia|
|5||Shui Quan||Ki 5||1 inch directly below Ki 3 Tai Xi in the depression anterior and superior to the medial side of the tuberosity of the calcaneum||Amenorrhea, irregular menstruation, dysmenorrheal, prolapse of uterus, dysuria, blurring of vision|
|6||Ying LingQuan||Sp 9||On the lower border of the medial condyle of the tibia, in the depression on the medial border of the tibia||Abdominal pian and distension, diarrhea, dysentery, edema, jaundice, dysuria, enuresis, incontinence of urine, pain in the external genitalia, dysmenorrheal, pain in the knee|
|7||Yang Ling Quan||GB 34||In the depression anterior and inferior to the head of the fibula||Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion|
|8||He Gu||LI 4||See table 3-1/Fig 3.4||See table 3-1|
|9||Qu Chi||LI 11||See table 4-1/Fig 4.4||See table 4-1|
Fig 8. 3
C: Heel lift and shoe wedge
There are many products in the market for heel lift, the principal is to lift the heel and reduce the stress on the Achilles tendon.
You may put the heel lift simply inside your shoe or have a shoe wedge outside your shoe to help reduce the stretch of the Achilles tendon.
Surgery is the last resort to repair your Achilles tendon.
Eric received physical therapy and acupuncture treatment from me for total 12 visits, he stopped sports related to the lower extremities. He also put ice on his Achilles tendon, and wedge into her shoes, she felt much better after the above treatment.
Tips to Patients:
- Stop your lower extremity exercise, such as running, tennis immediately if you feel Achilles tendon pain.
- Put ice on and massage the Achilles tendon.
- Try to use heel lift or shoe wedge to help yourself rest. You may buy one premade or go to the shoe maker or special orthotist to add a wedge at your shoe.
- Nerve allow anybody inject steroid at your Achilles tendon because steroid injection will cause rapture of Achilles.
Tips to Acupuncturists:
- Nerve use heating pad, lamp or moxa on the inflamed Achilles tendon, which will increase more inflammation at Achilles tendon.
- If you suspect Achilles tendon rupture, you must refer the patient to orthopedics to handle.
- Electrical stimulation will help healing.