Anatomy of the calf:
The calf is made up of two different muscles the gastrocnemius and the soleus. The Gastrocnemius is the large of the two and has two “heads” which attach to the back of the knee on both sides. The soleus is a smaller muscle and the bulk of the muscle is further down towards the heel.
The Achilles is the tendon of both the gastrocnemius and soleus, which attach to the calcaneus or the heel bone. The Achilles is actually the largest and strongest tendon in the whole body. (Freedman et al. 2014) The calf muscle work together to move the ankle up and down. Therefore in control of the movements that allow you to go up onto your tiptoes and back down, theses movements are called dorsiflexion and plantar flexion respectively.
Achilles Tendonitis is inflammation of the Achilles tendon at the heel. There are two types, one being at the insertion (so where the muscle attached to the heel bone) and the other is halfway up the tendon itself. The midpoint tendonitis is the most common making up around 66% of patients and thankfully has better success rate. Insertional Achilles problems often cause problems to other structures such as the bursa which is a fliud filled sac which acts as as hock absorber to the Achilles tendon. It is a relatively common condition and affects roughly 2% of population being more common in 9-10% in active individuals especially in runners. (de Jonge et al 2011) Achilles problems account for around 5-12% of all running injuries.
What are the risk factors of Achilles tendonitis:
Age: 36-60 years
Females more than men
Increase demand or overuse of the Achilles and calf this can be through different activity, intensity, or increase use of the calf.
It is normally aggreviated by going up strairs on hills.
High cholesterol is found in 33% of Achilles patients.
Increased movement in pointing your toes up towards the celling
Decreased calf strength
Wearing athletic spikes and other low heeled shoes
Obesity due to the increase pressure on the tendon
Increased pronation or flat feet
- Decrease movement of the ankle joint
- Increase movement of the heel bone.
- Decrease in stability of the ankle when putting pressure through it
- Thickening of tendon à as the body tries to heal it will put down new collagen fibres (fibres that make up the tendon) it this can often be disorganised and cause less movement in the ankle
- Swelling/ redness
- The problem can turn chronic with 60.3% still having some pain after 5 years!
Achilles tendonitis can be diagnosed clinically by a health profession by physically examination your ankle and calf. They will often get you go on to your tip toes and back down again to see if it causes pain. Depending on the severity of the condition depends on the further investigations you will need. If they are worried that you have completely torn the tendon then you may be sent for an MRI scan which will take lots of detailed pictures of the soft tissues that make up your calf including the different muscles such as gastrocnemius, soleus and the Achilles tendon itself.
Rehab and treatment:
It will not surprise you but stretching your calf out and reducing the tension in the muscle is essential to the recovery of the Achilles tendon. Youc an stretch your calf out in many ways here are my favourite static stretches:
Straight leg calf stretch:
Standing facing a wall place your arms out in front of you with one foot in front of the other with both heels on the ground. You want to make sure that you keep the back leg straight and make sure the foot is on the ground. You should feel the stretch down the back of the calf. The research shows that you should hold all stretches for 30 seconds to get the most effective result, do this exercise 5 times. It is better for you to do less reps but keep holding the stretch for the same amount of time.
Calf raise against the wall:
For this exercise you need to be standing in front of a wall and you want to point your foot up against the wall so it is pointing to the ceiling. You want to hold this position for 30 seconds before lowing it back down. Again you should feel the stretch at the back of the calf.
Step up and side steps:
As the movement at the Achilles tendon and the calf is primarily responsible for moving your calf up and down therefore doing exercises on to a step is very useful. You can do this my by practicing step on or just waling up and down the stairs. Furthermore you can modify this by doing side steps by stepping on to a box from one side and then to the other side.
Going on tip toes:
This exercise is similar to the eccentric loading more gentle. You can do this off weight baring to start with just pointing your toes up and down while you are sitting down this can be done either on the floor or in a chair. You can build this exercise up by added resistance bands to work again, building up to eccentrically loading the tendon later on.
The gold standard and first protocol for Achilles problems is eccentric loading or heel drop exercises. This is when you place the ball of your foot a step and drop the rest of your foot and ankle of the back of the step. You should feel a stretch in the back of the calf as you do this. Eccentric loading is a dynamic stretch so it involved you to do a little work. Don’t worry its not difficult all you have to do it go from the position with your heel of the step to going on to your tip toes and then back down again. You can develop this exercise by doing it on one leg as well.
This type of exercise not only has the most evidence but also the best outcome in terms of conservative treatment especially for mid portion Achilles problems. (Magnussen et al (2009). While it may not be as successful as alfredson the brains behind the exercise originally suggested with his 100% return to sport, he wasn’t far off!! It is well known to improve both the pain and the function fo the calf and heel by between 60-90%. (Fahlstrom 2003)
How does eccentric loading actually work?
It may not surprise you but like many things there are some controversy over the actual mechanism involved in the exercises especially to do with optimal load, frequency and duration that you need to do for the best results. The original guidelines for eccentric loading are the following:
The theory is that eccentric loading should increase remodelling and tissue repair in the tendons through improving the neuromusclear output or in posh words Therapeutic Mechano-transduction. (Khan & Scott 2009) In simple words the exercise works on reducing the load on the tendon and therefore the strain and force that the muscle will exert on the tendon and in turn the heel bone. That means the exercises work to increase the length of the tendon, increase the efficiency of calf contraction as well as reversing the neovascularisation of the tendon. However current studies saying that eccentric loading does not change the structure of the tendon at all but will effect the way that the tendon itself works. Research generally points to eccentric loading aiming to make the tendon more flexible as well as increasing the strength of the calf by up to 18%. (Masood et al 2014)
A work of warning if you do have a partial rupture of the Achilles lease check with your doctor first whether these exercises are appropriate as in some cases they can cause further damage to the tendon. (Alfredson 2015)
Proprioception and balance exercises are very important for ankle stability. Proprioception is just a posh word for the co-ordination at a joint. It is possible after an injury that your control of the joint will be affect or at least you certainly will be more weary of where you are placing your feet compared to normal. How confident you are with where you are placing your foot can make a lot of difference to your biomechanics. Also the confidence in where you place your ankle can help prevent you from twisting or rolling in/out with your ankle.
You can start small with these exercises by doing them on uneven surfaces like a towel or cushion or practicing moving you ankle up and down and to the sides in water then build your way up to a wobble board.
Going to see a physical therapist such as a osteopath or physio can help in aiding your recovery. They will work to increase the range of movement at the joint as well as decrease the tone in the muscles. Soft tis sue or massage has been proven to provide a measurable benefit to the dynamic biomechanics of the ability for the Achilles tendon to heal. (Imai et al 2015) My increasing the movement available at the joint it will mean that the calf wont have to work as hard to achieve the same amount of movement at the joint. While loosening off the tension in the calf muscle will cause the muscle to be more effective and therefore it won’t have to contract as hard to achieve the same amount of force. Therefore there will be less of a pull on to the tendon and the heel, which should reduced the pain.
First protocol like many other inflammatory conditions is Rest, Ice, compression and elevation should be protocol. The ice will work to reduce the inflammation at the tendon and therefore decrease the pain. It will also work to increase the blood flow to the area which will help to bring in new nutrients as well as help to transport the harmful metabolites that have build up in the joint. All these steps will work to reduce the inflammation around the tendon.
Footwear and orthotics:
Footwear and orthotics can be made and changed to help the achilled. Often a small heel more of a traditional style will be superior to flat shies like flip flops, spikes and pumps. The small heel will help to take a bit of pressure of the Achilles as it has less movement to do. It will also put a stretch through the sole of the foot which can also get very tight with Achilles injuries. Orthotics may help especially if you pronate or have flat feet. A heel lift through the same principle as having a little bit of a heel.
Imai, K., Ikoma, K., Chen, Q., Zhao, C., AN, K., Gay, R. (2015) Biomechanical and Histological Effects of Augmented Soft Tissue Mobilization Therapy on Achilles Tendinopathy in a Rabbit Model. Journal of Manipulative & Physiological Therapeutics , Volume 38 , Issue 2 , 112 – 118