The “Achille’s heel” can very often live up to its reputation as a vulnerable weak link, especially for athletes involved in repetitive loading movements such as running and jumping. Have you had pain or dysfunction in your foot, heel, lower leg or even moving up the kinetic chain to the knee or hip? Your Achille’s tendon may be part of the problem!
Achilles Heel Injury Descriptions
Here’s something to put it in perspective. According to Scott Douglas of Runner’s World, out of a group of 933 new runners, 254 met the definition of having a running injury during their first year. Of those injured runners, 12% had either Achilles tendinitis (tendonopathy) or a soleus injury, which is one of the three muscles that forms the Achilles tendon and will often lead to tendonopathy. To cite another specific example, individuals with a tight gastrocnemius muscle (1 of the other 3 muscles that become the Achilles tendon) are 3 times more likely to develop a running injury. Running isn’t the only sport that leads to overuse of Achilles tendon. Any sport involving explosive movements of the lower body can do so, such as volleyball, soccer, basketball, football, jumping and more.
The Achille’s tendon, or more properly named calcanel tendon, is a thick tendon made up of 3 muscles (4 muscle bellies) coming together. These are the “calf” muscles or properly termed triceps surae. The calcaneal tendon attaches at the calcaneus, or heel bone. The 3 muscles are gastrocnemius (medial and lateral muscle bellies), soleus and plantaris. Plantaris and gastrocnemius cross the knee joint and therefore are more susceptible to tightness or injury from repetitive knee stress. That repetitive stress coupled with predisposing tightness and static postures (desk job, prolonged sitting, deconditioning, etc.) can lead to a condition called Achille’s tendonopathy. This condition is also commonly called Achille’s tendinitis, but that nomenclature has changed because tendinitis refers to inflammation of the Achille’s tendon, which is an acute process. So yes, after an injury or an acute bout of exercise, you can have inflammation of the tendon and that would be called achille’s tendinitis. Tendonpathy refers to degeneration or chronic stress to the tendon and is what happens over time with repetitive overuse. However, even with normal stress, improper joint mobility and movements patterns can lead to repetitive stress to the tendon. This can be caused by previous injury and therefore adopted altered movement patterns. It can also be caused by shortness and tightness in the previously described calf muscles (triceps surae), an increased Q angle of hip and knee, or instability at the foot, ankle, knee and/or hip. Regardless of the cause, our job as chiropractors is improve the mobility of the areas that are tight and stiff, stabilize the areas that are weak or inactive, and give progressive loading exercises to strengthen and prevent the problem from coming back.
Achilles Heel Treatments
There are two types of Achille’s tendonopathy: insertional and mid-substance. As the name implies, insertional Achille’s tendonpathy refers to degeneration or overuse at the point where the tendon inserts on the calcaneus. Mid-substance Achille’s tendonopathy refers to degeneration or overuse in the middle area of the tendon, between where the muscles become the tendon and where the tendon inserts on the calcaneus. The only difference in treatment between the two is the location at which we do our soft tissue techniques and how we prescribe our loading and strengthening exercises.
Treatment in the office typically entails joint manipulation, instrument assisted soft tissue mobilization (IASTM) and/or dry needling, DNS stabilization exercises and eccentric calf raises to be educated and done at home in between treatments. Joint manipulation is our best tool to immediately improve the motion in specific areas that aren’t moving. Where we manipulate/adjust is entirely dependent on our ability to palpate and determine what joints are stiff and which ones are not. With that said, typically with Achilles tendinitis we can expect stiffness in the mid-foot and posterior hip capsule, as well as specific areas in the spine that need to contribute to the overall movement pattern. When a joint or group of joints isn’t moving well, your brain is being quite literally robbed of that joint information and is unable to fully control the correct movement pattern. Joint manipulation is also our best tool, when appropriately applied, to create an almost immediate reduction in pain in certain areas. Check out our Pro Chiropractic YouTube channel for videos on joint manipulation and more.
IASTM involve soft tissue (muscle) treatment utilizing a metal instrument while the patient performs the painful movement. For example, moving the ankle up and down while treating the Achilles tendon. Utilizing movement of the tissue during treatment is more effective than without movement because its more applicable to real-life as we are moving around throughout the day. We want to remodel the tissue and bring blood flow to the area during the movement that is provoking it in the first place for two reasons: healing and prevention.
Dry Needling (DNS) Effective Alternative Treamtent
Dry needling is also an extremely effective method to remove any trigger points in the calf, hamstring and quadriceps muscles, as well as promoting blood flow to the Achilles tendon for healing. The process overall involves very little pain when done efficiently.
DNS exercises are the most powerful tool to neurologically improve movement patterns and prevent the injury from coming back. If you really want to get to the root of the problem and treat the cause, DNS is 100% the way to go. For time purposes I won’t go into depth on its origin, but check out my blog on being recognize as the most highly trained DNS provider in the state of MT (https://prochiromt.com/dns-bozeman-mt/). I use foot doming exercises and the DNS hanging exercise to active the deep intrinsic foot muscles, which allows for effective tripod stabilization of the foot and ankle.
The at-home loading and strengthening exercise is eccentric calf raising. Eccentric refers to a slow voluntarily controlled lengthening of the muscle and tendon followed by a quicker concentric shortening of the muscle and tendon. This is where it really matters between insertional and mid-substance Achilles tendonpathy. You need an elevated surface such as a step. You will have the involved leg’s toes up on the elevated surface and will perform eccentric calf raises from:
- The level of the step for insertional tendonopathy
- Below the level of the step for mid-substance tendonopathy
The eccentric calf raises are to be performed in such a manner that you take 3 seconds to lower down and 1 second to raise up – “down for 3, up for 1.” Loading the tendon in a controlled fashion is vital component to the treatment protocol for Achilles tendonopathy. I prescribed 3 sets of 15 eccentric calf raises per day. Stay tuned for more informational blogs and videos!
Dr. Allen is accepting patients at the Pro Chiropractic locations in Bozeman and Belgrade, Montana.
Dr. Forrest Allen, DC, MS, CCSP®, CSCS®
Certified Chiropractic Sports Physician®
Certified Strength and Conditioning Specialist®
Bozeman and Belgrade, MT
(406) 219-2462 (Bozeman office)
(406) 388-9915 (Belgrade office)