The opinions herein are those of the authors and not the official policy or position of the United States Government, Department of Defense, or Department of the Navy.
Introduction
- James H. Flint, MD, LCDR, MC USN
- Michael D. Rosenthal, PT, DSc, SCS, ECS, ATC, CSCS
- John-Paul H. Rue, MD, CDR, MC USN
- Michael D. Rosenthal, PT, DSc, SCS, ECS, ATC, CSCS
Epidemiology
- •
Rising incidence of Achilles tendinopathy and rupture caused by increasing participation in recreational and competitive sports
- •
Most commonly an overuse injury from repetitive strain, as opposed to traumatic etiology
- •
Age: typically middle age (mean 40 years old)
- •
Sex: Men greater than women (although incidence in women increasing as participation in sports increases)
- •
Sport: mid- to long-distance running and jumping sports; basketball very common for acute rupture in recreational athletes
- •
Sports position: None specific; any position that involves repetitive excess load on the Achilles tendon
Pathophysiology
Intrinsic Factors
- •
Advancing age
- •
Gender
- •
Abnormal dorsiflexion range of motion
- •
Abnormal subtalar range of motion
- •
Decreased plantar flexion strength
- •
Forefoot varus
- •
Cavus foot
- •
Improper conditioning/training
- •
History of intratendinous or peritendinous corticosteroid injection
- •
Recent history of fluoroquinolone use
- •
Genetic predisposition possible
- •
Co-morbidity: obesity, hypertension, diabetes, high cholesterol
Extrinsic Factors
- •
Repetitive forceful loading or sudden extreme loading of the Achilles tendon (e.g., strong eccentric loading as when landing from a jump shot)
- •
Training errors
- •
Excessive mileage (volume)
- •
Increase in training intensity
- •
Uneven training surfaces (i.e., hills, excessively crowned roads)
- •
- •
Environmental factors
- •
Slippery and/or uneven roads/courts
- •
- •
Inadequate equipment
- •
Improper footwear (nonathletic shoes, unevenly worn/warped shoes)
- •
- •
Previous injury
Traumatic Factors
- •
Direct trauma or penetrating injury to the Achilles tendon
- •
Repetitive microtrauma within the tendon from excessive or frequent activity with inadequate rest periods
Classic Pathological Findings
- •
Paratenonitis: thickened paratenon, adherent to underlying tendon. Inflammatory infiltration of the paratenon seen microscopically.
- •
Paratenonitis with tendinosis: combination of paratenonitis and tendinosis
- •
Tendinosis: Noninflammatory degeneration of tendon fibers. Tendon may appear discolored and thickened or nodular. Microscopically: lack of inflammatory cells, scattered neovascularization, possible necrosis and/or calcification. Typically appears 2 to 6 cm proximal to the calcaneal insertion.
- •
Rupture (partial or complete): frank disruption and separation of tendon fibers. Evidence of tendinosis typically present.
The majority of Achilles tendon problems are in the category of tendinosis. In addition to a lack of inflammatory cells, ultrastructural findings include altered cellular (collagen) alignment and increased vascularity. This altered tendon structure has been shown to improve with eccentric loading.
Clinical Presentation
History
- •
Middle-aged recreational athlete or “weekend warrior”
- •
For elite athletes, inquire about changes/increases in training intensity and/or duration
- •
For paratenonitis: focal pain and tenderness after activity; progresses to symptoms at beginning of activity or with less intense/routine activities
- •
For tendinosis: typically nonpainful, patient may complain of swelling or nodularity of the tendon
- •
For acute rupture (partial or complete): patient may describe feeling of being kicked in the back of the leg, a severe cramping sensation, or feeling a “pop”
- •
Inquire about previous history of treatment, to include corticosteroid injection(s) or recent use of fluoroquinolone antibiotics.
Physical Examination
- •
Warmth, thickening, swelling, and/or crepitus
- •
Tenderness to palpation, typically 2 to 6 cm above the calcaneal insertion
- •
Tendon nodularity (painful when paratenonitis present, painless if pure tendinosis)
- •
Positive “painful arc sign”: pain originating within the tendon will move with ankle movement, whereas pain caused by paratenonitis will remain fixed
- •
Calf atrophy
- •
Decreased/painful ankle dorsiflexion
- •
Specific to partial or complete rupture
- •
Palpable defect in the tendon ( Figure 38-1 )
FIGURE 38-1
A palpable gap is characteristic of a complete tendon rupture.
- •
Hematoma/ecchymosis
- •
Inability to perform single heel rise or decreased plantar flexion strength
- •
Positive Thompson test: lack of foot plantar flexion with compression of superficial calf ( Figure 38-2 )
FIGURE 38-2
The Thompson test. Intraoperative exam bilaterally showing no plantarflexion of the right foot when the superficial compartment is compressed.
When performing the Thompson test, position the patient in the prone position. The knee may be flexed or extended (have the foot hang off the end of the exam table). Ensure that you isolate the superficial posterior compartment of the calf (gastro-soleus complex). Compressing the entire calf will stretch the deep posterior compartment (FHL, FDL, tibialis posterior), which can result in false plantar-flexion of the foot. Comparison with the contralateral side is recommended to assess for asymmetry of the magnitude of plantarflexion.
- •
O’Brien needle test: a sterile needle placed perpendicularly in the tendon, proximal to the injury, will move in the opposite direction of foot plantarflexion or dorsiflexion if the tendon is intact distally
- •
Hyper-dorsiflexion sign: with the patient prone and knees bent 90°, maximal passive dorsiflexion of the feet will show asymmetry. Increased dorsiflexion (DF) on the injured side indicates a loss of DF restraint provided by the Achilles tendon.
Imaging
- •
Plain radiography: not particularly helpful for Achilles tendinopathy, but may help rule out other diagnoses (i.e., symptomatic Os trigonum, Haglund deformity). Soft tissue swelling typically present with partial or complete rupture ( Figure 38-3 ).
FIGURE 38-3
Plain radiograph in a patient with posterior ankle pain. Note the presence of an os trigonum.
- •
Ultrasound: fast and inexpensive. May reveal peritendinous fluid or adhesions (as with tendinopathy), or partial/complete rupture on dynamic exam. Color Doppler may show abnormally increased blood flow. Potential utilization of US in determination of operative or conservative management of Achilles ruptures.
- •
Magnetic resonance imaging (MRI): usually second-line after ultrasound because of cost. Extremely helpful in classifying tendinopathy and for diagnosing partial and complete tendon tears ( Figures 38-4 and 38-5 ).
FIGURE 38-4
Typical T1-weighted ( A ) and T2-weighted ( B ) MRI findings in a patient with Achilles tendinosis. Note the thickened tendon without significant inflammatory findings on T 2 -weighted images.
FIGURE 38-5
MRI of a patient with an Achilles tendon rupture. T1-weighted ( A ) and T2-weighted ( B ) images show frank disruption of the tendon fibers.
Differential Diagnosis
- •
Acute rupture
- •
Partial rupture
- •
Achilles tendinopathy
- •
Retrocalcaneal bursitis—often associated with Haglund deformity. Pain localized to insertion site of Achilles tendon, however, will be anterior to the actual tendon on exam.
- •
Insertional tendinosis—often associated with Haglund deformity. History may include aggressive hill running. Pain is localized to Achilles tendon insertion.
- •
Symptomatic Os trigonum—pain with foot plantar flexion, as when going downstairs. Plain x-ray will reveal the symptomatic ossicle.
- •
Posterior ankle impingement
- •
Posteromedial tendon tendinopathy (tibialis posterior, flexor hallucis longus)
- •
Subluxation/dislocating peroneal tendons—pain/discomfort at distal aspect of lateral malleolus, typically with feeling of popping or clicking. If severe enough, will be reproducible on physical exam. MRI helpful in making definitive diagnosis when exam is equivocal.
- •
Sever’s disease
- •
Sural neuritis
- •
Systemic disease
Treatment
Nonoperative Management
Nonsurgical treatment options for Achilles tendinopathy include :
- •
Ankle/foot orthosis (AFO) to correct mechanical misalignment(s)
- •
Nonsteroidal antiinflammatory drugs (NSAIDs)
- •
Modification of training programs or sports activities (relative rest)
- •
Physical therapy
- •
Eccentric training exercises
- •
Brisement (injection of anesthetic or saline into paratenon sheath to break adhesions; for paratenonitis only)
- •
Extracorporeal shock wave therapy
- •
Corticosteroid injection—generally contraindicated because of risk of tendon disruption; however peritendinous injection has been beneficial in some cases of paratenonitis.
- •
Sclerosing agent injections (i.e., Polidocanol)
- •
Prolotherapy
- •
Air Heel brace
- •
Night splints
- •
Low-level laser therapy
- •
Iontophoresis
- •
Stretching exercises
- •
Soft tissue and joint mobilizations (manual therapy)
- •
Taping
- •
Heel lifts
- •
Night splints
- •
Casting/bracing
- •
Accelerated functional rehabilitation
Guidelines for Choosing Among Nonoperative Treatments
- •
For older individuals who are less athletic/active, treatment will initially consist of immobilization (along with rest and ice) of the lower leg with subsequent integration of conservative rehabilitation methods to restore mobility, strength, and functional capability.
- •
For younger, more active patients, or athletes, relative rest with modification of training regimens is important. The same conservative measures also apply.
- •
For tendinopathy, eccentric training exercises have been shown to be beneficial
- •
If initial conservative measures fail, additional nonsurgical treatment options may be pursued depending on patient desire and willingness
Surgical Indications
Surgical treatment options for Achilles tendinopathy include:
- •
Percutaneous tenotomy
- •
Open paratenon and/or tendon debridement/excision (with tendon repair/reconstruction as indicated)
- •
Open repair
- •
Percutaneous repair
- •
Open repair with lengthening, augmentation, or reconstruction (for chronic ruptures)
- •
Absolute indications: none
- •
Relative indications: Achilles tendinosis (or paratenonitis with tendinosis) that is resistant to conservative measures
- •
Absolute indications: open wound requiring irrigation/debridement
- •
Relative indications: failure of nonoperative measures, elite athletes who desire faster return to activity
- •
Choice of operative treatment should ultimately fall on the patient after appropriate discussion of the risks, benefits, and alternatives to surgery.
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Age
- •
Participation in competitive sports
- •
Severity/persistence of symptoms
- •
Adherence to prior interventions
- •
Response to prior treatments
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Patient characteristics (i.e., age, athlete or nonathlete)
- •
Underlying medical conditions (i.e., diabetes, peripheral vascular disease, skin condition)
- •
Patient preference
- •
Among athletes, desire to begin earlier, more aggressive rehabilitation with possible earlier return to activity
- •
Occupational/sports demands
Evidence
Multiple Choice Questions
- QUESTION 1.
Extrinsic factors associated with Achilles tendinopathy and ruptures include all of the following except
- A.
change in intensity of training program.
- B.
forefoot varus.
- C.
improper footwear.
- D.
running or jumping on hard or uneven surfaces.
- A.
- QUESTION 2.
Classic pathological findings of Achilles tendinosis include
- A.
inflammatory cell infiltrate.
- B.
thickened paratenon.
- C.
scattered neovascularization.
- D.
All of the above
- A.
- QUESTION 3.
A 40-year-old man feels a sudden, sharp pain in the back of his ankle while playing basketball. He reports a feeling of being kicked in the back of the leg and cannot walk off the court. What findings are likely to be present on exam?
- A.
Palpable defect in the Achilles tendon
- B.
Positive Thompson test
- C.
Inability to perform a single heel rise on the affected side
- D.
All of the above
- A.
- QUESTION 4.
The preceding patient elects nonoperative management. Which of the following are appropriate treatment options?
- A.
Peritendinous steroid injection
- B.
Brisement
- C.
Short-term casting with accelerated functional rehabilitation
- D.
Pain control with NSAIDs, and custom orthotics to allow immediate weight bearing and therapy
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Pathophysiology )
- QUESTION 2.
Correct answer: C (see Pathophysiology )
- QUESTION 3.
Correct answer: D (see Clinical Presentation )
- QUESTION 4.
Correct answer: C (see Treatment )
Nonoperative Rehabilitation of Achilles Tendinopathy
- Leslie C. Hair, PT, DSc, OCS, FAAOMPT
- Michael D. Rosenthal, PT, DSc, SCS, ATC
- James H. Flint, MD, LCDR, MC USN
- John-Paul H. Rue, MD, CDR, MC USN
- Michael D. Rosenthal, PT, DSc, SCS, ATC
- •
Restoration of normal joint mobility
- •
Progressive increase in neuromuscular demands (strength, endurance, and power)
- •
Evaluation and management of impairments throughout the kinetic chain likely to contribute to Achilles tendinopathy
- •
The goal of rehabilitation of Achilles tendinopathy is a safe and complete return to preinjury level of activity.
- •
In order to achieve this goal, a multimodal treatment approach is used. This approach focuses on restoration of mobility and muscular performance, not just isolated to the lower leg, but including the kinetic chain from the thoracolumbar region distally.
- •
Initiation of formal rehabilitation will vary depending upon the severity of tendinopathy at the time the athlete initiates care.
- •
However the milestones for management are the same whether care begins in the early acute, subacute, chronic, or acute on chronic stage.
- •
Milestones include normalization of talocrural and subtalar mobility, ability to perform single leg heel raises and eccentric gastroc-soleus exercises without pain, and progressive return to activities requiring rapid stretch-shortening cycles (i.e., running and jumping).
- •
Progression from phase to phase is based on improvements in functional performance and reduction in pain, not a rigid timeline.
Phase I (weeks 2 to 4)
Protection
- •
If the athlete displays an antalgic or altered gait, a CAM walking boot or crutches may be used to offload forces through the injured area.
| PHASE I (weeks 2 to 4) | PHASE II (weeks 3 to 12) | PHASE III (weeks 12 to 36) | PHASE IV (weeks 16 to 52) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Ice
- •
Pulsed ultrasound
- •
Low level laser therapy
- •
Iontophoresis
- •
Foot orthosis for correction of excessive pronation
- •
Heel lift to reduce strain on the Achilles tendon
Techniques for Progressive Increase in Range of Motion
- •
Initial treatment should include awareness of the athlete’s fitness level and consideration of what cardiorespiratory training may be used to mitigate deconditioning.
- •
Popular conditioning exercises in this early stage of rehabilitation include swimming, non–weight-bearing pool jogging (if pain free), and the upper body ergo meter. Exercises for the sound leg, core musculature, and upper body should be incorporated along with cardiorespiratory training treatment to optimize the athlete’s readiness for return to sport upon resolution of the Achilles tendinopathy.
- •
Restoration of range of motion (ROM) follows a thorough evaluation of talocrural and subtalar mobility.
- •
Additional ROM assessment of proximal (i.e., hip) or distal joints (i.e., first metatarsophalangeal joint) should also be included, particularly in patients with prior injury to these regions.
- •
Muscular performance assessment will vary based upon the severity and irritability of the patient’s condition.
Manual Therapy Techniques
- •
Identify mobility impairments through a manual exam of the foot and ankle. May use various techniques, including anteroposterior, posteroanterior, distraction, and translatory mobilization or manipulation to improve movement restrictions.
Soft Tissue Techniques
- •
The use of soft tissue mobilization (i.e., transverse friction massage, instrumented soft tissue mobilization) may be used to reduce pain and improve mobility. Utilization of these techniques in acute tendinopathy and paratendinitis is not recommended.
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
Stretching exercises, to include the gastrocnemius and soleus muscle groups, may improve function in patients with dorsiflexion restrictions. Stretching should be performed with both static stretching ( Figure 38-6 ) to restore normal musculotendinous extensibility (recommend comparison with the uninvolved limb), and by way of active and dynamic stretching ( Figure 38-7 ).
FIGURE 38-6
Strap assisted static stretch.
FIGURE 38-7
Active stretch performed with knee straight and knee slightly bent. The uninvolved side is “reaching” into the sagittal plane in a rhythmic manner.
- •
Static stretching performed two to three times daily with each set containing 5 to 10 repetitions and holding the stretch for 20 to 30 seconds. This type of stretching is incorporated into all phases of tendinopathy rehabilitation until symmetrical and pain free ROM about the ankle has been achieved.
- •
Active stretching performed for periods of 20 to 30 seconds, repeated for two to three sets, and repeated one to two times daily. Active stretching techniques will be implemented in all rehabilitation phases with the exception of the acute tendinopathy phase. Active stretching techniques will continue to be used once symmetry of ROM has been achieved and should be incorporated into the warmup portion of the rehabilitation and return to function phases.
Other Therapeutic Exercises
- •
Eccentric loading
- •
Two protocols are most frequently cited in the literature. Curwin and Stanish reported a program consisting of three sets of 10 repetitions and titrated by pain. This protocol included both concentric and eccentric muscle action. Increasing speed of the exercise was performed as part of the progression along with addition of light weight. This program is recommended in Phase I for patients with acute tendinopathy. Initial loading may be induced by use of a resistance strap or band ( Figure 38-8 ).
FIGURE 38-8
Resistance band eccentric loading.
- •
For those with chronic tendinopathy, the eccentric training program advocated by Alfredson is recommended. Alfredson’s protocol involves slow speed eccentric loading, exercising to the level of the athlete’s pain, and includes the addition of greater loads as part of the exercise progression. The unaffected contralateral lower extremity returns the affected ankle to the starting position.
- •
- •
Total leg strengthening to include the hip and thigh musculature
- •
Core strengthening exercises (i.e., side and front planks, pushups)
- •
Total lower extremity stretching to include the thigh, hip, and lumbosacral region
Activation of Primary Muscles Involved
- •
The posterior leg muscles, in particular the gastrocnemius and soleus, which join to form the Achilles tendon are the muscles targeted with the eccentric loading.
Sensorimotor Exercises
- •
Single leg balance exercises are introduced in this early phase of rehabilitation. Balance proprioception exercises progress from a firm to soft or unsteady surface.
Open and Closed Kinetic Chain Exercises
- •
Limited OKC exercises are incorporated. They include intrinsic foot muscle exercises to include towel/toe curls exercises and marble pickups. If the athlete is unable to tolerate weight bearing, OKC four-way (inversion, eversion, dorsiflexion, and plantarflexion) isometric or resistance band exercises may be utilized. CKC exercises include bridging with double leg support progress to single leg support.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Begin total lower extremity therapeutic exercise to include hip stabilization exercises; for example, hip abduction, gluteal strengthening, straight leg raises, and hamstring strengthening. This will include primarily CKC exercises of squatting (with varying base of support) ( Figure 38-9 A,B ), dead lifts (double leg progressing to single leg), and lunges in the frontal plane in Phase I. Power and endurance components will be addressed by changes in the speed and/or duration of movement.
FIGURE 38-9
A,B, Squatting with differing bases of support imparts varying stress on the Achilles tendon and can help in transition to higher level, functional, and sport-specific activities.
Milestones for Progression to the Next Phase
- •
Decreased pain
- •
Symmetry in lower extremity ROM: dorsiflexion measured in both the open and closed kinetic chain position ( Figure 38-10 )
FIGURE 38-10
Closed kinetic chain assessment of dorsiflexion.
- •
Normal gait
Phase II (weeks 3 to 12)
Phase II involves a significant systematic increase in the dynamic stresses applied to the Achilles tendon. Ice application is not recommended prior to exercising because it increases tendon stiffness and the pain inhibition produced by icing may mask awareness of excessive exercise intensity.
Management of Pain and Swelling
- •
Same as in Phase I .
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Same as in Phase I .
Soft Tissue Techniques
- •
Same as in Phase I .
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Static stretching will now be performed following cardiorespiratory and other rehabilitation exercises. The active stretching exercises will be a key focus of the warmup exercises before beginning higher level strengthening exercises.
- •
Static stretching performed one to two times daily with each set containing three to five repetitions and holding the stretch for 20 to 30 seconds.
- •
Active stretching techniques performed for periods of 20 to 30 seconds, repeated for two to three sets, and performed before higher level speed or resistance exercises to prepare the Achilles tendon for the increased loads.
Other Therapeutic Exercises
- •
Eccentric loading protocol (either the Curwin and Stanish or Alfredson protocol). Both protocols have been demonstrated to improve strength and function while decreasing pain in patients with midportion Achilles tendinopathy. Neither protocol has been proved superior.
- •
Total leg strengthening exercises will now progress to include split squat exercises, double leg and single leg deadlifting, and sagittal plane lunges.
- •
Total spine and lower body stretching will continue throughout all phases of rehabilitation.
Sensorimotor Exercises
- •
Balance and proprioception exercises will incorporate sport- or activity-specific surfaces (i.e., basketball court, track surface, or gymnastics pad) and multiple planes of movement. Examples of exercises include the star excursion exercise or wall reach ( Figure 38-11 ), which can include multiple angles/planes of movement. Exercise progression and promotion of tissue adaptation is accomplished by increasing the amplitude of movement (ROM), speed of movement (intensity), and volume of the activity (repetitions or duration of the exercise).
FIGURE 38-11
Wall reach. Reaching may be performed in the sagittal, frontal or transverse planes.
Open and Closed Kinetic Chain Exercises
- •
OKC exercises may include the use of isokinetic resistance exercises for dorsiflexion, plantarflexion, inversion and eversion. Although the focus is on progression of the more functional CKC exercises, such as squats and lunges mentioned previously in this phase, OKC exercises promote strength and local muscular endurance gains.
Plyometrics
- •
Gravity or weight bearing reduced plyometric exercises may be initiated during this phase. Examples include jumping or hopping in a pool, or using a gravity-reduced device (i.e., Total Gym or Shuttle Systems equipment). Plyometric volume should initially be very low and measured by foot contacts. Initial plyometric volume in the injured athlete should not exceed 30 foot contacts per workout with two to three workouts per week.
Functional Exercises
- •
Incorporate functional exercises such as squats, lunges, side lunges, and stepups into the total lower extremity strengthening routine.
Sport-Specific Exercises
- •
Form walking exercises (i.e., high knees with heel raise; Figure 38-12 ). Initiate sport-specific exercise into the routine for athletes. Start with low speed and low impact activities.
FIGURE 38-12
High knee walking with heel raise.
Milestones for Progression to the Next Phase
- •
Attainment of 5/5 strength of lower extremity muscles found to be weak during the evaluation and subsequent rehabilitation
- •
Symmetrical single leg squat and lunge
- •
Pain free heel raise × 15
- •
Pain free single leg hop × 5
Phase III (weeks 12 to 36)
Management of Pain and Swelling
- •
Same is in Phase I .
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
See Phase II .
Soft Tissue Techniques
- •
See Phase II .
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Static stretching should be performed one to two times daily with each set containing three to five repetitions and holding the stretch for 20 to 30 seconds.
- •
Active and dynamic stretching techniques should be performed for periods of 15 to 30 seconds, repeated for two to three sets.
Other Therapeutic Exercises
- •
Total body strengthening exercises during this phase include deadlifts, hang cleans or power cleans, and push-presses.
Activation of Primary Muscles Involved
- •
Although the gastrocnemius and soleus are the primary muscles involved, effective return to athletics requires the synergistic activation of trunk and lower extremity muscles.
Sensorimotor Exercises
- •
Further progression of exercises from Phase II with increasing amplitude of movement (ROM), speed of movement (intensity), and volume of activity (repetitions or duration of the exercise).
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Closed kinetic chain exercises are primarily used for increasing muscular strength, power, and endurance in the final phase. Exercise selection progresses from basic exercises (i.e., squats to squat jumps to weighted squat jumps) to sport specific exercises (i.e., static single leg hops to high skipping to bounding).
Plyometrics
- •
Final stage plyometrics include progression to full weight bearing plyometrics and a gradual increase in training volume and intensity. Progression involves counter movement jumps (double leg advancing to single leg) and box jumps (progressing in box height). Plyometric volume gradually increases to 40 to 80 repetitions. Athletes whose sport includes high volume and high intensity demands may approach 120 to 200 foot contacts no more than twice weekly.
Functional Exercises
- •
Multidirectional and transitional movement (i.e., anterolateral to posteromedial lunging)
- •
Reaction drills (i.e., change of direction movements; forward, lateral, jump).
- •
Walk-jog progression
Sport-Specific Exercises
- •
Selection is based upon demand/needs analysis of the athlete’s sport or functional impairment.
- •
Progressive increase from jogging to sprinting
- •
Agility drills (e.g., figure-eight runs, T-drills)
- •
Run and jump repeats
- •
Line drills
- •
Milestones for Progression to the Next Phase
- •
Countermovement jumping without symptoms
- •
Run without symptoms
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention (weeks 16 to 52)
- •
Inability to regain strength
- •
Inability to regain function
- •
Debilitating pain
- •
Patient preference
Milestones/Criterion-Based Rehabilitation Guidelines to Progress to Advance Sport-Specific Training and Conditioning
- •
Greater than 75% symmetry in hop testing
- •
May include SL hop for distance, SL vertical jump, SL triple hop, and box jumps
- •
- •
Symmetry with single leg heel raise endurance test (maximum repetitions)
Tips and Guidelines for Transitioning to Performance Enhancement
- •
The transition to performance enhancement involves the inclusion of both sport-specific activities as well as continued variety of training stimulus (modes of training) and application of training variables (amplitude of movement, speed of movement, duration of activity/volume, and frequency of training stimulus).
- •
Although this program involves a progression of each component of athleticism (e.g., mobility, strength, power, endurance), the transition to performance enhancement and return to sport should involve a careful manipulation of variables and incorporate an undulating periodization model.
- •
This model enables effective upregulation of certain training variables while down-regulating other training components.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Integration of training/sport-specific variables is required in the training “bridge” from rehabilitation to performance enhancement.
- •
This analysis should include all variables of the athlete’s chosen sport. For example, the sport surface (i.e., court, field), frequency of training and competition, and rest-work cycles during practice and competition.
- •
Additionally, if the athlete’s onset of symptoms was nontraumatic, a comprehensive kinetic chain assessment should be included in the later phase of rehabilitation in hopes of identifying possible strength and/or mobility asymmetries that could be the underlying cause of the condition and increase the likelihood of injury recurrence.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Greater than 85% symmetry in hop testing
Evidence
Multiple Choice Questions
- QUESTION 1.
The following training variable(s) are included in the eccentric training protocol described by Curwin and Stanish.
- A.
Only eccentric movement of the injured Achilles
- B.
Slow speed of eccentric movement
- C.
Performance with the knee bent and knee straight
- D.
Titration of training volume based upon pain
- A.
- QUESTION 2.
The following training variable(s) are included in the eccentric training protocol described by Alfredson.
- A.
Concentric movement on the side of the injured Achilles
- B.
High speed of eccentric movement
- C.
Gradually increasing training volume
- D.
Gradual increase in training resistance
- A.
- QUESTION 3.
The following modalities are appropriate for use with Achilles tendinopathy
- A.
Ultrasound
- B.
Low level laser therapy
- C.
Ice
- D.
There is limited evidence for use of modalities with Achilles tendinopathy and rehab should focus on restoring mobility and strength
- A.
- QUESTION 4.
Functional exercise and sport-specific exercise should begin in phase?
- A.
Phase 1 (weeks 1 to 2)
- B.
Phase 2 (weeks 3 to 12)
- C.
Phase 3 (weeks 12 to 36)
- D.
Phase 4 (weeks 16 to 52)
- A.
- QUESTION 5.
What criteria indicate a need for referral to the orthopedic surgeon and consideration of operative intervention?
- A.
Inability to regain strength
- B.
Inability to gain function
- C.
Debilitating pain
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Phase I )
- QUESTION 2.
Correct answer: D (see Phase II )
- QUESTION 3.
Correct answer: D (see Phase I )
- QUESTION 4.
Correct answer: B (see Phase III )
- QUESTION 5.
Correct answer: D (see Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention )
Postoperative Rehabilitation of Achilles Tendinopathy
- James H. Flint, MD, LCDR, MC USN
- Michael D. Rosenthal, PT, DSc, SCS, ECS, ATC, CSCS
- Charles E. Rainey, PT, DSc, DPT, OCS, SCS, CSCS, FAAOMPT
- John-Paul H. Rue, MD, CDR, MC USN
- Michael D. Rosenthal, PT, DSc, SCS, ECS, ATC, CSCS
Indications for Surgical Treatment
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Failure of nonoperative measures, typically after at least 3 to 6 months
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Patient preference
Brief Summary of Surgical Treatment
Major Surgical Steps
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Achilles paratenonitis
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Choice of anesthesia, patient in prone position on well-padded table
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Place tourniquet on affected extremity before rolling for ease of application
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Posteromedial incision to avoid small saphenous vein and sural nerve
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Full thickness incision through skin down to paratenon
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Identify any thickened or fibrotic areas of the paratenon and excise. Lyse any adhesions to the underlying tendon. Avoid excising anteriorly to preserve the blood supply to the tendon.
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Close the incision and dress the wound.
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Postoperative splint or boot for edema control and soft tissue rest/wound healing
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Rehabilitation should start as soon as the wound is sufficiently healed.
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Achilles tendinosis
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For solitary, well-defined nodules less than 2.5 cm, percutaneous longitudinal tenotomies can be performed.
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May be performed in outpatient setting without use of tourniquet in some cases.
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Rehabilitation can start (or continue) as soon as the stab incision(s) is sufficiently healed.
When performing percutaneous tenotomy, ultrasound guidance should be used to ensure precise placement of the scalpel within the affected portion of the tendon.
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For larger, or multiple, nodules, or in cases of tendinosis with associated paratenonitis, an open procedure is performed.
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The same operative setup and surgical approach is used as described in the preceding.
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Paratenonitis is addressed as in the preceding, and attention is then turned to the tendon proper.
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Intratendinous incisions are made as indicated over the nodular areas. Nodular tissue (degenerated tendon) is excised and the tendon is repaired side-to-side with a buried, absorbable suture.
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Close the remaining paratenon and skin in layers.
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Dress the wound and place the patient in a short-leg splint or removable boot.
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The patient may bear weight fully and perform gentle range of motion, but formal rehabilitation should be postponed until the wound is sufficiently healed.
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Factors That May Affect Rehabilitation
Anesthetic
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As indicated, patients may benefit from short-term narcotic analgesia. Be aware of the patient’s pain medication needs and tailor accordingly.
Surgical
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Degree of tendinosis and/or paratenonitis
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More advanced cases, which involve open procedures, need more time to recover and heal postoperatively when compared with simpler cases that may be addressed with percutaneous procedures.
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Size of exposure
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More extensive debridement may require more extensive surgical incisions. Rehabilitation should not impede sufficient wound healing. Soft tissue healing takes precedence over initiation of aggressive rehabilitation.
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Quality of the tendon
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For patients with severe tendinosis, with or without paratenonitis, consider allowing more time for soft tissue healing before starting aggressive rehabilitation.
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Other Surgical Techniques and Options
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Endoscopic debridement
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Advanced options (for patients with greater than 50% to 75% tendon degeneration)
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Tendon transfers
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For example, FDL, FHL
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Allograft tendon reconstruction
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Before Surgery: Overview of Goals, Milestones, and Guidelines 1
1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.
Guiding Principles of Postoperative Rehabilitation
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Understanding the stages of soft tissue healing and anatomic structures involved.
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Application of appropriate levels of physical stress to the healing soft tissue to promote optimal recovery.
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Development of a systematic approach to soft tissue overload with the long-range goal in mind.
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Effective patient education on the comprehensive rehabilitation program.
Phase I (days 0 to 14): Immediate Postoperative Period
Gentle non–weight-bearing motion should commence immediately. Active ROM and passive dorsiflexion with resistance band or stretch strap should be performed throughout the day. Active plantarflexion is allowed immediately.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 3 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 14) | PHASE V (weeks 14 to 24) | PHASE VI (weeks 24 to 52) |
|---|---|---|---|---|---|
|
|
|
|
|
|
Goals
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Protection of repaired structures
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Decrease pain and inflammation
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Prevent effects of immobilization
Protection
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Padded splint with the ankle in neutral dorsiflexion (DF).
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Crutch-assisted ambulation for the first 10 to 14 days.
Management of Pain and Swelling
Treatment for Pain/Analgesia
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Oral pain medications
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Cryotherapy to reduce pain and inflammation.
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Therapeutic modalities such as TENS and IFC e-stim.
Decrease Swelling
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Cryotherapy to reduce swelling
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Elevation of surgical limb
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
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Talocrural, subtalar, and mid-foot joint mobilizations
Soft Tissue Techniques
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Achilles tendon soft tissue mobilizations
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Scar mobilization to region of incision once closed
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Stretching/flexibility techniques for the musculotendinous unit
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Towel gastroc-soleus stretch (pain free)
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Ankle AROM (ABCs)
Other Therapeutic Exercises
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Straight leg raises
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May perform upper body and core exercises not requiring support of the involved lower extremity.
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
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Resistance band exercises—dorsiflexion (DF), plantarflexion (PF), inversion (INV), and eversion (EV)
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Four-way ankle isometrics
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Seated heel (PF) and toe (DF) raises
Sensorimotor Exercises
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BAPS board (seated)
Milestones for Progression to the Next Phase
Performs all Phase I rehabilitation exercises without pain or increase in swelling
Phase II (weeks 2 to 6)
Removable walking boot with adjustable heel is used for weeks 2 to 4. At week 2, weight bearing without crutches is allowed in the walking boot. Stationary bike is allowed when the patient tolerates full weight bearing. Discontinue walking boot at weeks 4 to 6.
Goals
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Protection of repaired structures
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Decrease in pain and inflammation
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Discontinued use of crutches and walking boot
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Full weight-bearing status
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Normal ROM
Protection
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Use a walking boot for ambulation without crutches
Management of Pain and Swelling
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Same as Phase I
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
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Talocrural, subtalar, and mid-foot joint mobilizations
Soft Tissue Techniques
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Achilles tendon soft tissue mobilizations
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Scar mobilization to incision
Stretching and Flexibility Techniques for the Musculotendinous Unit
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Towel calf stretch
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Ankle circles (ABCs)
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Ensure normal ROM in hip and knee and address any restrictions during this period.
Other Therapeutic Exercises
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Stationary bike
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Swimming and aqua jogging (wound healing must be complete)
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Straight leg raises
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Leg press, body weight squats
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
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Muscle activation of the gastroc-soleus complex during this second phase of rehabilitation begins with isometric plantar flexion and light resisted plantar flexion using a towel or resistance bands.
Techniques to Increase Muscle Strength, Power, and Endurance
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Lower body strengthening, including bodyweight squats, lunges, and wall sits; progressing to include leg press, step-up and step downs in the sagittal and frontal planes.
Functional Exercises
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Gait training from 3 to 6 weeks
Milestones for Progression to the Next Phase
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Full AROM
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Ambulates without assistance device
Phase III (weeks 6 to 10)
Goals
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Restore normal gait mechanics.
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5/5 lower extremity strength
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Begin a walk-jog program.
Protection
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Walking boot discontinued
Management of Pain and Swelling
Treatment for Pain/Analgesia
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Cryotherapy
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Therapeutic modalities such as laser therapy and electrical stimulation as needed
Decrease Swelling
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Cryotherapy
Techniques for Progressive Increase in Range of Motion
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Same as in Phase II plus
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Standing gastroc-soleus stretch (straight and bent knee)
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Gastroc-soleus stretching using a slant board
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Other Therapeutic Exercises
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Elliptical trainer
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Stairmaster
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Standing hip abduction
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Standing hamstring curls
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
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Resistance band exercises—dorsiflexion, plantarflexion, inversion, and eversion
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Sitting heel raises progressing to bilateral standing heel raises with slow eccentric lowering into maximal DF
Sensorimotor Exercises
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In-line tandem walking and lunging
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Single limb stance (with and without Airex pad)
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Rebounder exercises including ball toss and catch
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Hurdle step
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Standing BAPS
Techniques to Increase Muscle Strength, Power, and Endurance
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Progress from bodyweight squats and lunges to include increasing levels of resistance.
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Multi-planar lunges
Functional Exercises
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Gait training
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Form walking: high knees, lateral stepping, hurdle step overs/unders
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Walk to jog progression
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Stair climbing
Milestones for Progression to the Next Phase
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Normal gait
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Able to perform bilateral heel raises and lunges
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Symmetry in unilateral stance
Phase IV (weeks 10 to 14)
Goals
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Jogging 5 to 10 minutes
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Begin agility and sport-specific training
Therapeutic Exercises
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Outdoor biking
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Stair machine
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
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Single leg calf raises
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Eccentric loading ( Figure 38-13 A,B ) protocol with technique as described by Alfredson
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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