Achilles tendonitis , what it is and treatment of the condition.

 

Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achillis bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit

 

Achilles problems.
In this thread there has been some mention of Achilles damage. Here are the results of my own research.

Achilles tendonitis can be caused by a number of factors. These can include simply ignoring any pain at the back of the leg of heel, extra classes preparing for a Championship or show, such as dancing twice a week and suddenly practicing five times a week. Breaking in a new shoe that is far too stiff, and not warming up, or cooling down properly. Fortunately, you are a body and not a machine, however, machines break and so can bodies. Be sensible and warm up correctly.

Shoe pressure at the back of the foot, tying laces around the mid foot which stops the full functionality of the foot joints, getting kicked or damaging the tendon at the heel or just above the heel area.

Damage to Tendons from Dance Shoes?

I was asked about this in November 2005 at one of my lectures in dance Injury and avoidance. This was in regard to the difference between different dance shoes. The question was that if 18% of ballet dancers will suffer an Achilles injury at some stage in their dance life how does that compare to other Dance. This was my answer:

It depends on the dance discipline. In Highland Dance, around 35% of dancers will get some form of tendonitis injury and Achilles is one of the more common ones experienced by Highland Dancers. In ballet the damage can be caused by faulty landing and twisting but the cause of Achilles in Ballet is nearly always caused by the tapes or laces being tied too tightly around the ankle, causing compression of the sheath and subsequent damage.

In Highland and Irish Dance, the damage is further caused by tying around the arch that can reduce blood flow to the extremities of the foot. The tying around the ankle is secondary here but in tandem with the arch constriction then that sets the dancer up for an Achilles or tendonitis injury. In Irish Dance, there is likelihood of around 30 to 40% chance for an Achilles or arch tendon damage if the dancer ties their laces around the arch.

This was well researched by both me and many leading dance injury specialists including work done by the famous Justin Howse who wrote the book, Dance Technique and Injury Prevention with his associate, Shirley Hancock back in 1988. Mr Howse was the senior consultant and orthopedic surgeon to the Royal Ballet Schools, The Royal Academy of Dance and the Remedial Dance Clinic, London. Ms. Hancock was the senior physiotherapist to the to the Royal Ballet Schools, The Royal Academy of Dance and the Remedial Dance Clinic, London. I have consulted with them over the years when I was the fitter for over 160 Ballet companies all over the world. My own research in the 45 years of fitting to improve my range of dance shoes and to try and reduce injury which is rampant in Ballet, resulted in the creation of the Hullachan Highland range of shoes. None of the ballet shoe manufacturers I spoke to was, at that time, willing to invest in that research to reduce injury and so I started my own company making Highland and Irish Dance shoes. Why? Well I am part Scottish and Irish, and I invested everything I had to make that dream happen-at least for Irish and Scottish dancers. When I designed the Hullachan range it was Justin Howse who personally wrote e a letter congratulating me on both doing and the delivering that research in to a function shoe to go a very long way in helping  to reduce injury.


Treatment for Achilles Tendonitis.

R.I.C.E. treatment is, Rest, Ice, Compression and Elevation, so please get that into play immediately to reduce the problem and do it at least three times a day over three or four days.. See a doctor as soon as you can. If your Achilles is getting less painful still continue treatment of R.I.C.E. for the next two to four weeks or until it is healed.

Reduce practice of course to about half of that you normally do. Avoid too much stretching. However saying that use correct stretching and if you do get an attack of Achilles tendonitis from your dancing, do not stretch too enthusiastically, but continue to stretch gently or if attending a doctor, follow their advice. Avoid stair, wall, incline and towel stretches. Try not contract the muscles in the initial period of pain.

If this does not show positive results, use a firm heel support or lift of no more than a quarter inch or half a centimetre. Do not use flat shoes in day-to-day use such as trainers. The idea is to relieve the pressure on the tendon so that it does not stretch too much. A good preventative part of your general warm up should be gentle calf stretches.

Do not use overly cushioned insoles in Pumps that are too soft. Some materials feel great to start with but then collapse and become hard. Cheaper cushioning will do this.

I should point out that when I designed the Hullachan Shoe I inserted a special medically approved thin heel cushion and insole. This was not too thick and had the benefit of helping prevent heel strike as well as stopping too much depression following an Achilles tendon problem. Too much cushioning is very bad, as, after contact with the floor, the heel of the foot will sink down lower as the shoe absorbs the shock. That will then further stretch the tendon as the body moves over the foot. Too thick a heel cushion such as a rubber-cushioned insole can have the opposite effect of the preventative measures I incorporated into the Hullachan Shoe. Therefore avoid all trainers when practicing if you get Achilles tendonitis.

 

 

Next, we look at treatments

 

 

Treatments:

The ankle is the site of many dace and athletic-related injuries. There a number of options relating tp which treatment strategies are most effective for various conditions. This series of articles cites several treatments and helpful articles which may be able to  shed some light on the ongoing controversy regarding the best treatment options , from conservative to operative management, for the treatment of Achilles tendonitis. Achilles tendinitis is a frequentl problem fir dancers. Most specialists now  prefer to separate these  into “insertional” and “noninsertional” Achilles tendinitis. This is because it allows nonoperative and operative treatment to be looked at as problem specific and systematic

 

For further information beyond this I would suggest looking at The American College of Sports Medicine,  .http://www.acsm.org/ where you can subscribe and buy more detailed articles on this and other subjects.

 

1; Operative versus nonoperative treatment of Achilles tendon rupture

A prospective randomized study and review of the literature

 

One hundred eleven patients with acute rupture of the Achilles tendon were included in a prospective trial and randomly assigned to groups for operative (56 patients) or nonoperative (55 patients) treatment.

All of the patients were followed with clinic evaluations at 4 months and 1 year after the rupture. The major complications in the operative treatment group were three reruptures and two deep infections as com pared with seven reruptures, one second rerupture, and one extreme residual lengthening of the tendon in the nonoperative group. There were fewer minor complications in the nonoperative group than in the opera tive group.

The operatively treated patients had a significantly higher rate of resuming sports activities at the same level, a lesser degree of calf atrophy, better ankle movement, and fewer complaints 1 year after the accident.

The conclusion we reached through this randomized prospective study is that operative treatment of ruptured Achilles tendons is preferable, but nonoperative treatment is an acceptable alternative

René Cetti, MD Steen-Erik Christensen, MD Rolf Ejsted, MD Niels Melchior Jensen, MD Uffe Jorgensen, MD, PhD

2; Achilles tendon disorders in runners--a review.

Smart GW, Taunton JE, Clement DB.

The Achilles tendon and the classification, aetiology, diagnosis, treatment, and management of Achilles tendon disorders in runners are reviewed. Due to the presence of a paratenon sheath, the classification of Achilles tendon disease should be revised. Several etiological mechanisms have been proposed in Achilles tendon disease. The authors recognize: faulty foot biomechanics; poor lower leg flexibility; poorly designed athletic footwear; training surfaces; training intensity; overuse through excessive mileage; inactivity; local steroid injections; rheumatic conditions; and indirect violence. An accurate, thorough differential diagnosis is essential when the athlete presents with an Achilles tendon disorder. Except in total rupture and in extensive partial rupture, the authors do not recommend cast immobilization in the treatment of Achilles tendon disease. When the athlete presents with total rupture of the Achilles tendon, the authors believe that surgical repair is the treatment method of choice. Rehabilitation programs to follow successful treatment of Achilles tendon disease are also presented.

 

3; Non-Surgical Treatment of Tendo Achillis Rupture

Tendon step tretches

We have analyzed the results in sixty-six cases of Achilles tendon injury which were treated by a simple non-surgical method. A gravity equinus walking boot cast was applied for eight weeks. The patient then used a 2.5 centimetre heel elevation for four weeks. Resistance exercises were used to build up the triceps surae. The frequent complications in other series of operative repair were discussed. The virtues of this method are that the hazards of anaesthesia and open surgery are avoided. The complications of infection, skin slough, and scar formation do not occur, and the patient is spared the expense of hospitalization. Early return to work is a distinct economic advantage. The functional results are as entirely satisfactory as those from operative repair; the cosmetic appearance is much better.9Abtract from a bigger report from the Journal and Bone & Joint Surgery)

Robert B.Lea; Lyman Smith.

 

 

4; Achilles Tendonitis: Are Corticosteroid Injections Useful or Harmful?

 

The use of local corticosteroid injections for the treatment of Achilles tendonitis is controversial. Some authors advocate their use based on efficacy in accelerating the healing process of Achilles tendonitis; others feel the associated side effects should preclude their use altogether. The purpose of this study was to comprehensively review and critically appraise the available literature in order to examine the evidence concerning this clinical dilemma.

Data sources: MEDLINE was searched using MeSH and textwords for English- and French-language articles related to Achilles tendonitis and corticosteroids published since 1966. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 145.

Study selection: All clinical study designs were included as well as related animal studies using experimental and quasi-experimental designs.

Data extraction and synthesis: In reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, the factors associated with effectiveness and safety of injected corticosteroids were examined.

Main results: The only rigorous studies (one randomized controlled trial, one cohort study) showed no benefit of corticosteroids over placebo. In animal studies, corticosteroid injections decrease adhesion formation, temporarily weaken the tendon if given intratendinously, but have no effect on tendon strength if injected into the paratenon. The overall incidence of side effects with locally injected corticosteroids is ~1%. Most side effects are temporary, but skin atrophy and depigmentation can be permanent. Although there are many case reports of Achilles tendon rupture following local corticosteroid injection, there are no published rigorous studies that evaluate the risk of rupture with or without corticosteroid injection.

Conclusions: There are insufficient published data to determine the comparative risks and benefits of corticosteroid injections in Achilles tendonitis. The decreased tendon strength with intratendinous injections in animal studies suggests that rupture may be a potential complication for several weeks following injection.

(C) Lippincott-Raven Publishers. Shrier, Ian M.D., Ph.D.; Matheson, Gordon O. M.D., Ph.D.; Kohl, Harold W. III Ph.D.

5; Aftercare treatmnet

 

A retrospective review was performed of the results of operative treatment of stenosing tenosynovitis of the flexor hallucis longus tendon or posterior impingement syndrome, or both, in thirty-seven dancers (forty-one operations). The average duration of follow-up was seven years (range, two to thirteen years). The results were assessed with use of a questionnaire for all patients, and a clinical evaluation was performed for twenty-one patients (twenty-two ankles). Twenty-six operations were performed for tendinitis and posterior impingement; nine, for isolated tendinitis; and six, for isolated posterior impingement syndrome. A medial incision was used in thirty-three procedures; a lateral incision, in six; an anterior and a medial incision, in one; and a lateral and a medial incision, in one. Thirty ankles had a good or excellent result; six, a fair result; and four, a poor result. (The result of the second procedure on an ankle that was operated on twice was not included.) The result was good or excellent for twenty-eight of the thirty-four ankles in professional dancers, compared with only two of the six ankles in amateur dancers.

Pain in the Posterior Aspect of the Ankle in Dancers. Differential Diagnosis and Operative Treatment

WILLIAM G. HAMILTON, M.D.; MARK J. GEPPERT, M.D.; FRANCESCA M. THOMPSON, M.D., NEW YORK, N.Y.

 

6; Flexor Hallucis Longus Tendon Injury in Dancers and Nondancers

G. James Sammarco, M.D., Paul S. Cooper, M.D.

 

Abstract

Thirty-one cases of flexor hallucis longus injuries in 26 patients were treated over a 16-year period (1977–1993). Groups were divided into dance-related injuries (group I) and other causes (group II). The two groups were compared with regard to age, activity, duration of symptoms, operative findings, histopathology, and postoperative time to resumption of full activities. Twenty-seven cases required surgery for unsuccessful nonoperative treatment. In group I, 71% of patients had a partial longitudinal tear of the flexor hallucis longus compared with 30% in group II. Another common finding was isolated tenosynovitis (21% in group I and 53% in group II). Eight cases had magnetic resonance imaging (MRI) evaluations before surgery. Clinical correlation was found to be an important factor in interpreting the MRI. Dancers tended to have symptoms for a longer period of time before seeking treatment than did nondancers. Follow-up was 19.2 months for dancers and 25 months for nondancers. Surgical correction of tenosynovitis, pseudocyst, and tendon tear yielded good or excellent results in 14 of 15 dancers and 9 of 11 nondancers. Surgical treatment of tendon tears and other pathologic tendon conditions gave consistently good results in patients with refractory flexor hallucis longus disease.

 

Functional postoperative treatment of Achilles tendon repair

Thomas R. Carter, MD, Peter J. Fowler, MD, FRCS C, Cathy Blokker, MD

 

Craig Coussins Articles

Achilles Tendon Disorders in Athletes

Anthony A. Schepsis, MD*, Hugh Jones, MD and Andrew L. Haas, MD

 

 

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