Achilles Tendon Injury

Achilles Tendon Injury

Achilles tendon is located at the back of the leg near the heel. It makes up the confluence of the posterior superficial leg muscles and is regarded as one of the strongest and largest tendon in the human body. Despite its strength, it is frequently subjected to injury and accounts for one of the most common sports injuries, an Achilles tendinopathy. It is important to distinguish between the type of tendon injuries associated with the Achilles.

An Achilles tendinopathy (AT) involves localized pain, swelling near the back of the leg near the heel with impaired physical function. There are two types based on location of injury: the mid tendon, and the distal insertional attachment. An Achilles tendinopathy is usually found in physical activities such as running, sprinting, and jumping, which are common athletic movements in a training program. Some factors to consider which may lead an athlete to higher risk of an Achilles injury include: leg length discrepancy, hyperpronation (flat feet), limited ankle mobility, various health systemic conditions, overloading the tendon, over training, excessive hill training, training on hard surfaces, increasing millage without progressive adaptation, poor shock absorption, and poor choice of footwear. Of course, the latter most risks are potentially avoidable with proper strength and training programs, whereas the former need medical guidance.

When one sustains a Achilles Tendon injury, consistent with a tendinopathy, it is important to consider rehabilitation options and medical management immediately, otherwise if the source of pain persists, the area of degeneration of the tear may worsen overtime, and can lead to an Achilles Tendon rupture (briefly discussed below). While there are no gold standards to treatment, research has suggested these non-operative managements to be helpful: initial rest, walking boot with modified activity, orthotics with specific modifications, graduated heel lifts/wedges that reduce dorsiflexion of the ankle, low level laser therapy, eccentric exercise program, and shockwave therapy, deep friction massage and tendon mobilization. Between a mid tendon and an insertional Achilles tendinopathy, there are specific eccentric exercises that studies have shown to be helpful for an individual’s recovery which will further improve healing and reduce the likelihood of re-injury, or potential rupture if left untreated.

In some cases, an Achilles tendon can undergo a traumatic injury in which the tendon can rupture, causing significant deficits. While one would immediately jump to the conclusion that surgery is automatically necessary, advances in non-operative management for acute Achilles tendon ruptures are on the rise. There has been a common consensus in literature to reduce the need to intervene with surgery in Achilles tendon ruptures, where functional outcomes show that there are similar results with pain management and function in the presence of rehabilitation. It appears that early loading has been shown to decrease tendon elongation, improve mechanical properties, and improve functional outcomes. Research has shown that a stepwise progression of tendon loading with exercise, working within tolerable ranges of motion, weaning off mobilizations, and advanced exercise and proprioceptive exercises are all helpful in post injury management.

In all regards, the Achilles tendon, one of the most powerful and strongest tendons in the human body can succumb to injury, and more often in sport related incidents such as running and jumping. It is important to consider rehabilitation options in non-operative management first, as research shows significant results to improving outcome and function when addressed quickly. Next time you, your athlete or loved one complains of pain in the heel/lower part of the leg, be sure to get it checked out!

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

References

Alfredson H. and Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine. 2007 Apr; 41(4): 211–216.

Shapiro E, Grande D, and Drakos M. Biologics in Achilles tendon healing and repair: a review. Curr Rev Musculoskelet Med (2015) 8:9–17.

Li, H and Hua H. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Research International (2016) Volume 2016, 1-9.

 

Importance of a Warm-up

Every elite athlete knows that an effective warm-up is an important tool in preventing injury and improving performance. I would like to introduce to you the importance of a warm up, why it is important to have both a static and dynamic component to warm ups and briefly touch on today’s research.

Why Warm up

Warm-ups are important in helping muscle, joints, the heart, and the entire nervous system have a chance to loosen up, and become primed before sport or exercise. As your heart rate increases during a warm up, your blood circulates to internal organs, muscles, tendons and joints, and of course to your brain, which gives your mental game some much added sharpness. It is important to identify sport specific movement patterns and then organize your warmup around these movements. By recognizing these movement patterns, you can then begin to create a warmup specific to your sport which can help activate and prime the joints, muscles and soft tissue involved in sport specific movement.

In private practice, I often run into many young athletes who simply skip the warm up entirely, or don’t adopt an effective routine, which can lead to unwanted injuries. Now that I have illustrated what a warm-up can provide and the specifics of tailoring it to your sport, we must understand the types of warmups there are.

The Dynamic Warm-Up and the Static Warm-Up

When we think of warm-ups, we usually default to a simple hold and stretch type of exercise, that helps loosen some muscles and make us feel good. However, there is much more to a warm-up. There are two types of warm-ups, the dynamic and static warm-up, and they should be used in tandem.

A dynamic warm-up involves actively moving your muscle and joints through cycles of repetition, thus priming movement and preparing muscles for movement in healthy ranges. A static warm-up involves keeping the muscle and joint(s) in motionless position to achieve an increase in flexibility. Let us take the example of an ice hockey goalie who needs to perform splits in a butterfly stance. This athlete’s hip motion needs to have both flexibility and power to properly get in and out of this stance. Training hip flexibility would be achieved using a static warm-up, while a dynamic warm-up can help improve power output and explosive performance of the hip muscles which are needed to achieve proper positioning. While I have illustrated merits to using both methods, it is important to include both, as dynamic warm-ups have been identified in helping reduce any deleterious effects caused by using static warm-ups in isolation. Studies have identified that using only a static warm-up can reduce power output of muscles. So using it just before sport, is not highly recommended, especially in isolation.

What does research tell us

Much of today’s research suggests that static stretching, when used alone, can lead to a reduction in peak power performance and muscle force output. Some researchers suggest that anywhere from 30-90 second hold static stretching can induce these deleterious effects. When a dynamic warm-up is added with a static stretching warm-up, we see much of these deleterious effects reduced. Some research on the use of dynamic warm-ups showed an increase in muscle temperatures, improvements in nerve conduction, an increase in muscle motor unit recruitment, and an increase in the frequency of which fast twitch muscles fire, thus improving force output of the muscle (Layec et al., 2009, Bishop, 2003). Combining a dynamic and static warm-up are both important in helping sport specific movement patterns which can help athletes recover and prevent injuries. Overall incorporating a warm-up with both static and dynamic techniques is extremely important in helping the athlete with flexibility and power output.

A warm-up should include exercises like body weighted lunges, squats, and deadlifts, 20 minutes of cycling, band work, foam rolling, stretches. A common exercises routine that I find a lot of my soccer athletes perform, is the Fifa 11. Try this out, and see if you feel a difference. If you are a follower of my blog, stay tuned to a upcoming program that I am developing with Team Shut Out goalie school.

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

Resources:

Bishop, D. (2003) Warm up I: potential mechanisms and the effects of passive warm up on exercise performance. Sports Medicine 33, 439-454.

Layec, G., Bringard, A., Le Fur, Y., Vilmen, C., Micallef, J.P., Perrey, S., Cozzone, P.J. and Bendahan, D. (2009) Effects of a prior high-intensity knee-extension exercise on muscle recruitment and energy cost: a combined local and global investigation in humans. Experimental Physiology 94, 704-719.

Samson M, Button DC, Chaouachi A, and Behm, D. Effects of dynamic and static stretching within general and activity specific warm-up protocols. Journal of Sports Science and Medicine (2012) 11, 279-285

 

Acupuncture, what does it do…

Western medical acupuncture is based on a contemporary understanding of the body’s mechanisms. This practice has earned its place in modern healthcare and has been growing in sports injury management. Western medical acupuncture is used with contemporary medical diagnoses to induce physiological changes in the body, whereas traditional Chinese medical acupuncture is used with diagnoses that arise from understanding the body’s imbalances which are corrected with needles. It is very important to distinguish between the two approaches, as they are used quite differently among practitioners.

There are five mechanisms for understanding how medical acupuncture works in a manual therapy setting, such as in sports injuries and regular sprains and strains.

1) Local Effects

Acupuncture stimulates nerve fibres in the skin and muscle. When needling the skin, it has many sensory nerves that are stimulated and are interconnected within a network. When this network is stimulated, it releases a substance called calcitonin gene-related peptide (CGRP) which causes local blood vessels to expand and increase blood flow. As a result, increases in blood supply can promote local healing of injured tissue.

2) Segmental Analgesia

When an nerve is stimulated, it not only has local effects, but it has effects that reaches the spinal cord and depresses the activity in the region where pain is derived from. It is believed that this process, called, segmental analgesia, inhibits pain using the segmental region of the spinal cord. Acupuncture reduces pain in the segments where the needles are inserted.

3) Extrasegmental Analgesia

After a nerve at the segmental region is stimulated, producing pain relief, the stimulation then travels up to the brainstem, further reducing pain throughout the body. This stimulation is helpful in adding to the reduction of pain at the segment, and else where in the body.

4) Central regulatory effects

As the stimulation of an acupuncture needle can also have effects on structures within the brain. As the midbrain

5) Myofascial trigger points (TrP)

Pain can arise in many different ways, from bones, joints, strained ligaments and tendons, and of course muscles. After heavy overwork, lengthy stretch, awkward posture, muscles can develop small damaged areas that are painful and slow to heal. These small damaged areas begin to manifest into myofascial trigger points (TrP). Usually a TrP can be evident when a taut band of tissues is felt, with a tender spot and reproduced with pressure that can cause referral pain. The patient also complains of biomechanical pain when the area is moved. Acupuncture helps inactivate myofascial trigger points.

In sports injuries, our clinic uses medical acupuncture to the effect of improving tissue healing, improving the neurology of the muscles and tissue, and encouraging an oxygen rich environment for the healing tissue to work in. This often allows the patient/athlete to get back to their sport in a safer manner which is both controlled and monitored, as well as offering a preventative method to future re-injury.

Take home point: Acupuncture is a safe and effective treatment tool for sports injuries, general sprains and strains, and preventative medicine.

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

References available upon request.

 

Anterior Knee Pain and OSD

Many children often present in practice complaining about anterior knee pain. One condition that is worth mentioning is Osgood Schlatter disease (OSD). This condition involves an inflammation of the patellar tendon as it inserts on the tibial tuberosity. It is well known to occur in late childhood and often characterised by pain over the bony prominence just below the knee cap (tibial tuberosity). As children are growing, there are growth centers made up of immature bone and cartilage that become mature and ossify into larger bones after skeletal maturity. However, in late childhood, the tibial tuberosity is subject to much stress as activity level increase, and the patellar tendon tugs away from the growth center of the tibial tuberosity leaving inflammation. Pain is usually felt after physical activity, sometimes pain is permanent and steady regardless of the time of the activity. The pain is sometimes followed by a visible inflammation around the patellar attachment of the tibial tuberosity (Figure 1). Activities such as running, climbing up stairs, jumping, bending at the knees can usually exacerbate the symptoms of OSD.

Figure 1 – OSD: Anatomcial signs showing palpable growth on tibial tuberosity (left), and Xray findings showing fragmented growth (right).

 

The first line of defense is resting from pain generating activities, the use of conservative management that targets reduction of pain and swelling, and the use of ice and protective padding. In practice, I tend to use manual muscle release techniques to help reduce the tension along the bony prominence and a combination of electrotherapy and rehabilitation to strengthen muscle groupings. It is important to examine the child’s lower limb biomechanics as poor biomechanical functioning can lead to added complications and poor recovery time.

In some cases, where either conservative management has failed, or the condition has progressed, an x-ray is needed to examine the affected area for bony fragmentation of the tibial tuberosity. And, sometimes an Ultrasound of the soft tissue swelling is important to rule out differential diagnoses. In more extreme cases, a second line of defense involves surgical removal of a bony fragment if pain persists after conservative management. But research tells us that there is no benefit with surgery versus conservative care.

It is also important to consider that there are many other reasons for anterior knee pain such as tumors, infections, muscle and tendon tears, other bony lesions etc.

Take home point: Don’t delay anterior knee pain on a child, get it checked out by a medical health professional.

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

References
Vaishya R, Azizi A, Agarwal A, et al. (September 13, 2016) Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus 8(9): e780