Focus On: The Achilles Tendon
The Achilles tendon is the thickest in the human body. It serves to attach the gastrocnemius, soleus and plantaris muscles of the calf to the calcaneus (heel) bone. These muscles then act via the Achilles tendon, causing plantar flexion (downward motion) of the foot at the ankle.
The term "Achilles' heel" is of course often used in our society, referring to a particular vulnerability. This relates to the mythical story of Achilles, an ancient Greek war hero whose most notable feat during the Trojan War was the slaying of the Trojan hero Hector outside the gates of Troy. It is believed that Achilles was killed near the end of the Trojan War by Paris, who shot him in the heel with an arrow. This was thought to be his only site of vulnerability as he was dipped into a river as a baby by his mother to gain a magical coating of invincibility. Because Achilles's mother held her son by one heel as she put him into the river, the heel was not exposed to this protective coating and therefore remained his one site of weakness.
Achilles tendons are indeed vulnerable to injury and common problems we see in clinic are tendinopathy, musculotendinous tears and ruptures.
Achilles Tendinopathy
Tendinopathy is characterised by pain in the back of the leg or heel which is usually intermittent, worse in the morning, and aggravated by activity or exercise. Tenderness, swelling, and crepitus (crunching) may be felt along the tendon. A feeling of stiffness is often reported and may occur in the morning or after a period of immobility, and ease with movement.
Physiotherapy management of tendinopathy involves the identification and appropriate management of underlying medical causes and contributory factors. Additionally, a biomechanical assessment may find a lower limb malalignment or muscle weakness that is potentially contributing to the injury.
Advice on an initial period of rest or relative rest (stopping high impact activities, such as running) until pain subsides. Exercise can be restarted gradually when pain allows and graded loading (strengthening) exercises to the Achilles is currently the best evidenced way of improving long term outcome. Symptoms normally take 12 weeks to resolve and simple analgesia (such as paracetamol) may be used for pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs such as Ibuprofen) may be useful for pain relief in the very early phases but are not recommended in the longer term.
Benefits of using Aquatic-Therapy for tendinopathy management:
• Aquatic Therapy in a pool is a perfect environment to undertake a graduated loading programme on the Achilles.
• You can remain very active in the water without anywhere near the high loads running and jumping on land produces in the tendon.
• No need to stop exercising and retain your cardiovascular fitness.
• Reduce pain due to the warm water temperature, circulatory, nervous system and hormonal effects of submersion.
• Improve your mood through reduced fear / anxiety /apprehension due to the problem.
Achilles tendon rupture
Rupture of the Achilles tendon may be suspected if an audible snap or pop is felt during sport or running activity. This is usually followed by sudden, significant pain in the calf or back of the ankle and is often described as being hit by a racquet or kicked in the back of the leg.
Approximately a third of people with tendon rupture do not complain of pain after the acute pain of the rupture has eased. Usually there is an inability to walk or continue the precipitating activity and a limp is often present. However, in some cases the person may be able to walk, as plantar flexion of the foot involves muscles other than those related to the Achilles.
If Achilles rupture is suspected, then urgent referral is needed for Orthopaedic assessment where surgical and non-surgical methods may be used as treatment.
Recovery after Achilles rupture is usually staged over a period of approximately 12 weeks depending on functional goals of the individual. An ‘accelerated rehabilitation’ approach has shown to give best outcomes where a protocol of early weight bearing is employed with staged amounts of dorsiflexion (upward ankle movement) allowed in a special boot.
Benefits of using Aquatic-Therapy after tendon rupture:
• Increased circulation due to hydrostatic pressure which can give the whole ankle area a boost and help reduce swelling.
• Offloading buoyancy effects of being in water means walking gait can be normalised quickly, and loading to the Achilles can be safely graduated.
• Functional strengthening exercises for the whole limb can begin earlier.
• Scar tissue can be mobilised, desensitised and realigned using the drag and turbulence properties of the water.
• No need to stop exercising and safely retain your cardiovascular fitness specific to your sport.
• Reduce pain due to the warm water temperature, circulatory, nervous system and hormonal effects of submersion.
• Improve your mood through reduced fear / anxiety /apprehension earlier in the recovery process.
