The return to training and competition after Achilles tendon injuries

By Susanne Kroesche

AUTHOR

    Susanne Kroesche is a graduate of the German Sport University in Cologne and is currently the head of training in a sport therapy centre in Limburg, Germany. After finishing her career as a heptathlete she worked in several institutions as a therapist.

ABSTRACT

    Achilles tendon problems comprise a complex of complaints wide-spread in sport, particularly among athletes in the running and jumping events. In an accompanying article, the author provided descriptions from the current sports medicine literature of the biomechanics of the Achilles tendon, the main problems that affect it, the mechanisms at work in injuries and the factors that must be taken into account in the prevention of such injuries and conditions. Drawing on the same literature, this article addresses the rehabilitation that is necessary for an athlete to return to training and competition while minimising the risk of reinjury. The aim is to provide practical information that will be of value to therapists, coaches and athletes as they work together to plan and structure individualised rehabilitation programmes. It contains an overview of the main types of measures used in the rehabilitation of Achilles tendon injuries and conditions, including training, physical and therapeutic, conditioning, biomechanical and local pharmaceutical means. It then gives abstracts of therapeutic concepts in which these measures are employed that have been developed by five authors. The article concludes with some general advice on the design and implementation of a rehabilitation programme.

Introduction

    Part I of this article provides descriptions from the current sports medicine literature of the biomechanics of the Achilles tendon, the main problems that affect the Achilles tendon, the mechanisms at work in an Achilles tendon injury and the factors that must be taken into account in the prevention of such injuries and conditions.
    This second part address the rehabilitation that is necessary for a return to training and competition. The following sections cover the types of measures use in the rehabilitation of Achilles tendon injuries and conditions as well as the main theraputic concepts in which these measures are employed. The aim is to provide practical information that will be of value to therapists, coaches and athletes as they to work together to plan and structure individualised therapy programmes.
    It should be kept in mind that the symptoms of Achilles tendon injuries can vary from those that lead to only minor limitations on the practice of sport to those that cause major restrictions to the day-to-day activities of life. Rehabilitation programmes, therefore, must be adapted according to the individual diagnosis and the status of the injury and there must always be an emphasis on minimising the risk of follow-up injuries.

Overview of rehabilitation measures

Training measures
    If training has been determined to be the cause of an Achilles tendon injury, interruption and or modification of the contents and loading would seem to be important initial measures. The corresponding decision should be based on the degree of pain and the duration of the symptoms. In this respect, MYERSON & BIDDINGER (1995) recommend a reduction of training by 50% while PETERSON & RENSTROM (2002) and THIEL (1982) suggest a complete interruption. However, MAYER et al. (2000) point out that, generally, recommendations regarding loading are given without proper evidence.
    In cases where the training volume can be considered a reliable factor for triggering the injury, SCHEPSIS et al. (2002) advise runners to reduce volume by up to 25% of their average and then gradually increase it again by 10% per week, depending on the improvement of the symptoms. They also recommend a) temporary suspension of interval training and uphill running, b) training on soft rather than hard surfaces and c) the use of orthodic devices in the shoes (see below).

    LOHRER (1996) found that the choice of the surface for training is of critical importance. Soft surfaces such as snow or sand and uneven surfaces (grass or frozen grass) could cause movements with either inward (pronation) or outward (supination) turning of the calcaneus and must therefore be avoided. High speed running with pronatated movements on hard surfaces (concrete, asphalt) can also cause pain. WELSH & CLODMAN (1980) warn explicitly about training on indoor surfaces.

    MAYER et al. (2000) consider running speed and increased body weight, caused for example by weightlifting, to be an important risk factors for the development of Achilles tendon injuries. In the framework of conservative therapy, the suspension or reduction of such training is essential and could be compensated for by using less stressful exercises to avoid the loss of physical fitness. For this purpose, a number of authors (BRODY, 1987; ALFREDSON & LORENTZON, 2000; KLUMPER, 2000; MAYER & DICKHUT, 2002; SCHEPSIS, 2002) have found that aqua-jogging, swimming or cycling can be used. As transitional exercises towards the running movement, SCHEPSIS (2002) recommends cross-country skiing and stair climbing.
    For LOHRER (1996), the pain-causing load is a criterion for the conceptual setup of the rehabilitation programme. If the symptoms occurred for first time as the result of a sprinting or jumping load, it can be assumed that micro ruptures in single fibres of the tendon occurred. Consequently, distance running could be used as a training exercise. If the symptoms occurred for the first time as a result of low intensity distance running, it can be assumed that degenerative changes occurred. Consequently, post-recovery training could contain highly intensive exercises (such as sprints or tempo runs), because the increased muscular activity within the upper ankle joint stabilizes the functional leg axis.

Physical and physiotherapeutic measures
    According to MAYER et al. (2000), successful treatment of many Achilles tendon injuries can be achieved by applying local physical and physiotherapeutic measures. A number of other studies confirm the positive effects of such measures for the purpose of increasing the metabolism and the blood circulation. Specifically:

       •   KLUEMPER (2000) recommends ultra­sound therapy, especially for a chronic irritable condition. The longitudinal waves sent out by an ultra-sound device mas­sage the inner tissue with tensile and compressive forces. Furthermore, they provide a beneficial effect through the transformation of kinetic energy into heat.
       •   LOHRER (1996) recommends the use of diadynamic electricity ("stimulation current") for which DEUBEL et al. (1998) have determined the following effects: hyperaemia, analgesia, improvement of the cell wall permeability and re-absorption activities, normalization of the metabolism, the muscle and vascular regulation, improvement of the con­tractibility of the muscles and the regen­eration by increased blood circulation.
       •   Both LOHRER (1996) and KLUEMPER (2000) suggest treating the affected area with ice after training and, in the case of acute pain, to primarily reduce the turgor (swelling) and the incipient hyperaemia.
       •   THIEL (1982) and PETERSON & RENSTROM (2002) point out the positive effect of cooling applications, which can be applied 2-3 times per day during the acute phase.
       •   MAIER (1995) emphasises the use of heat application and hyperaemia by massage and brushes.
    According to MAYER et al. (2000), painful symptoms can sometimes be explained by an asymmetrical pull of the forces acting on the Achilles tendon. Coordinative measures on the peg top, trampoline or wobble board (see Photos 1 to 10) by using the proprioceptive neuromuscular facilitation (PNF) have been shown to have positive effects (ALFREDSON et aI., 1998; BRUCKNER & KHAN, 1993; FYFE & STANISH, 1992).
    BRUCKNER & KHAN (1993) FREDERIC­SON (1996) and GALLOWAY et al. (1992) recommend myofascial techniques, mobilizations and cross-frictional massage for the loosening post-inflammatory adhesions or scars. According to DEUBEL et al. (1998), this massage should be precisely applied above the affected area and the therapist should move his/her fingers with sufficient amplitude and depth across the direction of fibres. It is expected to bring pain relief, mobilization, a lowering of the tonus, and local blood circulation. MAYER & DICKHUT (2002), MULLER (1996) and LOHRER (1996) confirm the positive impact of cross-friction­al massage but KLUEMPER (2000) points out that pain and the risk of increased symptoms can be caused.

Conditioning measures
    MAYER et al. (2000) stated that "despite the fact that the positive effect of eccentric strength training in combination with stretching exercises for the calf muscles has been well known for many years, it has not been appropriately considered within a physiotherapeutic treatment framework."
    However, within the framework of conservative therapy, various authors do recommend measures for the improvement of flexibility and strength. These include stretching exercises for the Achilles tendon, eccentric strength training for the calf muscle and a combination of both. Specifically:
       •   SCHEPSIS et al. (2002) recommend light intensity stretching using the passive-static method. In the acute phase, it is important that the athlete does not over-stretch and thereby increase the symptoms. Stretching exercises for the calf muscles should be applied before and after training with both a bent and extended knee. It is sometimes helpful to use a splint to give dorsal flexed position of the foot over night, for six to eight weeks in order to maintain and increase passive dorsal flexion.
       •   KLUEMPER (2000) recommends stretching exercises on inclined ground, under supervision of an experienced physiotherapist. After reduction of the acute inflammatory symptoms, the use of strength training can be considered.
       •   MYERSON & BIDDINGER (1995) suggest using the isometric method and to develop the load progressively.

       •   The use of electro-stimulation at an early stage with a following transition to isotonic and, later on, eccentric strength exercises is recommended by SCHEPSIS et al. (2002).
       •   The use of eccentric strength training for the calf muscle seems to be especially effective. ALFREDSON et al. (1998) con­ducted a study with 15 athletes and a control group of similar size (following a conservative therapy). The athletes applied highly intensive eccentric strength training. Almost all were free of pain after 12 weeks. It is assumed that either the effect of the stretch respective to the extension of the muscle-tendon unit with a lowering of the muscle tension or the hypertrophy and the increase of the tensile strength caused the effect. Moreover, eccentric strength training possibly causes structural changes within the tendon.

    According to SCHEPSIS et al. (2002), such training measures as mentioned above should be accompanied by anti-inflammatory medications and ice massage. It is also important to keep in mind that any immobilization phase is kept as short as possible to avoid potential atrophy (NICOL et aI.1991).
 

Biomechanical measures
    It is known that the type or the state of the shoes worn can affect the biomechanics of Achilles tendon function during the running stride, which impacts both injury causing factors and rehabilitation. LOHRER (1996) mentions that old and used shoes can force a latent compensating movement, while stable shoes could force the foot into unwanted movements. Therefore it is recommended that athletes change shoes frequently with the occurrence of achillodynia.
    Previously GOLLHOFER et al. (1984, 1987) had reported that over the course of an athlete's career the musculoskeletal system adapts to specific shoe types, even brands. However, MAYER et al. (2000) point out the vagueness about the extent to which the construction and form of a shoe cause the symptoms of achillodynia. Differ­ent publications assume increased pronation during running, which is not proven in all cases.
    A number of authors have found that biomechanical measures, such as use of orthodic devices or shoe inserts, correct inappropri­ate movements of the foot that may lead to Achilles tendon injury or prevent recovery (CLEMENT et al., 1984; GROSS et aI., 1991; JORGENSEN, 1990; MYERSON & BID­DINGER, 1995; SEGESSER, 1995, LOHRER, 1996; WEN et al. 1998).
    However, LOWDON et al. (1984) found that the use of visco-elastic orthodic inserts is not always advantageous. They can lead to uncontrolled movements after the landing phase of each stride, which could intensify rather than reduce achillodynia. Moreover, DIXON & KERWIN (1998) have identified three different types of runner characterised by the touch down in the landing phase of each stride ("ball", "metatarsal" and "heel" runners). When an orthodic device is used, the mechanical loading for the Achilles tendon (especially because of important changes of the leverages) is counter productive for metatarsal and heel runners.
    Apart from shoes and orthodic devices, muscular deficits and imbalances should be addressed by training of the leg axis using exercises close to the characteristics of the discipline technique (LOHRER 1992, 1996). MAYER et al. (2000) seems to agree, stating that the influence of mechanical elements might not be as important as the change of muscle function through proprioreception.

Local measures
    The main local measures for treating Achilles tendon problems consist of antiphlogistic therapy, using tablets or through transdermal administration. Mostly these are measures that are applied when the first symptoms occur.
    For transdermal administration many authors (JUNGMICHEL & NAWROTH, 1989; MAIER, 1995; LOHRER, 1996; MULLER et aI., 1996; KLUMPER, 2000; SCHEPSIS et aI., 2002) recommend the application of creams. Taking into account that the pharmacological effect could be limited due to an insufficient absorption, creams contain­ing steroids have shown positive effects because of the superficial location of the Achilles tendon (MAYER & DICKHUT, 2002). However, GALLOWAY et al. (1992) state that nowadays treatment with steroid addi­tives can no longer be considered as a meaningful alternative. According to LOHRER (1996), if symptoms have been persistent over several months and other therapies have not shown success, starting a serial infiltration therapy using a highly dosed glucose solution should be considered.
    Both LOHRER (1996) and KLUEMPER (2000) recommend deep skin x-ray radiation for anti-inflammatory purposes. However, even if this method has shown satisfying results, the disadvantages of high dosages of radiation may be too great of a disadvan­tage and this method does not seem to be popular with therapists.
    For many authors the application of cortisone medications for achillodynia is seen as critical (KRAHL & PLAUE, 1971; EHRSAM, 1974; HUDLER et aI., 1983; ALFREDSON & LORENTZON, 2000; ULREICH et aI., 2002). An injection with corticoids could be consid­ered for reducing pain, but it could also sup­press the necessary regeneration processes. For this reason, the injection of corticos­teroids frequently leads to Achilles tendon ruptures (KLUEMPER, 2000). According to ASTROM (1998) a retrospective study of 342 patients with chronic tendopathy showed that injection with corticosteroids led to a certain predictability of partial ruptures. LEPPILATHTI et al. (1991) report that of 150 patients undergoing Achilles tendon operations, 72 were previously treated with corticosteroid injections. However, ALFREDSON & LORENTZON (2000) raised concerns about this finding, saying a cause­effect relationship could not be shown. In any case, it does not seem to be logical to apply corticosteroid injections if there is no clear indication of an inflammation.
 

Overview of therapeutic concepts

    There are, in fact, only a few programmes that specifically address the treatment of achillodynia. Most of the published pro­grammes focus on rehabilitation after Achilles tendon ruptures (EHRICH & GEBEL, 1992; STEININGER & BUCHBAUER, 1994; SCHULTE-FREI, 2003; EHRICH & GEBEL, 2000). However, the main principles of these could also be used for specific programmes for achillodynia.
    In this section, the therapeutic concepts for treatment of Achilles tendon injuries developed by five prominent authors are outlined. The concepts each share the aim of full rehabilitation of the Achilles tendon and a return to training and competition. More specifically, they also share the following objectives:
       •   preservation and recovery of the sport performance ability
       •   acceleration of the healing process
       •   prophylaxis of an acute relief syndrome and other subsequent damage
       •   compensation of irreversible damages
       •   development and improvement of the intrinsic cognition of the body and senses
       •   deceleration of the reduction of physical and mental abilities
       •   prevention of new damage
       •   increase of individual motor control abilities
 

BRENKE et al.: Rehabilitation of achilfodynia from a sport therapeutic perspective
    For BRENKE et al. (1979), an absolute immobilization for the treatment of achillodynia is not necessary, because a break in training would lead to an involution of the vascular system within the Achilles tendon and consequently a loss of optimal blood circulation (see also FRANKE, 1977). Therefore, the authors recommend the maintenance of cardio-vascular capacities through swimming, cycling and ergometer. It is recommended to not apply any runs, jumps or strength training exercises that would require intensive plantar flexion. The duration of the programme depends greatly on the degree of the injury and has to be adapted individually.
    In swimming, the crawl stroke and the dolphin kick are optimal. This is because in the active phase of leg extension the Achilles tendon is not affected, as the plantar flexion of the foot is performed mostly passively. Fins could be used to increase resistance with a corresponding strengthening effect, provided the athlete is already symptom­free. In cycling and ergometer training, only the heel or the metatarsal should be placed on the pedals. With increasing recovery, the foot placement can be changed towards the ball of the foot. The resistance should be set between 1 - 2.5 watt/kg. It is advantageous to cycle with higher number of revolutions because of the positive cardio-vascular effect.
    In addition to the cardio-vascular training, gymnastics in sitting or lying positions should be used, particularly exercises that involve major parts of the body (e.g. abdominals, back, extensor and flexor loops) are helpful. Exercises for strengthening the legs to avoid atrophy are also recommended. In particular, the shin muscles need to be trained (see Photo 11), as the muscle dysbalances between them and the ankle muscles are frequently an important factor for the occurrence of achillodynia (consistent one-sided pull). A period of up to 10 days with low stimuli before returning to a reduced regular training is recommended.

ALFREDSON et at.: Eccentric calf muscle training for the rehabilitation of Achilles tendon injuries
    From the initial experience that ALFREDSON et al. (1998) made with eccentric calf muscle training after Achilles tendon ruptures, they tried to adapt the findings to a concept for therapy of other Achilles tendon condi­tions, especially tendinosis. Their main objective was to observe the effects of highly intensive eccentric calf muscle training on achillodynia symptoms. It is interesting to note, that up to this point, with one exception STANISH et al. (1986), there were no empirical data available for this kind of therapy concept. The therapy concept ALFREDSON et al. arrived at featured a high degree of efficiency, a simple set-up and low efforts.
    A group of 15 athletes autonomously performed such strength training twice a day, seven days a week for 12 weeks in total. Running was permitted during this period, provided there was no pain or very low pain. Therapists controlled the process regularly. Two types of exercises were used. In both exercises the initial position was in the toe-stand (heels up), which was achieved by the healthy leg. While the injured leg performed the exercise without strength effort, the healthy calf muscle was loaded in two different ways. Lowering of the heels a) with an extended knee and b) with a bent knee (to active the m. soleus) (see Photos 12 and 13). Each exercise was performed with 15 repetitions and three sets, with slow speed. The athletes were told that during the first two weeks they could expect pain in the trained muscle group. In the beginning the intensity for the injured leg resulted from body weight and during the eccentric phase only. No concentric contraction was performed. The athletes were told to stop if the pain was perceived as too high. When the pain level became less, additional weights were increasingly applied. Later on, a strength­training machine was introduced to apply higher weights.

    The result of this study was interesting. The effect of the eccentric strength training was measured on a visual 100mm scale on which the athletes (and a control group) estimated the pain in the affected Achilles tendon. The experimental group showed a significant reduction of pain (P<0.0001), measured from week one to week 12. All the athletes in this group returned to train­ing after three months and were able to come back to regular training loads. Within the control group with conservative therapy, no treatment was considered success­ful. All members eventually needed an operation

SCHULTE-FREI: Training therapy for injures to the Achilles tendon
    This concept, developed by SCHULTE­FREI (2003), is divided into four phases. In the first phase the status of functionality and abilities is evaluated. It is very important to identify the acute symptoms (pain, turgor) and to treat them with physiotherapeutic and physical therapies. Water treatment is also recommended to increase blood circulation. Another focus is on the proprioception, to lay the foundation for further coordinative stimuli. Aerobic training using ergometer, upper body ergometer and water training (aqua jogging, swimming) is the third main focus. According to the authors, the primary goal of this phase is the "facilitation and the innervations of the entire muscle groups in the lower leg and foot, including the improvement of the cognition and balance abilities."
    In the second phase, when pain and turgor have significantly reduced, it is possible to increase the load. The use of endurance and strength diagnostics is recommended. Isokinetic testing should use predominately isometric and dynamic assisted methods. The muscular abilities can be developed until strength endurance loads can be performed without pain. Here also, isokinetic training is advantageous, because of the possibility to steer training loads more precisely and have stable positioning during the exercise. Training the senso-motor abilities is also a focus, especially balancing exercises. First training of reaction, including discipline specific movements, should be performed in the safe environment of water.

    The third phase is characterised by an additional increase of the load. The treatment of the acute symptoms is completed and the new foci are a) coordination and balancing training and b) strength training. Within the coordination training, the load is increased again, while the security measures are reduced by degrees (e.g. wobble board without hand support). In the strength training, the major emphasis is on the development of intermuscular coordination and hypertrophy training (see Photos 12 and13).

    In the fourth phase it is expected that the athlete will be released back into daily life and training, equipped with an individual training programme. In most cases, however, both therapist and athlete neglect this phase, which includes risks for the transition period back into training. The athlete should follow his/her individual programme for an extensive period, to allow the adap­tation processes to take place. An exit diagnostics should ensure the adaptation progress.
 

FREESE: Training therapeutic measures for Achilles tendon injuries
    FREESE (2001) recommends interrupting training until the inflammation has subsided. When absence of pain is achieved, intensive stretching should be introduced (see Photos 14 and15). Strength training for the dorsiflexors of the foot (e.g. m. tibialis anterior) is complementary. Jumps should be avoided until walking, running and stretching can be performed without pain. The long-term therapy includes a number of measures designed to avoid future injury (see Table 1) A close cooperation between athlete, coach and therapist is necessary to identify the reasons for the symptoms.

EHRICH & GEBEL: Build-up training after Achilles tendon injuries
    EHRICH & GEBEL (1992) also divide their therapy concept into four phases - Mobilization, Stabilization, Functional and Muscle Loading - and have elaborated specific training contents for each phase (see Tables 2 a - d).

    In the first phase, the focus is on basic mobilization of the ankle joint using exercises for walking (on mats), isometric exercises for strengthening of the calf muscles, and cardio-vascular training on ergometers.
    In the second phase, the focus is on improvement of mobility of the ankle joint and the strengthening of the calf muscle, both of which are achieved through an increase in the complexity and intensity of the exercises. In this phase, the return to the normal walking movement is given more attention.
    The aim of the third phase is to achieve control of the roll-off movement of the foot of the injured side. Cardiovascular and stretching exercises are also continued.
    In the fourth phase, the stretching exercises for the lower leg muscles are intensified (Photos 16-18), runs with changes in direction (and rotational movements) and jumps are introduced.

Final notes

    Before any therapy concept is applied a thorough review and analysis of the case is essential. This includes the athlete's medical history, acute health status as well as analysis of his/her training, technique and performance abilities. It is very important to dedicate enough time to find out what factors could have influenced the occurrence of the symptoms. For this aspect, cooperation between the therapist, coach and the athlete is critical.
    Keep in mind that the training loads within the programmes will always be individual but they should follow the guidelines and care should be taken to avoid counterproductive overload. The various adaption times for the different organ system also need to be considered in planning. For example, muscular structures adapt much quicker than tendons, ligaments or bones.
    The expected results of the therapy should then be developed together with the athlete. His/her wishes, expectations and individual disposition will strongly influence the motiva­tion to follow the programme and its success. Understanding of the problem and the set-up of the therapy concept requires educational efforts from the athlete's whole environment.

FROM: IAAF/NSA 3.2009