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Intro: What do Jumper's knee, Tennis elbow and Achilles heel have in common? They are all injuries or painful conditions that relate to tendons and until now have posed taxing for physios worldwide to cure.
There is new hope on the horizon Tendons are bands of collagenous tissue that attach the muscle belly to the bone. This tissue contains small nerve transmitters that constantly provide the brain with information that is essential for balance and joint positioning. Embedded in a jelly-like ground substance, tendons look white and shiny when they are healthy, and can stretch to a maximum of eight percent of their length, taking the load of the contracting muscle and pulling on the bony surfaces to create movement. Any more stretch and rupture becomes a potential reality.
The Achilles tendon that attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneum) is the most common area to be affected. It is the largest tendon in the body and contains a spiral of fibres ('the spring in our tail'), which offer shock absorption but also rather poor blood supply.
Many athletes and sports enthusiasts suffer pain and stiffness in this tendon. This pain is not necessarily connected with a specific injury, but can occur gradually, arriving niggling in the background and slowly worsening until you end up with tender, swollen Achilles tendinitis. Unfortunately, this condition does not respond to the usual treatment of anti-inflammatory medication, ultasound and rest that normally helps with acute soft tissue strains and sprains repair.
Before I get to the solution to the problem, I need to clarify that we don't call the condition 'tendinitis ' anymore. This term suggests that there is inflammation in the tendon tissue, in other words that the whole area is full of inflammatory chemicals and cells. Thanks to intensive research by Professor Jill Cook, physiotherapist at La Trobe University's musculoskeletal research unit, we now know that it isn't the case.
This is what actually happens: injury or overload activates tendon cells called tenocytes. These try to patch up the damage by producing more ground substance or fluid, which causes the whole area to swell. This, in turn, separates the collagen fibres, weakens the tendon and causes a loss of normal blood supply which leads to pain. Not a pretty picture. Jill describes it as a 'failed healing response' or even degeneration and has encouraged all physios and doctors to use 'tendinopathy' as a true desciption of the condition.
She travelled to New Zealand late last year at the request of the Taranaki Sports Medicine group to give a speech on her latest research establishing better tendon treatments and therefore better outcomes for sports enthusiasts, helping them back to pain-free action. Jill has personally rehabilitated many national-level basketballers with Jumper's knee - a tendinopathy of the patella tendon. She emphasises that tendinopathy is not age related but it tends to be more severe in the older athlete.
So how, according to Jill, does one get to the root of this evil? Gone are the days of resting up, she says. Deep massage of the area, ice and stretching are valid and effective in getting the blood flowing again. However, the most important treatment for the achilles and any other problem tendons (be it in the shoulder or knee) is a good biomechanical assessment to check posture alignments. In the lower limb the orthotics need to be assessed. "The whole kinetic chain (in other words our movements) has to be looked at from the pelvis muscles down to the ankle. Even analysing long bone alignment (tibial/femoral torsion) is important if an effective treatment regime is to be implemented."
And even once assessed, treatment isn't easy. If the tendon pain has been grumbling for more than a few weeks the body starts to adapt to different movement patterns and becomes unbalanced very quickly. Says Todd Wolfe, a physio registered with the sports academy of NZ who attended Jill's weekend lecture: "The biggest problem I have is convincing people that they will have to work at exercise daily and that it will take in excess of three to six months (sometimes up to nine) of hard graft before they will be back on the field… and they have to put up with the pain too!"
During the lecture, Jill provided some practical rehab strategies hot off the press. For candidates with Achilles tendinopathy she prescribes a daily regime of biomechanical balancing exercises involving the whole limb and specific 'eccentric' exercises aimed at the tendon. An eccentric contraction of a muscle is one that maintains tension but lengthens, as when one lifts up a weight during a biceps curl, then lowers it down again slowly. This type of exercise, when applied to a 'sick' tendon, encourages increased collagen deposition and better tissue repair, thereby improving strength. The energy-absorbing capacity of the whole limb is also improved. Joint stiffness at the ankle is another issue that needs to be addressed.
There is a need to personalise each treatment programme, as each tendon is unique, has an individual history and presents with its own pain pattern. Having said that, Alfredsson and his colleagues in Sweden have come up with a tried and tested regime for the Achilles that has stood the test of time as well as research endorsed by Jill Cook. The emphasis is eccentric calf raises using both muscle belly contractions of gastrocnemius and soleus, building to 180 reps per day through pain! Pain does reduce after four weeks and under the guidance of a physio strength, neuromuscular pathways and motor pattern retraining all occur in the first three months of treatment. Exercise load is slowly added, building up to dynamic exercises and sport-specific training.
One Achilles-related success story I have witnessed in my practice is Howie Tamati. Although not 100 percent as fit as in his heyday as a top NZ rugby league player, he still dedicates much time to an active lifestyle by playing touch, golf and cycling. But it all came to a grinding halt six months ago, due to the recurrence of an Achilles tendinopathy. "In the past I used to just train through the pain and even had an operation, but this time it happened gradually with just a minor knock and niggling pain after touch," Howie says. "It got worse and worse until I was hobbling around for at least an hour after getting up in the mornings and had to stop all sport. I didn't believe that the exercise would work after such a long time and having suffered so many injuries, but I am back on the field. Okay, so I'm not as fast as I used to be… but maybe that's just age!" (Howie is in his early fifties.)
Although age is not a risk factor for tendon pain, previous calf strains are and the peak incidence of Achilles rupture is between age 30 and 50. Prevention is still and always will be the best option so check your training schedule and beware of 'too much, too many, too hard, too soon'. Also make sure your footwear, equipment and training surface are adequate. Genetics and athletic ability play a small part, but the best you can do is not stubbornly soldier on. Achilles tendinopathy will not get better on it's own. Seek the advice of a physiotherapist - the sooner the better your chances will be for a speedy recovery, a healthy tendon and the joy of exercising without pain.
