achilles tendon

[Derrick241]

Hi,
I have a really bad problem with my achilles tendons

It all seems to have started about 4 months ago

I was doing training for a trek to Africa

I was carrying a bergen with about 45Kgs in it, I was walking on a flat surface and covered about 8-9 K's, I was wearing boots

I noticed that after my walking, my calves were stiff and my achilles tendons ached, I used ice packs on them and raised both feet

I carried on with the walking, but decreased the weight, it never improved, in fact it got worse, I used ice bandages on them while walking, it helped but not a lot

Anyway I went on my trek, my achilles tendons were still sore and stiff, but I persevered, it camer to a head when I was climbing a mountain <3000 meters>to see gorillas, I pulled a calf muscle, I had a choice, up or down, I went up (I was so close to seeing gorillas for the first time, I didnt want to let an injury stop me)

Coming down was painfull, but going down is easier than up, but I paid for it the next day, I used a compression bandage on my calf muscle, which really helped

There was a lot of walking, up and down hills, dirt tracks, grass strips, anywhere you could walk really

Anyway the trek finished, I still had problems, after a fair bit of stretching and calf raises and lowers, I could stand it no more, I was having trouble coming down stairs in the mornings

This has put paid to any serious running or walking now, I cant do either

I went to see a PT who looks after Ruilsip Rugby club

She used a ultra sound machine and deep tissue massage (so she said) it was for about 7-8 minutes on each ankle

It was a bit better afterwards, but as the day goes on it always is, a bit stiff, but I can walk without looking like an old man

I have silicon heel cups in my boots, the ones with the blue dot on them, I was told they would help with any shock when walking (I only wear boots, always have, dont own a pair of shoes or trainers) she looked at them, said they were fine

Now I have to go back on Monday, for another examination, apparently my feet arent bearing my weight, they turn in at the ankles and I may need orthotics

I have never had a problem with my achilles tendons before or walking with a heavy bergen on my back (when I was in the Falklands I carried an awful lot more and for a greater distance, my boots are better than what I was wearing then)

Is the PT really doing what she says ?

Does ultrasound really work and how ?

Does a deep tissue massage do anything apart from aggravate the injury (she called it 'frictioning')

As I sit here now, if I cross my feet over and put pressure on my achilles tendons, they are painfull and I know I am going to struggle coming down stairs in the morning

Could anyone here give me some advice on the above questions (am I going to need these orthotic things ?

Is the PT taking me for a mug ?

Is her treatment going to be effective ? (I'm paying 45 quid a visit)

Would my wife be avble to do this frictioning thing ? and could I buy/rent a ultrasound machine ?

Your views and opinions would be appreciated

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[msk101]

HI, I feel your pain and frustration. this is a lengthy reply!!
Your physio is not taking you for a mug. Essentially boots (hiking, work boots etc) are not suitable for hard track/bitumen walking and you're not the first person to develop achilles tendinopathy doing this (i have done this also - and i'm a physio- i knew better but did it anyway!).
Firstly ultrasound. The basis for this treatment is that it essentially vibrates the cell membranes (with the ultrasound waves) to speed up the metabolism which in turn can improve healing, increase metabolite exchange (bad stuff out and good stuff in). It may feel warm but should not be hot (microwaving you from the inside is not the plan!) or painful/burning etc.
Secondly Friction massage - the theory here is that if you tipped out a box of matches onto a table they'd be everwhere but if you kept rolling your finger back and forth over them in the general direction of across the matches then they would eventually all line up... this is the theory applied to the collagen fibres in tendons and if they are inflamed/torn the body tries to heal the area by laying down new collagen, and if there is a tear then the fibres are every which way, so frictions across the fibres are to try to align the fibres in the "right" direction.
So now we get onto your ongoing problem. it would be best if you did have a pair of shoes (not boots) that did not sit around the achilles area at all or at the least, like a good pair of sneakers, are well padded and soft here.
then you also need to be doing some eccentric heel drops off a step (ask your physio) as these will encourage healing with strength in the tendon. They do hurt. they will make you feel worse before better but that's ok because they work. The eccentric exercise is controlling your body weight descent against gravity. The achilles tendon is a tendon within a sheath - an outer casing which helps the tendon slide up and down when the calf muscles contract (ie. like a piston inside a cylinder where the cylinder is the sheath, there's a bit of lubricating fluid, and then the tendon which moves inside the cylinder). in cases of ongoing achilles tendinopathy there are small blood vessels and nerves that grow into the outer layer of the tendon from the sheath (they're not meant to be there) and cause ongoing pain with movement and perpetuate the irritation because they stop the tendon sliding freely within the sheath. the eccentric exercises will tear these blood vessels and nerves away (this is a good thing) but that's why these exercises will initially be painful. then your tendon should be able to restore normal movement within it's sheath and the muscles are strengthened then the chronic irritation should settle. This can take a few months. you can also use local topical anti-inflammatory creams (eg. voltaren = diclofenac sodium) either by applying a few times a day or putting a dolop on and covering it with plastic wrap and leaving it overnight. but these are NOT meant to be used long term.
So essentially. see your physio, do your eccentric exercises, get some better non-irritating shoes and your problem may take time but should settle.
good luck

msk101

[Derrick241]

Hi msk
Thanks for your reply

I have no problem with the length of any reply

I have alway worn boots, both for recreation and work and while I was in the forces, the boots I wore while I was with the forces were terrible, no padding around the ankle at all, the boots I wear now, give plenty of support and are well padded and are designed to hill, fell, walking,

I have the same make and model for at least 10 years, I have used them while running, treking, and hill climbing with no problems (just going back the four months of this year)

When at home I dont generally wear any thing, maybe a pair of 'crocks' for going in the garden, but its generally bare feet, I only wear boots when going out and doing any training, I dont think it is the boots causing the problem, because I havent worn them for a month

I follow the make up of an achillles tendon and it is like a big rubber band in a sheath, with lubrication, not really sure what causes the pain, but it feels 'tight'

The exercises I have been doing are stand on a step and raise up up my toes, hold for 10 seconds, then lower my heels until they are below the step and hold again (I'm not sure if you understand that) the sort of stretch and compress the tendon (compress on the toe raise and stretch on the heel lowers

I also put my toes on a brick (heel on the ground) and push the knee forward, I find this has stretched the tendon, do you get the idea ?

My PT told me to do calf stretches, lean against a well with one leg back and keeping my foot flat pull on my calf, I have tried it, I can feel the tension in my calf, not so much in the tendon though

Would my wife be able to do this 'frictioning' thing ?

I have been doing a bit of research on the ultrasound machines, they seem to be used a lot for cosmetic things (facial skin and for weight loss, no idea how that would work)

But could I rent/buy one ? if so what type would I be looking at ?

I was given Ibuprofen for the pain, but all that does is mask the pain, it doesnt cure the problem, I was also perscribed Feldene gel (Piroxicam) that doesnt really do much for it either

I can live with the pain, I can gauge if there is any improvement that way, but as I said, it gets less as the day goes on, I guess moving around eases the movement of the tendon in the sheath

I did have problems getting downstairs this morning as I said I knew I would

I havent noticed any improvement since I visited the PT yesterday, so I guess it will take more than one visit

Would visiting a sports massuer for a longer massage on the achilles tendon area be of any help and give any improvement ?

I remember when I used the TENS machine, it tightened and relaxed the muscle, it was painfull, but it did work, the muscle got stronger and I guess healed its self, I did have massage along with the TENS machine

I dont know if this will have any bearing on this injury, but I am 60 yrears old, used to be in the forces and USED to jump from aircraft (my akles and knees used to take a real pounding) but has never stopped my exercising and I havent suffered any problems over the years

Thanks for the reply

I really thought I would have more replies, I thought this website was for PT's to pass on help/information or even opinions, oh, well back to google or yahoo

[Judith Mollet]

Hi there, thought I'd reply as you don't seem satisfied with one answer (can't blame you really but....)

" havent noticed any improvement since I visited the PT yesterday, so I guess it will take more than one visit"

It will take more than a couple of visits and you are going to have to be patient and probably rethink your hobbies and active exercise for a good while. And it's not just the physio time spent with a physio but your re-managing everyday that will heal. Ever heard of time will heal?..physios help advise you and facilitate healing that nature provides and hopefully do the right things to make the process as optimal as possible.
" dont know if this will have any bearing on this injury, but I am 60 yrears old, used to be in the forces and USED to jump from aircraft (my akles and knees used to take a real pounding) but has never stopped my exercising and I havent suffered any problems over the years"
OK, you have given your legs a pounding and you have got away with it till 60 which is super. The training with 45k was too much. You overdid what the structures in your lower leg were then prepared to take. The Treck was done and I'm sure it was worth it but was also too much as the irritation continued and you also pulled a muscle that was really trying it's best to keep going. . This is a very individual thing in the end. Yeah, there are probably many 60 year olds who do masses of sports and get away with it. Not everybody can. (I'm only 4 years behind you and had to learn a while ago that the body doesn't take it all) So you have a problem that may sit in various structures, not just in one. 1. Any or many of your lower leg muscles can have chronic problems in function due to chronic inflammation, triggerpoints, tears at whatever level etc. 2.The fascia, which is the white membrane stuff you see in a piece of raw meat and surrounds every muscle like a sheath can become structurally changed and /or /not give the required give allowing the muscles to function. It can in fact become effectivly too tight for the muscles contained (google "compartment syndrom" even if it's not your diagnosis at present) 3. If your feet seem to turn inwards downwards or pronate special orthopaedic inner soles might be a good answer to manage them as once the bony arch and its supporting ligaments fall too much it's pretty impossible for you to regain them with exercise. Feet turned down influence knee and hip function (and more). No big deal, they just have to be the right ones for your feet made by someone who knows what he/she is doing. 4. The tendon itself can be inflamed, acute or chronic. Slightly raising the heel with the aid is OK for a start.
You have then 4 differents sorts of structures in your leg that need looking at, assessing, treating and lets say rebalancing. The structural make up of tendons, muscles, fascia, bone and ligaments is different and the treatment/mending and time span of is not the same.
Ultrasound as part of the treatment is OK but as a part only. Frictions may be OK but not for ever and ever as friction itself is aggressive and can cause in the end more problems (CAN) There are also various gentle so called Myofascial Methods which a physio can use to help soft tissue recovery and regeneration. Aggressive methods and "alot" of stretch and exercise may aggravate more than help but not being on site it's impossible to assess you online. "More" and "longer" treatment or sport massage may not help more than "less"
I'm not sure how old how experienced and how trained your physio is and can't pass judgement. You can check if the physio is a Chartered Physiotherapist and maybe somehow find out about the range of CPD he or she has done, or in what sort of situation he/she works otherwise. The Physio will be doing the best it can. Maybe another could do it better, give this one a chance (phew, earns more than me here in Switzerland!) and keep your eyes open for other ones.
"I really thought I would have more replies, I thought this website was for PT's to pass on help/information or even opinions, oh, well back to google or yahoo [/QUOTE]"

Well maybe this long answer may provide some background of understanding for you. Take it slowly, this thing doesn't do with a quick quick fix, allow the body to repair itself so that you can return to being active. And treat your body with respect, you'll want to remain active till 90 so it's worth it! regards JM

[Derrick241]

Judith Mollet

Now this is more like the reply I was hoping for
I have had 3 visits with my PT, each time its painful, but the next day, I can actually walk, he has given me a range of exercises to do to stretch and strengthen the tendons, its going well
I think my PT is in his 30's he does seem as if he knows what he is doing, he looks after Ruislip Rugby team, he was recommended to me by a guy in the gym I use
He has only used the ultra sound once, but does the frictioning each time, along with a deep tissue massage on the calfs, I'm not going to say its enjoyable, it takes my breath away
He has looked at my boots and the wear on them, he has said I wont need orthotics, but I should keep on walking, not running yet or carrying anything, and not to rush, a stroll, he reckons I will know when I can do more
I know I have used my legs a bit more than some and in some unusual ways and carried some ridiculous weights, but thats army life
Maybe the trek was a bit too much and may cost me in the long run, but seeing what I saw was worth it (you may disagree)
My mates wife is a sports masseur, she gives my legs a massage every other day (the PT says that is good) then heat packs for 10 minutes
After every walk, he told me to put on ice packs (I have told him I dont want to take the pain killers, he agrees) so far, my achilles tendons are getting more flexible, well, I can walk without pain, I have done 5k without incident, but I do stretches along the way
Incidently, I do these stretches about 4-5 times a day, I dont wear shoes or slippers around the house
The stretches I do are as follows, place my toes on a brick or step, put my heel on the ground and push my knee forward until I can feel the tendon stretch, hold for 10 seconds, then change over, I do this 3 times on each leg, it seems to be working
Then, stand on a step, raise up on both feet on my toes, so it compresses the tendon, then lower so my heel is below the level of my toes, hold for 10, then raise up, again 3 sets of 10

My PT is quite happy with the exercises I am doing, he has said, that not to expect a miracle, but it will heal in time (everyone has said 'give it time'

I am in no rush, now, I keep doing the exercises, the strolls, but I am really looking forward to putting on a ruck sack with 10 pounds in it, I know then I am geting better, then istead of just lumping it on my back, work into it, a bit at a time

Thanks again for the lengthy reply, it was really appreciated