Monday, July 12, 2010

Achilles Tendon Injury – Seeing the bigger picture

Treating the Achilles tendon requires a complete history and biomechanical analysis, removal of any restrictive adhesions, and implementation of effective exercises. The biomechanical analysis, or determining which structures in the kinetic chain are involved, is extremely important. From patient history and subjective findings it will be easy to figure out where it hurts, but not where the source of the problem is coming from.

Biomechanical analysis

Biomechanical analysis is essential in determining which areas of the patient’s kinetic chain must be addressed. Through the observation of abnormal motions in a person’s gait we can discovered key links on what areas to treat and what areas on which to focus our exercises programs. Consider the following two motion examples; abnormal plantar flexion and abnormal or restricted knee flexion, and how they could be related to Achilles tendon problems:
Abnormal or Restricted Plantar flexion (Calf raise action ) - The action of Plantar flexion is performed by these muscles.
  1. Triceps Surae
  2. Peroneus longus
  3. Peroneus Brevis
  4. Flexor digitorum longus
  5. Flexor hallucis longus
  6. Tibialis posterior
Plantar flexion is a downward movement of the foot (calf raise). The strongest muscle group of your leg, the Triceps Surae, performs much of the action of plantar flexion. The Triceps Surae is formed by the Soleus (deepest calf muscles) and the Gastrocnemius (Superficial double headed calf muscle). Both these muscles form the Achilles tendon, which attaches to the posterior surface of your heel bone (calcaneus).

When these muscles contract, or shorten, they pull your heel bone up, and push your toe down (calf raise – plantar flexion). Therefore, pain or abnormal motion during this action is often directly related to these key structures; but not necessarily, because these structures are also affected by knee function and stability.

Consider this; the Gastrocnemius muscle crosses three joints – the knee, ankle and subtalar joints. Any alteration in the function of these joints will have the effect of increasing tension on the Achilles tendon.

Abnormal or Restricted knee Extension - The action of knee extension is performed by these muscles.
  1. Quadriceps
  2. Tensor Fascia Latae
  3. Gluteus Maximus
If you are unable to fully extend the knee without stress, perhaps due to restrictions in the hamstrings (knee flexor antagonists), you will develop considerable tension in the Achilles tendon. This is because a hamstring restriction creates calf muscle restrictions, which directly tightens the Achilles tendon.

It is not that hard to see how a restriction in one area can cascade into multiple restrictions. The key to resolving Achilles Tendonitis is to remove all these restrictions along the entire kinetic chain, not just at the point of pain.

Your treating practitioner must consider the primary muscles performing the action, antagonist muscles and synergist muscles. Problems in any of these muscles can create abnormal motion patterns which perpetuate injuries. Many practitioners do not consider these relationships and only treat the symptomatic area. This will lead to minimal short term results with the injury often returning. For example consider a problem with the Quadriceps. In this case each related muscle must be assessed and treated if necessary.

Quadriceps as primary mover:
  • Acts as powerful extensor of the knee, and extensor of the hip
Quadriceps synergists:
Quadriceps Antagonists:
Manual therapy (Active Release, Graston, Massage Therapy, Fascial manipulation) is very effect at doing this, but it will take someone trained in biomechanical analysis to determine all of the areas that are involved.
The location of these restrictions, or weak links, will vary from person to person. Three individuals may have the same diagnosis of Achilles Tendonitis but the areas of restriction will often be completely different.

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