What is Achilles Tendinopathy?
The Achilles tendon is a tendon that connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Achilles tendinopathy is an overuse issue that results in an inflammation of the Achilles tendon and its surrounding soft tissue.
How can it occur?
Achilles tendinopathy is usually rooted in compromised stabilization of the back foot, related to complex muscle dysfunction of the muscles responsible for this stabilization. As a result of this muscle dysfunction, the foot will not be properly stabilized and the heelbone (calcaneus) will roll inwards. This places an increased mechanical load on parts of the tendon, causing overuse inflammation. Muscle dysfunction can seriously affect leg alignment and stabilization and is an important contributing factor to knee injury and overuse issues concerning the lower extremities. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. They can therefore be referred to as “functional dysbalances”. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with dance injuries. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy. The increased amount of stabilization work needed to compensate for leg length discrepancy will overcharge different groups of muscles. The peroneals – a group of two active foot stabilizers on the lower leg – are often affected. With impaired function of the peroneals, both active leg and foot stabilization will be affected and overuse symptoms can arise in the back foot. What are the typical symptoms of Achilles tendinopathy? Achilles tendinopathy may cause aching and burning pain especially after periods of rest. The pain may improve slightly with initial activity, but often will become worse with further activity. The Achilles tendon may be tender and swollen, typically in an area of 2 to 6cm above its insertion on the heel, a zone that due to its anatomy has a poor blood supply.
How can an Achilles Tendinopathy be diagnosed?
Your doctor will examine your lower leg and ankle and review your symptoms as well as your current training activities. He will check your foot statics and test the active stabilization of the foot. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of Achilles tendonitis is often challenging and your doctor may ask a specialist in manual medicine for his opinion. An ultrasound or MRI scan may be necessary to reveal structural changes of the Achilles tendon in chronic or very acute cases.
This MRI scan shows an inflammation of the Achilles tendon. The tendon has already thickened significantly, witch is a typical sign for a chronic inflammation.
What are the treatment options?
If you have severe or constant pain in your Achilles tendon, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
Wearing the right kind of shoes outside the studio is very important. Choose comfortable shoes that have a stable foot bed and a good support of the heel. Floppy shoes and all kinds of “natural running” shoes may worsen the pain because they provide little to no stability to the foot. Custom orthotics (shoe inserts) may be helpful in some cases to support the foot.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations. Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine. Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Shock wave therapy as well as injections of autologous platelet rich plasma (PRP) are advanced (and relatively costly) treatments available to promote tendon healing. Your doctor or a sports medicine specialist will advise you if they are a good option in your case.
Do you have acute Achilles tendon pain and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Flexibility training: Achilles tendon release, Foot release, Professional calf and foot release, Deep back release, Rectus femoris release, Psoas release, Piriformis release, Compex “DECONTRACTURE” program (peroneal muscles)
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.