More On Achilles Tendons II

Traditional approaches of therapy for Achilles tendonitis include: joint and soft tissue mobilizations; concentric exercises; stretching exercises; ultrasound; ice; iontophoresis; laser; friction massage; splinting; orthotics; NSAIDs; corticosteroids; activity modification; rest; and surgery. What is interesting is that there is a gaping chasm between health practitioners on what works “best”. What I have found is the old “if the only tool you have is a hammer then everything looks like a nail” approach. Whatever your practitioner is trained in or certified in is what they will recommend AND tell you it works. Wrong! I’ve been through it all, podiatrists want orthotics & splints; physical therpaists want every exercise variation (depending on their backgrounds and certifications); orthopedists will give you drugs tell you to rest - might send you to PT and as a last resort do surgery; chiropractors think it’s linked to your posture and your back so of course you need adjustments; massage and trigger point therapists think it’s related to tight muscles and you have to have them worked on - and of course do stretching.

Of course I’m generalizing so get off my case if you know of an exception or two. I’m relating to my 30+ years of on-again off-again tendonitis/tendonosis as well as volumes of anecdotal information from runners, the research and comments from the health professionals themselves.

Achilles tendinitis is what historically has been the label for that condition affecting the Achilles tendon. However, more and more over the recent years the term Achilles tendonosis is being used. Why? Because doubt had been raised as to how much inflammation (”itis” means inflammation) is actually the culprit or involved. It is indeed a “condition of” (”osis”) the tendon. There are a number of studies of the ailment now that have found no inflammatory cells present. Chronic tendonosis is usually anything that lasts more than 3 months. I will use the terms interchangeably mostly because I’ve known it as an “itis” for so long and most people know that term best.

There was an interesting meta-study (a study of studies) done on Achilles tendon treatments. They found for the most part very poor research design for the most part. Few had valid control groups. Why is that important? It means that the selection of subjects or the use of treatments can more easily be swayed. An important error researchers can be prone to is one of bias. Researchers are prone to “getting what they are looking for”. In practice that might mean I’m a PT who does a unique combination of exercises and deep massage and so I do a “research study” to show the efficacy of my treatments. Lo and behold, my data shows that with my treatments the subjects report a 75% decrease in pain symptoms and they return to activities within 6 weeks - 2 weeks faster than conventional methods. Without controls, randomization or blinding a study (subjects don’t know whether they are the experiment group or control group) the results are simply interesting but inconclusive. There are too many other reasons someone improved under that therapy regimen. This does not mean that the study doesn’t support the claim, it might.. but the way it was conducted - it also might not. Therefore it cannot be completely relied upon.

This meta-analysis did come up with at least one interesting conclusion. Eccentric exercises (i.e. heel drops) were benficial to rehabilitating Achilles tendonosis. However, it was not effective with insertional Achilles tendonitis. This is if your tendonitis is at the insertion point on your calcaneous (heel bone).

Here is the protocol followed in most of those studies. It is called the Alfredson eccentric protocol.

Perform 3 sets of 15 reps eccentric heel drops; twice a day; seven days a week; for 12 weeks; progressively add weight and work through non-disabling pain.

What is interesting is that the authors of the meta-study could not recommend the “work through non-disabling pain” part because ethically they couldn’t do this to their patients.

I personally have not tried this treatment as outllined. I have done heel drops as part of rehabilitation along the way. A heel drop is performed like this:
Stand on a step (or anything that lets your heel drop below level). Then raise yourself up onto your forefoot (tippy toes). From here there are two variations. Two-leg or single-leg drops. You may start with the two-leg one, it’s easier. However, if you think about it, we only run on one leg at a time and so the most “running-specific” method is to do a single leg drop. Slowly, drop your heel below level until you feel a stretch. Start with body weight and then you can add dumbells or a barbell with weights for added resistance. Raise yourself up and repeat.

Now, my orthopedist advised me absolutely NOT to do these. My PT said I absolutely should do them. So again, you can see why it is so difficult for Achilles tendonosis sufferers to figure out what to do. Still nobody completely agrees. What works for one doesn’t for another.

I’m going to look into two new methods of treatment out. One is the Pro-Tec support. The other is a physical therapy treatment called ASTYM. If anyone has experience with these, I would love to hear from you.