Self-care for the client/patient
Self-care (and therapist assisted) stretch for the soleus. Permission: Joseph E. Muscolino. The Muscle and Bone Palpation Manual, 2ed (2016), Elsevier.
Self-care for the client/patient during the acute stage is RICE: rest, ice, compression, and elevation. Of these, rest and ice are most important. Icing should be applied until the area is numb and then removed. Flexible gel ice packs are best, especially when the pack needs to contour to the client’s/patient’s body. For client/patient comfort, a paper towel or thin cloth towel should be placed between the pack and the client’s/patient’s skin. The client/patient can also stretch and if possible strengthen the opposite-side triceps surae for the neural cross-over effect.
During later stages of treatment, moist heat and stretching are extremely important so that the area does not heal with excessively tight muscle tone, myofascial trigger points, and myofascial adhesions. Instruct the client/patient on how to stretch into ankle joint dorsiflexion, both with the knee joint extended (for the gastrocnemius) and flexed (for the soleus). One effective method is for the client/patient to stand near a wall with one foot forward with the knee joint flexed and the other foot in back with the knee joint extended. In this position, the soleus is stretched in the front limb, and the gastrocnemius is stretched in the back limb. It is important for the heels to remain flat on the floor. And, proper consultation about the shoe wear is important if the client/patient has Achilles bursitis.
During the chronic stage, activity can be gradually reintroduced, as long as it is done incrementally in baby steps. It is also extremely important for the client/patient to warm up extremely well before working out. The best form of warm up involves active/dynamic stretching so that local circulation of fluids (blood, lymph, and synovial joint fluid) is increased, muscles are stretched and contracted, and neural patterns for movement are facilitated. After the physical activity is completed, then the client/patient can perform static stretching if desired.
Medical approach
The typical medical approach to Achilles tendinitis is RICE. Anti-inflammatory medication is often prescribed; this might be non-steroidal (NSAID) or steroidal (cortisone/prednisone). If there is a fear of rupture, an MRI will usually be ordered. If a rupture is found, surgery is performed. After surgery, the client/patient must wear a brace for approximately 6-8 weeks to immobilize the ankle joint and allow the tissue to heal. After that time, physical therapy is usually prescribed.
Rolla is a 43-year-old computer software designer who led a sedentary life until recently when she decided to begin a physical fitness program. Without any warm up, Rolla began walking two miles each day at lunchtime. Within two weeks, she began to notice mild pain at her back of her right ankle, but she continued walking hoping that it would go away. After another two to three weeks, the pain had increased and was occurring whenever she walked, both for exercise and during the activities of her daily life. She was also experiencing pain up into her right calf. She decided to consult a massage therapist who works orthopedically.
Upon examination, the therapist observed swelling at her right Achilles tendon. The area was warm to touch and pain was elicited with moderate pressure. Any attempt by Rolla to actively plantarflex her foot against resistance brought on immediate pain, as did passive and active ankle joint dorsiflexion. The pain on dorsiflexion was worst when her knee joint was simultaneously extended. The Achilles tendon pinch test performed was positive and the triceps surae squeeze test was negative. The therapist assessed Rolla as having a moderate case of Achilles tendinitis.
The therapist performed a few minutes of gentle distal-to-proximal effleurage strokes along the Achilles tendon on both the medial and lateral sides, followed by moderate depth work into the triceps surae musculature. He then performed gentle stretching of the foot into dorsiflexion, first with and then without the knee joint flexed, and finished working the area by icing for approximately five minutes. Because Rolla was limping, the therapist decided to work the remainder of her right lower extremity, her left lower extremity, and her low back. The therapist also stretched the left triceps surae group with the purpose of creating some neural cross-over inhibition of the right side triceps surae musculature. At the end of the session, the therapist returned to the right Achilles tendon and triceps surae musculature and repeated the soft tissue manipulation, stretching and icing.
The therapist gave Rolla self-care advice regarding icing and continuing to stretch her right-side calf, and cautioned her to try to minimize her walking until the discomfort and swelling decreased. The therapist also recommended a treatment frequency of once per week for the first four weeks while the injury was acute, and then to increase the frequency of care to twice per week once the acute inflammatory stage had passed.
The therapist continued with the same treatment approach, but very gradually increased the depth of pressure and the amount of time spent working on the right Achilles tendon and triceps surae musculature as the inflammation subsided. By the fifth week, because the acute strain was well healed, the therapist increased the frequency of care to twice per week and transitioned to working with moist heat and deeper pressure into the region: cross-fiber work into the tendon and short deep strokes into the bellies of the musculature. The intensity of the stretching was also increased. The goal of the therapy was aimed at decreasing global tightness, myofascial trigger points, and fascial adhesions that might have formed during the acute stage.
Rolla was also able to carefully begin walking again, this time beginning with a shorter distance, approximately ¼ mile, and then gradually over a period of many months increase the distance walked toward the original goal of two miles per day.
