The Achilles tendon may become acutely or chronically injured. There are different levels of the Achilles tendon that may become injured.
Levels of Achilles Tendinopathy
Midsubstance Achilles tendinopathy occurs at the watershed area of the tendon. This area has poor blood supply, which makes it a tough area to heal. A tight calf muscle can restrict range of motion, and initiate Achilles tendonitis. Insertional Achilles tendinopathy occurs where the tendon inserts into the back of the heel bone. Treatment protocols are similar to midsubstance Achilles tendinopathy.
Therapeutic exercises, such as voodoo flossing and dynamic contracture therapy, can free up tight knots in your calf muscle (aka trigger points). Once you free up these knots, stretching can be more effective. Incorporate eccentric calf raises in your daily rehab routine. Non steroid anti-inflammatories (i.e Ibuprofen, Aleve) should be avoided. These medications disrupt healing of the injured tendon’s collagen. Poor healing will result in less resilient, more injury prone tissue. Contrast baths are recommended during the healing process.
Changes in the tendon collagen’s structure will occur in chronic Achilles tendinopathy. Clinically, the tendon will appear thicker when compared to the healthy tendon on the opposite leg. Ultrasound can also confirm tendon thickening.
Calf tightness and ankle range of motion will be evaluated during your initial consult. We will discuss eccentric calf exercises, as well as other therapeutic exercises.
Radial Pulse Shockwave Therapy is a non-invasive treatment modality that delivers high frequency mechanical energy to tissues in order to stimulate blood flow and growth factors to the injured area. Platelet-rich Plasma (PRP) injections are offered to help stimulate healing by bringing growth factors to the injured tissue (learn more about Regenerative Medicine).
Surgery may be necessary for insertional Achilles tendonitis if a large spur develops where the tendon inserts to the bone. Simply removing the spur and any unhealthy tissue from the Achilles will alleviate symptoms. Surgery is less common in the midsubstance area of the Achilles tendon. However, removing areas of thickened, degenerative tendon is a viable option for chronic tendinopathy.
Chronic ankle instability can result after ankle sprains. The #1 predictor of an ankle sprain is a history of a previous ankle sprain. Patients often present to clinic complaining about an ankle sprain, or instability (i.e. the ankle giving out). For conservative treatment, bracing, as well as strength and proprioception exercises are recommended. For the unstable ankle that fails conservative care, there are excellent surgical options to stabilize the ankle.
Proprioception training for your injured ankle ligaments is paramount to restoring stability. Various ankle stabilization exercises can be seen here. An over the counter ankle brace is recommended while walking on uneven terrain. Ice after activities to reduce pain and swelling. Strengthening your peroneal muscles can aid in ankle stability if the ligaments are stretched or torn.
If conservative treatment fails, surgical intervention to provide structural stability of the ankle is warranted.
Every joint is surrounded by a capsule which contains synovial fluid. If a joint capsule becomes inflamed, it is termed capsulitis. Capsulitis can occur at any joint in the foot or ankle. It is most commonly seen in the metatarsal phalangeal joints or the ankle joint. The metatarsal phalangeal joints are relatively small, and sustain a lot of impact during propulsion. Capsulitis can be painful and debilitating. As we age, the fat pat under the ball of our foot wears down, and is unable to absorb shock. As a result, the metatarsal phalangeal joint capsules take on a lot of the load and can become inflamed. Symptoms are worse when patients are barefoot.
Shoes help to absorb the impact on the lesser metatarsal phalangeal joints. Evaluate your shoes to make sure that the forefoot padding hasn’t worn down. Ice for swelling and pain relief. Low impact cross training is recommended until symptoms subside. If symptoms don’t improve, seek medical attention.
Platelet-rich plasma (PRP) injections are offered during your initial consult. PRP suppresses inflammation, and promotes healing (learn more about Regenerative Medicine). Corticosteroid injections are also offered to decrease inflammation and pain. Custom orthotics with a metatarsal pad to offload the affected area is recommended. Patients can expect to return to full activities once symptoms subside.
Neuromas develop from pressure applied to a nerve, which results in enlargement of the nerve tissue. Neuromas are most commonly seen in the forefoot and more specifically between the 3rd and 4th metatarsals (aka Morton’s neuroma). The intermetatarsal nerve can become injured if the metatarsal heads are too close together, causing impingement of the nerve. This can occur if the metatarsal heads are anatomically position too close together, or if the heads shear against each other during gait. Neuromas are most painful in shoe gear since the nerve is getting compressed between the metatarsal heads.
Avoid shoes with narrow toe boxes. You will likely find relief while barefoot.
The entire foot will be evaluated during your initial consult. X-rays will be performed to evaluate the anatomical position of the metatarsal heads and to evaluate for any other potential causes of pain. An ultrasound guided corticosteroid injection can help reduce inflammation within the neuroma. If conservative treatment fails, surgical removal of the neuroma is warranted. This is an outpatient procedure that allows you to be weight bearing immediately after surgery. Since a large portion of the nerve is removed during surgery, patients should expect numbness to the toes that were receiving sensory input from the nerve. Nevertheless, patients can expect complete resolution of their pain.
Plantar fasciitis occurs when there is increased tension and resultant micro tears of the plantar fascia at its origin. There is a localized point of tenderness on physical exam. Symptoms may include increased pain with the first few steps upon getting out of a lying or seated position. Pain may or may not subside throughout the day. Typically the pain will persist until appropriate conservative therapies are implemented.
Home physical therapy is the first line of treatment. This includes various stretching and mobilization activities. Voodoo tissue flossing is a great modality for breaking up tissue adhesions in the calf and hamstring. Foot strengthening exercises exercises are highly recommended. Non steroid anti-inflammatories (i.e Ibuprofen, Aleve) should be avoided. These medications disrupt healing of the injured tissue, and sets it up for future injury. Contrast baths are recommended during the healing process.
We take a top down approach when treating this condition. Often times the calf and hamstring are the culprits leading to biomechanical asymmetry and subsequent strain on less resilient structures of the foot (i.e. the plantar fascia). Additionally, weak glutes can lead to gait disturbances. Rather than just treating the symptom, (i.e heel pain) we address all lower extremity weaknesses that could potentially lead to faulty biomechanics.
X-rays are always recommended to evaluate for possible boney pathology. Cystic changes in bone, as well as stress fractures can mimic plantar fascia pain. Ultrasound is used to evaluate the soft tissues surrounding the heel, including pathological changes of the plantar fascia itself.
Orthotics can aid in the healing process. Orthotics serve as a bridge to decrease tension of the plantar fascia, as it heals. Nevertheless, I don’t recommend long-term daily use of custom orthotics unless there is a structural deformity of the foot or ankle. Rather, strengthening and stretching exercises are encouraged.
Shockwave therapy is a non-invasive treatment modality that delivers high frequency mechanical energy to tissues in order to stimulate blood flow and growth factors to the injured area. Platelet-rich Plasma (PRP) injections are offered to help stimulate healing by bringing growth factors to the injured tissue (learn more about Regenerative Medicine). Corticosteroid injections have utility in treating chronic plantar fasciitis. The injections work locally to decrease the swelling and thickening of the fascia. These injections are performed under ultrasound guidance for improved accuracy. I do not recommend corticosteroid injections on the initial consult. Most patients have significant resolution of their symptoms after 2 weeks with the modalities above. Very rarely is plantar fascia surgery necessary. This is always the last line of treatment.