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ACHILLES PAIN

England Squash Physio Phil Newton of Lilleshall Sports Injury Rehab

explains why the Achilles can be a pain and why, surprisingly, the best method of treatment can be exercise.

“I thought my opponent had hit me with the ball or with his racket.” This is the classic description that squash players who have snapped their Achilles tendon give when recounting the moment of injury. Snapping or rupturing the Achilles, which is the largest tendon in the body, is a serious injury. Happily it is a rarely encountered problem for squash players. However, the Achilles is a common cause of pain.

Achilles pain ranges from mild discomfort that doesn't interfere with your game to agony that prevents even a modicum of exercise. Let's start with a look at the thankfully rare but dramatic injury of Achilles tendon rupture and then consider the much commoner Achilles conditions, which afflict many squash players.

Rupture

Achilles tendons that snap don’t always give you a warning by being painful. There are many instances of apparently normal, pain-free tendons simply giving up the ghost and snapping. The usual way this happens is that a player makes a backwards movement, which stretches the tendon as the heel drops to the ground, followed by a sudden, quick forward movement. This transition from a stretch under load to an explosive shortening imposes a great deal of strain upon the Achilles. If this load exceeds the intrinsic strength of the tendon, it snaps – often accompanied by an impressive cracking sound.

But how can an apparently healthy tendon snap in this way? The answer is probably to do with the natural aging process that all tendons are subject to and which results in small areas of the tendon degenerating, thereby weakening it. This process is usually pain free, so no warning signs are evident before the fateful on-court manoeuvre, which acts as the proverbial ‘last straw’.

Most cases of ruptured Achilles tendons are treated surgically to repair the tear. There then follows a period of immobilization in a cast or a brace. Getting back to match fitness can be a lengthy process, six months to a year being the norm.

Tendinopathy

This is the term that is used to describe a range of conditions that cause tendon pain. Recent research has shown that chronically painful Achilles tendons don't exhibit significant signs of inflammation, which was traditionally thought to be the cause of pain. So instead of diagnosing painful tendons as 'tendinitis', we now use the ‘tendinosis’ label. This is important because the treatment for tendinosis is very different from that for tendinitis.

Tendinosis describes the condition where a tendon has microscopic areas of damage (probably caused by overuse). The body tries to heal these by increasing the flow of blood to the tendon. Consequently, very small blood vessels, which are accompanied by microscopic nerve endings, develop. It is these small nerves that make the tendon painful.

A number of studies have demonstrated that the best way to treat painful Achilles tendons is to exercise them. This seems counter-intuitive – after all, how can a tendon that is hurt by exercise be cured by exercise? Scientists don’t have a definite answer to this but there are a number of theories as to how the exercise cure works – and it does for most people.

One theory is that regular exercise causes physical and biochemical changes within the tendon, which stimulate it to become stronger. Another theory is that repeated movement of the tendon desensitises the nerve endings that accompany the microscopic blood vessels.

A painful Achilles can be treated in other ways. Some recent treatments have included the use of aprotinin injections into the Achilles. This substance is thought to prevent tendon tissue breakdown. Another new treatment is to apply nitrate patches (used to treat certain heart conditions), which are thought to promote healing.

These treatments haven’t yet been widely tested, however, and there is much more evidence to support the use of exercise to treat Achilles pain. The exercise programme is pretty simple but should be overseen by a physiotherapist.

Achilles Exercise

Several studies have shown that some simple exercises can significantly reduce certain types of Achilles tendon pain. These exercises emphasise what is known as the ‘eccentric’ phase of muscle and tendon work, when the tendon is stretched in combination with muscle tension.

Loading the Achilles tendon in this way stimulates it to strengthen and also desensitises some of the small nerve endings, which are thought to be the cause of the pain.

These exercises have been shown to be effective when they are performed twice daily. Relatively high numbers of reps have to be completed e.g. four or five sets of 15-20 reps of each exercise. However, the exact number of reps and sets needs to be determined on an individual basis so it is recommended to see a physiotherapist, who can give appropriate individual advice.

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