Title: Understanding Achilles Tendinopathy: Causes, Symptoms, and Treatment
Achilles tendinopathy (formerly known as ‘tendonitis’) can put a halt to your active lifestyle if left untreated. The Achilles tendon, the largest tendon in the body, connects the calf muscles to the heel bone. This crucial structure facilitates movement such as walking, running, and jumping. However, repetitive stress or sudden increases in activity like tennis can lead to overload and degeneration of the Achilles tendon, resulting in Achilles tendinopathy.
Causes:
Achilles tendonitis often occurs due to overuse or strain on the Achilles tendon. Athletes who engage in activities such as tennis that require repetitive jumping, running, or sudden changes in direction are particularly susceptible. Other contributing factors include changes in footwear, recent weight gain, hill running, and biomechanical issues such as overpronation or high arches. Additionally, individuals who suddenly increase the intensity or duration of their workouts without proper conditioning are at risk.
Symptoms:
The hallmark symptom of Achilles tendonitis is pain and stiffness along the back of the heel, especially upon waking up or after periods of inactivity. This pain may worsen at the start of activity and subside with rest. Swelling and tenderness may also be present along the tendon. In severe cases, individuals may experience difficulty walking or standing on tiptoe.
Treatment:
Early intervention is crucial in resolving Achilles tendinopathy and expediating return to sport and activities. Here are some effective treatment options:
Relative rest and symptom recognition: Resting the affected leg from excessive loading (e.g. avoid playing tennis on consecutive days and applying ice packs when necessary to manage pain can be useful. It's essential to identify the activities that aggravate the symptoms and discuss these with your physiotherapist.
Stretching and Strengthening Exercises: Gentle stretching exercises for the calf muscles and Achilles tendon can improve flexibility and reduce tension. Strengthening exercises targeting the calf muscles are considered the most evidence based treatment strategy for Achilles tendinopathy.
Orthotics and Supportive Footwear: Wearing supportive footwear with proper arch support and cushioning can alleviate stress on the Achilles tendon. Orthotic inserts may be recommended to correct biomechanical issues and improve foot alignment, or your physiotherapist will suggest the best type of runners for your foot type eg Hoka, Asics etc and where best to shop for runners in Dublin.
Physiotherapy: A physiotherapist can provide personalized treatment plans focusing on stretching, strengthening, and biomechanical correction techniques to address Achilles tendonitis.
Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to alleviate pain and inflammation. However, long-term use should be avoided due to potential side effects.
Modalities: Modalities such as extracorporeal shockwave therapy and Platelet Rich Plasma injections may be used to promote healing and reduce pain. Your physiotherapist can advise you on these options.
Prevention:
Load management is important in Achilles Tendinopathy prevention. Gradually increase the intensity and duration of workouts, and avoid sudden changes in training regimens. Additionally, wearing appropriate footwear and maintaining flexibility and strength in the calf muscles can reduce the risk of injury.
In conclusion, Achilles tendonitis can be a debilitating condition, but with prompt treatment and preventive measures, individuals can effectively manage symptoms and resume their active lifestyle. If you experience persistent heel pain or suspect Achilles tendonitis, Eva, Kaitlyn or Lorraine at Physiofusion can assess for an accurate diagnosis and personalised treatment plan.
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Pelvic Girdle Pain
Lessons learned from treating PGP over a 20 year career.
Pelvic Girdle Pain is a broad term which describes pain in the buttock, pubic and groin region during pregnancy.
I first treated pubic symphysis pain in sportspeople- usually men- in the early years of my career when I worked with rugby players, GAA players and elite soccer players. In many areas of medicine, the techniques which we use in day to day life trickle down from research and evidence based medicine developed in the highest levels of sports medicine. In the sports world, the accurate diagnosis of pelvic pain and the ability to develop a strategy for recovery to high level sport and high loads and forces on the pelvis are essential for a sport physiotherapist.
The first key element of treating pelvic girdle pain in women is establishing the severity and irritability of the pain –
· How is it affecting this patient?
· Is she able to sleep at night?
· Is she able to eg walk where she needs to in day to day life?
· Is she able to look after her other child(ren)?
· Is she experiencing pain at rest?
· Is she able to cope with the pain?
This leads into a deep dive into our more general medical training – Could there be anything more sinister causing this pain, either related to the pregnancy or otherwise? Do we need to refer the patient to their GP or hospital for investigations? Physiotherapists are trained to differentiate musculoskeletal pain from other causes of pain, much like a doctor - and we will liase with the patient’s doctor if we deem it appropriate to do so. This is very rare, as most pelvic girdle pain patients presenting to physiotherapy have a musculoskeletal cause of their pain which can be very successfully managed at physiotherapy.
Many women experiencing pelvic girdle pain try to manage their pain at home with rest and reduced activity. This can be quite effective with mild presentations when it is initiated early. It is my experience that when a woman presents to physiotherapy and has already tried this option and it has not worked, it has already become a significantly more stressful situation, and she has began to worry that it will continue to worsen throughout the pregnancy. Given that the second trimester is a time when PGP usually starts, she may have jumped to thinking that there may be up to 3-5 months of pain ahead.
Fortunately we know that this is not the case. The vast majority of women who attend for treatment with a physio who is experienced with pelvic pain in pregnancy have excellent outcomes. We strive and expect to resolve pelvic girdle pain – not merely prevent it from worsening over time.
So how do we treat Pelvic Girdle Pain?
We take time to analyse the cause of the pain, and the main tissues involved eg referral from the lower back / sacroiliac joint pain/ muscular buttock pain / hip joint pain / groin tendon pain / pubic joint pain / nerve referred pain.
We give specific guidelines on how far the patient is advised to walk each day / and whether activities such as swimming / yoga /pilates would be helpful for them at that stage of their pregnancy. We recognise the importance of supporting a woman to stay active and involved in physical and fitness activities and we endeavour to work with this as a central goal.
We advise them on positions to avoid or minimise – eg prolonged sitting, or weightbearing mainly on one leg in standing.
We discuss whether a pregnancy support belt would be helpful, and where to source one.
We make recommendations on the use of hot/cold therapy for their condition.
We sometimes show their partner how to do eg massage to a particular area, if having some manual work done regularly at home will be beneficial for them (this also keeps physio bills down!).
We prescribe specific exercises which will help to strengthen the important supporting muscles of the pelvis eg the gluteals. These can be modified around existing conditions also eg co-existing knee pain.
We liase with the relevant hospital care team/midwife/consultant to raise awareness of the condition prior to delivery in order to facilitate early planning for positions for labour etc. This is increasingly rare however as we find most women make huge improvements with treatment and are not fearful of worsening of their condition with labour.
We liase with the woman’s workplace where we can make suggestions eg working from home/ reducing work hours during exacerbations etc and we do this in conjunction with the woman’s GP for enhanced communication across the care team.
Confidence and Reassurance
As a young physiotherapist, I was a little apprehensive about treating pregnant women who were in pain, and I recognised that I had the potential to worsen their pain. As a result, I tended to undertreat them. I don’t think I was alone in this, as it was not an area that received a large amount of focus in our undergraduate University training at the time. Hopefully it has changed and improved since then.
Now with a Masters Degree in MSK physiotherapy, I have twenty years of experience in treating complex groin pain in athletes aswell as pelvic pain from all musculoskeletal sources during pregnancy. I have completed numerous postgraduate courses in Pelvic Girdle pain both in Ireland and abroad and thankfully I feel that those hard days are long behind me. Having had three pregnancies myself, I understand how exhausted women can be while working, minding other children and managing pain, and this is my driver now to do my best for them during their pregnancy.
I now begin each session knowing that I have the tools to help each patient and the dramatic results we see from treating PGP make it one of the most rewarding aspects of my job as a Musculoskeletal Physiotherapist. We see a refreshed and much happier patient who is excited again about their pregnancy and feels prepared for the weeks and months ahead.
Lorraine O’Reilly
CORU State Registered Physiotherapist, MPhty (MSK Physiotherapy)
Contact: lorraine@physiofusion.ie
From ‘pain’ to ‘chronic pain’
It all begins with an idea.
May 2021
At Physiofusion we see many patients who seek treatment for pain that is persistent or chronic, despite taking rest from their usual activities to allow time for the tissues to heal. This can be the case for pain in almost any part of the body, but most commonly we see it as chronic back pain, neck pain and buttock pain.
So why do some aches and pains go away by themselves, and other aches and pains persist?
Most muscle and joint pains (‘musculoskeletal pains’) occur as a result of us increasing our activity levels by doing too much too soon, with insufficient recovery time. Our muscles, tendons and joints need to be strong enough to cope with the loads and demands we place on them every day. When we apply too much load or we do it over too short a time, our tissues react to this and send signals to our brain to tell us that something may be wrong – our brain perceives this as a ‘threat’, and our brain also then acts to produce the sensation of ‘pain’ so that we pay attention to the ‘threat’.
All pain is produced by our brain!
It is true to say that all pain is produced in our brain– even though we feel it in the injured areas of our arms, legs or spine etc.
Usually, we will pay attention to the ‘threat’ or the pain sensation that the threat has produced, and we make a decision of how to react based on a number of influencing factors – whether we have had this pain before and if so what we did to resolve it; maybe we heard that our friend who had the same pain rested for 2 weeks from football and so we choose to copy that as it sounds sensible; or maybe we decide to take pain medications to mask it as it is too inconvenient to rest from sport or work that week, or we decide to continue as normal and to take no action, if we consider that this pain does not represent a strong threat to our wellbeing overall. This might be the case in back pain for example, if we frequently experience a similar type of pain and if we rationalise that it has usually resolved by itself in the past and so no further action may be required.
On the other hand, we are also influenced by other factors as we make our ‘what to do’ decision, and these can escalate the significance of the perceived threat… For example if we know of a neighbour with back pain who went on to be diagnosed as a spinal tumour, our brain might pay more attention to the ‘threat’ of our own back pain and we may then worry that we may also have a tumour and then pay more and more attention to the back pain. If we have other stressful issues going on in our lives at the time the pain starts, this can have an effect on how our brain interprets and deals with the pain also – and our brain can magnify the pain sensation or ‘output’ it produces if we perceive this threat to be significant. A pianist with a sore finger pain may report higher levels of pain for the same injury that a footballer would be expected to report, as the personal and financial significance of the injury is different for both individuals.
So our brain is capable of escalating the level of pain we experience for a given injury or ‘threat’, and this influences the decisions we make as we decide how to protect our injured area. Both conscious an unconscious decisions can drive the course of the recovery – ie the persistence of the pain. Studies show that poor sleep quality, work dissatisfaction and overall stress levels are important predictors of pain outcomes.
“Learning about how your body works, and how it generates and responds to pain signals can help with recovery”.
Knowing this, how can we identify which pain may become ‘chronic pain’?
As physiotherapists, it is important for us to gain a sense of your ‘whole person’ during our initial assessment so that we can create a better understanding of how ‘your’ pain is affecting ‘you’. In acute or ‘recent’ pain or injury, we will take a thorough history and listen to your description of the onset and behaviour of the pain, and how it affects your ability to walk/play sport etc. On another level, we are listening to the words that you might use to describe your pain, and we try to uncover any underlying ‘pain beliefs’ or past experiences of pain which might help us to determine the best approach for us to take when managing your pain.
In pain that has been present for longer duration, we are trying to identify how much of a ‘threat’ you may perceive their pain to be, and we implement strategies that will help to address these issues also.
The best time to intervene in the pain system is within the first three months. Our bodies do their best healing of ‘actual’ tissue damage within the first three months after the injury/onset of the pain.
Pain that persists beyond three (and in particular six months) is less likely to be coming from the tissues themselves, and more likely to involve changes in our pain processing system. This means that chronic or longstanding pain will most likely need a broader approach to treatment than massage or hands-on treatment alone. This is not always the case, but we need to consider it when we treat chronic pain.
At Physiofusion our team of physiotherapists are all senior physiotherapists with over ten years of experience in the diagnosis and treatment of chronic persistent pain. This is particularly valuable when assessing and helping patients who have tried various forms of treatment in the past without results. We take an individualised approach to each patient which involves a thorough initial assessment from your first visit so that you can be assured you of a high quality treatment plan towards a successful recovery.
Watch out for our next blog on the strategies that we use at Physiofusion as we work together with our patients to treat chronic pain.
Please contact us if you wish to speak to one of our physiotherapists to discuss if we can help you with persistent or chronic pain.