A rifle shot or a car backfiring is the sound many of our patients describe hearing when they rupture their Achilles. They hear the shot and find themselves on the ground and wonder how they got there and who could have tripped them when there’s no one around.
The middle-aged weekend tennis player or basketballer are among the usual suspects attending our clinics post Achilles rupture. Their sport requires explosive change of direction and speed for which they are inadequately prepared due to poor fitness and little or no warm-up on top of a history of low-grade Achilles dysfunction. Throw in diabetes and corticosteroid use and you may as well book time off the court now.
First-timers are usually managed conservatively with crutches and a ‘moon’ boot to deload the damaged tissues and allow healing to take place.
Physiotherapy treatment to reduce inflammation and manage pain starts early on and as recovery progresses the physiotherapist works with the patient to restore muscle length, restore tendon and muscle strength and regain joint range of motion. The other component of rehabilitation involves addressing factors contributing to the original injury including poor foot and lower limb biomechanics; restricted neural tissue; balance and proprioception; and cardiovascular fitness.
For the patient presenting for a second or third lap around the Achilles rupture block or for those whose work or sport requires high-level function it’s off to the friendly local orthopaedic doc for a surgical repair. Depending on the doc’s point of view it’s 6 to 12 weeks in the boot before starting a similar rehab process outlined for conservative management.
One of the first patients I ever treated as a newly-minted physio was a lovely old bloke with a decidedly unlovely ankle sprain. The ankle, courtesy of a slip on wet cement, was gothic horror movie purple, blue and black and about four times the size of its uninjured companion. The injury itself was only minor – what we refer to as a Grade 1 sprain (minor tissue damage to the ligament but no change in its length or function when stressed) – but its little shop of horrors appearance was due to the patient being on blood thinners for a heart condition.
Risk Factors / Causes
The most common ankle sprain is the plantar flexion-inversion sprain aka rolling over on the outside of the ankle. As per my patient this typically occurs on unstable or uneven surfaces or with landing or jumping onto an awkwardly positioned foot. The sprain is either a Grade 1 (as above); a moderate Grade 2 – damage of more fibres with a concomitant increase in ligament stretch or laxity; or Grade 3, a complete rupture. The bad news – if you’ve had one you’re at greater risk for having another. The good news – work on your balance, reaction timing and proprioception and you’re well on the way to avoiding a repeat performance.
Good management starts immediately at the time of injury with the ever reliable rest (R), ice (I), compression (C), and elevation (E). Get this part right and your recovery time can be dramatically reduced.
Physiotherapy treatment to reduce inflammation and manage pain starts early on and as recovery progresses the physiotherapist works with the patient to restore muscle length, restore tendon and muscle strength and regain joint range of motion.
We then work to address factors contributing to the original injury including poor foot and lower limb biomechanics; restricted neural tissue; balance and proprioception; and cardiovascular fitness.
The last, and often overlooked, component of rehab is sport, work or lifestyle-specific retraining. If your job has you walking on uneven ground; you live in a high-set house and run up and down stairs all day long; or you play in the NRL and need to regain full explosive agility – whichever it might be we work with you to return you to your full pre-injury level of function.
We see lots of these in the clinic particularly in active kids hitting their peak growth spurt during adolescence. Severs disease is an inflammatory condition affecting the growth plate of the heel bone.
Kids who play lots of running and jumping sports; who have poor lower limb biomechanics or those with a poorly rehabilitated ankle sprain are at greatest risk of developing Severs. The growth plate in question is at the back of the heel adjacent to the insertion point of the Achilles tendon. Prolonged or frequent loading through the tendon, as occurs with running and jumping, can overload the tissues of the growth plate resulting in an inflammatory response.
Severs is a self-limiting condition that is fully resolved by the time the growth plate fuses but in the mean-time the condition must be managed to allow the individual to continue to play sport, exercise and enjoy a pain-free adolescence.
The first, and perhaps hardest step for the active adolescent is to reduce the amount of sport or exercise they are participating in. What we usually do is ask the individual to list all the sport/exercise they play and rank them from least to most important/enjoyable – the ones at the bottom of the least get scratched and as necessary you continue up the list, hopefully stopping before the top.
We then work to address factors contributing to the condition including poor foot and lower limb biomechanics; restricted neural tissue; poor balance and proprioception; restricted joint range of motion or muscle length and cardiovascular fitness.
As pain resolves and strength and power return to the affected limb(s) we gradually reintroduce the activity that was taken out at the beginning of the rehab phase whilst keeping a close eye on any aggravation of symptoms.
Another frequent flyer in the Construct Health clinics, plantar fasciitis is an irritation of the plantar fascia, a thick band of connective tissue that supports the arch of the foot from the heel bone to the toes.
Risk Factors / Causes
The primary cause of plantar fasciitis is repetitive or prolonged loading of the plantar fascia as occurs with high volumes of walking, running and jumping particularly when combined with poor lower limb and foot biomechanics. Dancers, gymnasts and volleyballers who combine high force, high volume and end of ranging loading of the plantar fascia are often at risk. In our clinics we frequently see underground miners presenting with plantar fasciitis symptoms – primarily due to the long distances they walk over uneven ground in heavy boots.
A less frequent cause of plantar fasciitis is an acute high volume loading of the connective tissues as occurs when landing from height.
As in everything we treat the first steps involve managing the pain and associated disability but the real trick is to dig down to the root cause of the problem.
If it’s poor biomechanics, poor footwear, obesity, inadequate task rotation at their work OR as is often the case a combination of all of the above, we work with the injured person to address all of these factors to return them to full healthy pain-free functioning.
The treatment process itself will generally involve deloading the aggravated tissues through strapping or orthotic prescription; restoration of normal length to the calves and range of motion at the foot and ankle; selecting appropriate footwear and working with the patient to lose weight and improve balance, proprioception and cardiovascular fitness.
As the symptoms improve we work with the patient to gradually reintroduce them to sport, work and the normal activities of daily living. Over time the patient is able to return to their pre-injury status and in some cases are fitter, stronger and healthier than before