Ask the Experts - Injury

Answers from Sean Fyfe:

Q. At first I didn't realise that I'd done anything even slightly serious slightly overstretching when playing football with a four-year-old in Spain. That was in April this year.

Slowly over a month or so I became aware of some pain in my right Achilles tendon. I rested. Took things really easy apart from a few stretching exercises. In July in Spain a doctor gave me (I think it's called a back slab?) plaster of paris under the sole of my foot and up my calf, held in place by a crepe bandage. It lasted two weeks. Total comfort, and I thought all was well again, although the area was still slightly swollen.

But the pain returned quite quickly, with only minor exercise. In England during August a physiotherapist treated it with ultrasound, without any noticable effect. Two doctors and the physio have said it's tendonitis.

I have been doing the exercises recommended in Sports Injury Bulletin. The swelling and the pain persist: a fierce burning sensation when walking - as I transfer my weight to the ball of the foot. What do you recommend?

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Answer:

Well it sounds as though you’ve done bits of pieces of correct management, but the timing of the management process has been out of “whack”.  What I mean is that during a recovery process, there is a time and place for each stage depending on the stage of healing for the injury and hence certain stages must follow each other.  This is the same for any injury and it ensures that the injury, after it has settled, is progressively loaded to a point where it is strong enough to withstand exercise again. 

In your case, it sounds as though you actually strained the Achilles tendon slightly initially and because it wasn’t managed correctly, it then turned into a tendonitis.  I would assume, because of this that your Achilles tendon is quite weak and will require a lengthy and precise rehabilitation.  You had the backslab, which served to take the load of the Achilles so the inflammation and pain could settle and it did this successfully.  This needed to be followed by a very graded exercise program, like the one you are doing now which is outlined in -http://www.sportsinjurybulletin.com/archive/achilles-tendon-pain.html.  However, you went straight back into to trying to exercise.  You needed to do very graded and modified walking, followed by the exercise regime (ensuring that the exercises are progressed very slowly) and then a slow return back to exercise.  You went back into exercise with an Achilles tendon that was less inflamed and less painful, but the tendon was very weak and susceptible to being overloaded again and that’s what happened.  The tendon couldn’t handle the load and became inflamed again.

I know you must be incredibly frustrated, but here is my advice.  You need someone to project manage your injury from start to finish.  That someone is a good Sports Physiotherapist.  The Physiotherapist needs to send you to a Sports Doctor to decide the best course of management to get the tendon to settle down.  This can include a number of things such as a walking boot, night splint, an injection and anti-inflammatories.  Once the tendon has settled considerably, you can begin the exercise program and the Physio needs to step you through how many repetitions, sets, weight, degree of knee bend etc and direct you as to exactly how much walking can be done.  The injury needs to be monitored all the way and the Physio also needs to ensure that the soft tissue range of movement is in order.   On your behalf, patience is required and commitment to the program is required.  Good luck.