Tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading. Achilles tendinopathy is the preferred term for persistent Achilles tendon pain and loss of function related to mechanical loading, this injury is commonly categorized into two types:
- Insertional (affects 20–25%)
- Non-insertional (affects 75–80%)
The presentation of pain in a tendon, does not always mean that the tendon is the primary contributor to pain. The multifactorial model of tendinopathy suggests that an impaired motor system, local tendon pathology, and changes in the pain/nociceptive system contributes to the complex clinical picture of tendon pain (Eckenrode et al., 2019).
A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
- Self-Rated Recovery Question
- Patient Specific Functional Scale
- Brief Pain Inventory (BPI)
- Visual Analog Scale (VAS)
- Lower Extremity Functional Scale (LEFS)
- Foot and Ankle Ability Measure
- Foot and Ankle Disability Index
Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.
- Thompson’s Test
- Tinel’s Sign
- Royal London Hospital Test
- Arc Test
Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. There may be times that focal irritability (i.e., nerve irritation, trigger points, nervous system sensitization) co-exists with Achilles tendinopathy. Structures to keep in mind while assessing and treating patients suffering from Achilles tendon pain may include neurovascular structures and investing fascia of:
- Plantar Fascia
- Adductor Hallucis
- Flexor Hallucis Brevis
- Metatarsals & Interossei
- Peroneals (peroneus longus, peroneus brevis)
- Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
- Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
- Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
- Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
- Ankle Joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint)
Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for patients with Achilles pain including manual therapy, simple home-care recommendations and remedial exercise, such as slow eccentric heel-drops. Remedial loading programs such as eccentric heel drops do-as-tolerated repetition and specific Alfredson Achilles tendinopathy rehabilitation protocol have both been shown to be useful for Achilles tendon pain (Head et al., 2019).
Multimodality options self-care techniques such as exercise therapy, relative rest, activity modifications should be considered as the first line treatment of tendon pain (van der Vlist et al., 2020). Clinicians should be thoughtful and skilled in managing the load on the tendons and supporting structures through several rehabilitation considerations including, but are not limited to manual therapy, education on psychosocial factors such as fear avoidance, and remedial loading programs.
Manual joint mobilization and soft tissue techniques for the calf muscles may modify a contributing factor in the experience of pain. In cases that involve nerve entrapment, a massage therapist may use a specialized technique called neural mobilization. The goal of neural mobilization is to free the entrapped nerve by mobilization of the nerve itself or muscles that surround the nerve. There research to support the use of neural mobilization. A 2017 meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy showed that nerve mobilizations are an effective treatment approach for patients with back, neck and foot pain (Basson et al., 2017).
PhysioTutors: Alfredson Achilles Tendinopathy Rehab Protocol
Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for Achilles tendon pain based on patient-specific assessment findings including, but not limited to:
- Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
- Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
- Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
- Hydrotherapy (hot & cold)
- Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)
References and Sources
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