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A 17 year old female athlete presented with Achilles tendinopathy. A protocol of water and land based rehabilitation was designed to achieve non-weight bearing and pain free activity, so that she could rapidly return to her event (400 m hurdles). After three weeks, she returned to regular training, and after a further three weeks she successfully competed in a 400 m hurdle event. She has been able to compete at national level symptom free for the last 18 months.
The Achilles tendon is the largest and strongest tendon in the human body and experiences high loads in all sporting activities. It has been shown to have a high capacity to withstand tensional forces.1 Chronic painful conditions located in the Achilles tendon are relatively common, especially in runners.2 The cause of such conditions is not known, but they are often associated with repetitive loading and overuse.3 Achilles tendinopathy is difficult to treat.1 Most recommend a conservative regimen as the initial strategy.4–6 Non-surgical treatments include a combination of rest, anti-inflammatory drugs, correction of malalignments, and stretching and strengthening exercises.
There is sparse scientific evidence that these treatments are successful, and surgical treatment is required in about 25% of patients.1 In a recent prospective study, treatment with heavy load, eccentric calf muscle training showed very promising results and may reduce the need for surgical treatment of tendinopathy located in the mid-portion of the Achilles tendon.1 The short term results of surgery are often very good, but in the few studies with long term follow up there are signs of deterioration with time.1,7 In addition, over the last two decades there has been a considerable increase in the incidence of Achilles tendon rupture.8
Many athletic trainers propose an active land based rehabilitation training programme for Achilles tendinopathy, which includes strength and stretching exercises and balance exercises on unstable boards. However, many physiotherapists and aquatic exercise specialists have been using water to treat conditions of the lower extremity for many years.9 They maintain that water is the ideal environment for the rehabilitation of injuries for which weight bearing needs to be limited. Range of motion (ROM), strength, and functional activities performed in deep water are used to prepare the limb for weight bearing. The combination of buoyancy induced skeletal unloading and muscular relaxation can enhance ROM and flexibility. Land based tasks should be initiated before the water programme is finished to facilitate a smooth transition from pool to land.9 Over the last two decades, many athletes have routinely exercised in the pool when recovering from injury.
This study focuses on a specific rehabilitation programme (combination of aquatic and land based exercises) prescribed for a young female runner with early stage Achilles tendinopathy.
A 17 year old female athlete presented with gradually increasing pain located in the Achilles tendon area of her left foot. The clinical diagnosis was Achilles tendinopathy. She was prescribed anti-inflammatory drugs to alleviate the mildly painful symptoms. The symptoms decreased and she was able to compete in the preliminary rounds of the 400 m hurdles and gained a place in the finals to take place six weeks later. The following day, the painful symptoms in the Achilles tendon increased rapidly and spread around the posterior ankle area, so that even walking was painful. More specifically, the point tender pain and swelling was over the Achilles tendon (the middle section proximal to the calcaneal insertion). The tendon was sore on rising in the morning and stiff when she started to run. In addition, crepitus was present. She could not stand on tip toe, to go up or down stairs. On examination, movement from the neutral position to dorsiflexion (supine) was painful. After a clinical examination, she was advised to stop training. The athletic training team (an orthopaedic surgeon, a physiotherapist, and an athletic trainer) designed an aquatic rehabilitation programme to achieve early non-weight bearing and pain free activity.
The goals were gait normalisation, to increase pain free dorsiflexion from 0° to 20°, proprioception ability, calf muscle strength, and strength throughout the lower extremity, and to maintain cardiovascular endurance (table 1).
To maintain her cardiovascular condition, the athlete followed a daily swimming programme. The ankle joint was taped for protection and to keep the heel in a neutral position.
The early phase (1st week) of rehabilitation consisted nearly exclusively of exercises in the pool. Passive stretching exercises in the pool to increase ROM of the ankle joint (dorsiflexion and plantar flexion) paralleled stretching exercises on the land. Mild static balance and isometric exercises (after the 5th session) were performed in the water. Gait normalisation activities, including walking at different stride lengths in different directions at various depths and different speeds in the pool, were performed. Single-leg balance and wobble board exercises in the water were included. Strengthening exercises in this phase were primarily open kinetic chain because of the pain and substitution that occurred with closed kinetic chain activities. Dynamic strength exercises for the other lower limb muscle groups were also performed with specific equipment in the pool.
The intermediate phase focused on increasing gait endurance. Mild dynamic exercises for the gastrocnemius and soleus muscles were initiated in the pool in gradually decreasing depths of water. Full passive ROM was achieved. During this week, the pain decreased considerably. Land based exercises progressed to full weight bearing activities as tolerated, with the focus on stress to the Achilles tendon.
During the third week (the late rehabilitation phase), the time spent on land based exercises was increased and the amount of time spent in the pool was decreased. Impact exercises were initiated in the pool and progressed to land, first on grass and then to the traditional track and field surface. Passive and active stretching for the ankle and calf was performed. Over the next three weeks, the athlete started a progressive training programme in order to compete in the 400 m hurdle event. She won the race, achieving a new national record (61 seconds). She has had no further symptoms.
On initial presentation, the athlete was treated with anti-inflammatory drugs. Although the symptoms decreased, the Achilles tendinopathy was not resolved. Kader et al10 maintain that Achilles tendinitis is a degenerative, not an inflammatory, condition. Although the present case was an early stage of Achilles tendinopathy, it also was not an inflammatory condition.
In our case study, a water based exercise programme was devised for the Achilles tendinopathy because it limits weight bearing using buoyancy. During the rehabilitation period, it is very important to protect the muscle-tendon unit from excessive torque or damaging vibrational forces. Premature loading of a damaged Achilles tendon can cause a number of adverse chemical, metabolic, and vascular changes. Rehabilitation progresses consistently when inflammation is kept to a minimum.9 Therefore, the aquatic rehabilitation programme provided the early initiation of specific exercises (strengthening, stretching, and balance exercises of the ankle joint) to prevent atrophy, motion loss, and abnormal movement pattern development.
The cardiovascular swimming programme had two positive effects. Firstly, it maintained the athlete’s cardiovascular condition, which is also an important aspect of early intervention. Secondly, as supported by many studies,1,11–13 it had positive effects on the healing tissues. These effects include increased blood flow and neurological stimulation, with minimisation of adjacent tissue weakness and adverse psychological effect. However, it is important that the athlete works within the constraints of his/her limitations. 1,11–13
Passive and active (later) stretching exercises were necessary to maintain normal gait and facilitate normal anthropokinematics of the ankle and calf. Both types of stretching can be performed in or out of the water.1,14
The wobble board exercises are good for stimulating proprioception.15 Water is an ideal environment for proprioception training because of its viscosity. Viscosity provides a slow motion, three dimensional resistive environment which facilitates proprioceptive feedback through functional movement patterns. This proprioceptive activity enables the athlete to incorporate safely advanced levels of dynamic stabilisation earlier in the rehabilitation schedule by decreasing both the demands of deceleration and joint excursion.9,14
During the early phase (first week), static and isometric exercises were performed. Dynamic activity was contraindicated because of the joint compression, vibration, and torsional forces that accompany these techniques, resulting in increased pain and inflammation. The athlete in this study was able to perform mild dynamic exercises (second week) earlier in the pool because of minimisation of some of these forces in this environment. Concentric and eccentric loading in single and then multiple planes (late phase) encouraged normal gastrocnemius and soleus function.
Aquatic rehabilitative exercises for Achilles tendinopathy provide an opportunity for the athlete to train in a gravity minimised environment while being immersed in a resistive medium. The unloading is critical as rehabilitation time can be minimised because safe and functional rehabilitation can be started immediately. This can minimise the injury and reduce recovery time.
The aquatic and land based programme reported here offered an effective rehabilitation protocol for the female athlete. However, a case study does not allow generalisation of the conclusions. Further investigation is needed to estimate the effectiveness of this early intervention in achieving rapid return to unlimited activity.