Ankle and Leg Tendonitis and Orthotics
REHAB
Kevin Wong
When patients and athletes report problems in the ankle and lower leg, a close examination of foot and ankle function must be performed. With any physical activity, whether it is work related or from recreational or competitive sports, nagging symptoms can develop that are not due to any injury or recent trauma. Often there is chr onic irritation of a tendon with the development of a persistent tendonitis. While acute treatment for the inflamed tendon is necessary, long-term prevention also must be considered. Recurring injuries to ankle and leg tendons can significantly affect sports enjoyment and performance levels, and further chronic irritation can end participation in competitive and recreational sports completely.
Causes of Tendonitis
All forms of tendinitis are due to microtrauma, either from excessive or abnormal activity on a normal tendon, or from normal stresses on an abnormal tendon. Tendons are connective tissues attached to muscles that are exposed to frequent movement, so they are very susceptible to overload. When they are overloaded, they develop a non-acute inflammatory response (tendinitis), which is more accurately termed a “tendinosis” condition.1 Inflammation develops in and around the tendon (peritendinitis). Symptoms usually are described as diffuse pain that is aggravated by activity, such as walking, running, or climbing stairs. Palpation will often identify a tender thickening of the peritendon, and there may be crepitus during plantar and dorsiflexion. Patients usually present with the complaint of being unable
to participate in sports activities due to pain at the ankle, lower calf, or shin. Often, a recent increase in activity level or change in footwear is reported.
Lower Leg Tendonitis
Excessive movements of the tibia due to overpronation are a frequent cause of tendinitis in the ankle and lower leg. The tendons in the shin and the Achilles tendon, in particular, are at risk from excessive pronation. Studies have demonstrated a significant decrease in tibial internal rotationii and on pronation velocity111 when using orthotics, which will help prevent injuries to this area.
Shin Splints
A chronic tendonitis that affects either the anterior or posterior tibialis muscle can present as “shin splints.”ivThe anterior tibialis tendon is stressed when the foot is unable to adequately absorb the forces of foot deceleration at or after foot strike, while the posterior tibialis tendon develops microtears from attempting to stabilize excessive foot pronation.' Therefore, orthotics can reduce the likelihood of developing shin splint tendonitis.
Achilles Tendonitis
The Achilles tendon inserts on the calcaneus medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint.V1 Therefore, whenever excessive pronation occurs, this tendon eventually undergoes overuse degeneration and inflammation. Investigators at the University of British Columbia in Vancouver, Canada
www. theamericanchiropractor. com
describe how “pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially. Through slow-motion, high-speed cinematography we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon.
This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.”™ These scientists feel that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendonitis. In fact, researchers reported that “virtually all cases of Achilles tendon injury appear to result from structural or dynamic disturbances in lower leg mechanics... ” They reported good treatment success by providing flexible orthotics to balance the “functional overpronation” that they determined was “of primary importance to the etiology of Achilles tendon disorders.”
Treatment Methods:
Anti-inflammation
• Restricted Activity - Jumping, running, and other activities that stress the tendons are eliminated, while easy walking is still encouraged. Bicycling is allowed, as long as the pedals aie pushed with the heels and not with the forefeet. Immobilization is not recommended.
• Cryotherapy - Frequent (hourly) ice massage and/or cold packs help reduce inflammation.
• Vitamin C with Bioflavonoids - A natural anti-inflammatory that will speed healing.
Better blood flow
• Ultrasound - Initially pulsed, then constant and direct (once inflammation has subsided).
• Deep Friction Massage - To stimulate healing deep in the tendon and prevent adhesions.™1
Improved biomechanics
• Orthotics for Pronation - To reduce the stresses on the tendons due to “whipping action.”
• Shock Absorption - Viscoelastic inserts will decrease the amount of shock at heel strike, reducing the eccentric contraction stress on the tibialis muscles.
Rehabilitation
• Heel Cord Stretching - “Runner’s stretch” against a wall. All exercises should be performed with corrective orthotics in place.LX
• Isotonic Resistance - With elastic tubing can improve the strength and function of the tibialis and gastrocnemius muscles.
• Eccentric Strengthening - Stand on the edge of a stair, do a toe raise, then rapidly drop the involved heel as far as possible, and then return by pushing back up with the uninvolved leg.x
• Wobble Board Training - To stimulate proprioception and neuromuscular control.33
Conclusion
Most cases of tendonitis in the ankle and lower leg can be treated easily with conservative methods. Steroid injections and immobilization casting are seldom used these days. One of the most important treatment methods is to reduce any tendency to pronate excessively and to control the stress of the heel strike. In addition to custom-fitted orthotics, runners should wear well-designed shoes that provide good heel stability. This helps prevent tendon problems, and it is especially important for athletes who run for more than a few miles at a time. Once the local inflammation has been controlled, the additional stability provided by custom-made orthotics will support a return to functional exercises and prevent the recurrence of ankle and leg tendonitis.
References:
i. Khan KM, et al. Overuse tendinosis, not tendinitis, part
1 : a new paradigm for a difficult clinical problem. Phys & Sportsmed 2000; 28:38-48.
ii. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther
1995; 21:317-27.
iii. Eng JJ, Pierrynowski MR. The effect of soft orthotics on three-dimensional lower limb kinematics during walking and running. Phys Ther 1994; 74:836-44.
iv. Souza TA. Differential diagnosis for the chiropractor. Gaithersburg: Aspen Pubs; 1998. p. 313.
v. Roy S, Irvin R. Sports medicine: prevention, evaluation, management, and rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. p. 434, 438.
vi. HornLM, Subotnick SI. Surgical intervention. In: Subotnick SI, ed. Sports medicine of the lower extremity. New York: Churchill Livingstone; 1989. p. 475.
vii. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-84.
viii. Lear L. Transverse friction massage. Sports Med Update 1996; 10:18-25.
ix. Herding D, Kessler RM. Management of common musculoskeletal disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. p.405.
x. Standish WD, et al. Tendinitis: analysis and treatment for running. Clin Sports Med 1985; 4:593-609.
xi. Kibler WB, et al. Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MD: Aspen Publishers; 1998. p.282.
Dr. Kevin Wong is a 1996 summa cum laude graduate of Palmer College of Chiropractic West. A past instructor of chiropractic technique for the college, he is currently part of the adjunct faculty. Dr Wong is also a past lecturer and instructor for the International Chiropractic Association of California. Currently, he is in full-time practice in Chinda, California, and has been a speaker for Foot Levelers for many years.
