Achilles Tendinopathy

So I'm going to take you back to ancient times, where Gods ruled the lands, and the Greeks invented the Achilles heel! This weeks post is going to focus on Achilles Tendinopathy.

Other common rock climbing foot issues will come in a later post.

Achilles tendon anatomy

Movements of the Achilles

Function

The Achilles tendon supports 6-15 times your body weight and provides spring like action.

Tendonitis/tendinosis/tendinopathy, what is the difference?

Tendonitis – inflammation

Tendinosis – chronic tendinopathy

Tendinopathy – a disorder of the tendons – an umbrella, catch-all term

Obviously, depending on -osis/-itis depends on the management strategies (to counter the inflammatory process or not).

The common consensus is that these conditions are a tendinosis rather than a tendonitis.

Enthesopathies

The entheses is where the tendon attaches to the bone, and an achilles tendinopathy that occurs within the first 2cm of the tendon attachment to the calcaneus is an enthesopathy.

Differential

• Rule out complete tendon rupture using the calf squeeze test. See above picture.
• Posterior ankle impingement
• Os trigonum syndrome
• retrocalcaneal bursitis
• Posterior Tibial Tendon Dysfunction
• Haglund's deformity

However, to discuss what all of these things are would take a whole blog post unto itself, so I'm just going to leave it there!

Symptoms

• Pain in the heel/around the tendon
• ?swelling - if a tendinitis
• ?heat - if a tendinitis
• Painful to touch or on movement
• Early morning stiffness
• Difficulty standing on your tip-toes (/single leg stress/repetitive/hop)

Causes

Tendinopathy:

• Repetitive strain on tendon
• overuse
• inappropriate footwear
• poor technique
• high-arched foot
• increase intensity in training regime
• lots of jumping
• tight calves
• excessive inversion or eversion

Achilles tendinopathy is more a problem for runners or walkers, but can affect climbers, especially as many climbers are mutli-sports persons.

Enthesopathies: compression of calcaneus from repeated platarflexion e.g. aggressive climbing shoes and/or dynoing etc. as climbing shoes with an aggressive heel, such as 5:10's, could cause this repeated compression on the calcaneus. (obviously, other aggressive climbing shoe are available!)

Treatment

If you suffer from the "5:10 syndrome" as mentioned above, you could try this method of editing your climbing shoes by Llanberis Resoles

NSAIDs....?

I mark this with a question mark, because it depends on your school of thought – whether it is a chronic overuse, or an inflammatory response. If you find it is swollen, then NSAID's may well help, but there is a school of thought that they may inhibit healing if used inappropriately.

There is also the dangers of overuse of NSAID's, as listed in Risks of Ibuprofen post

Acute management (see Management of Acute Injuries post) – again, may not be necessary if the tendinopathy is not an inflammatory process. e.g. if you use RSI of the wrist as an example.

GTN (Glyceryl trinitrate)

This is the same as the spray commonly used for angina, but is utilised topically – i.e. localised patch of GTN. However, the reasoning behind why it works is unclear, and commonly patients exhibit headaches and/or a rash as side effects.

Steroid

A corticosteriod injection may help, but has been shown to only have a short term pain-relieving effects, and not much else. Also, these injections may increase the risk of tendon rupture by weakening the tendon.

Surgical

A surgical intervention is rarely required for Achilles tendinopathy, and would always be a last resort. A very last resort!

There are other such treatments such as extracorporeal shockwave therapy and sclerosing injections, but they are rarely used.

The best bet is for physiotherapy, and using specific protocols, outlined below:

Physiotherapy

Mobilisations of the Achilles tendon

Ultrasound – useful if the tendinopathy is a tendonitis, as ultrasound can be used to reduce the inflammation.

Protocols/Exercises

Eccentric – Alfredson et al 1998

Two types of Eccentric Exercises will be used: (Refer to Photo A, B, and C)

• The calf muscle is to be eccentrically loaded with the knee straight.
• To maximize the activation of the soleus muscle, also performed with the knee bent.
• Perform each exercise 3x with 15 repetitions.
• Use your hand on the wall as a guide for balance
• Begin with weight bearing load, progression to backpack weight when patient can perform the
• exercise routine without pain or discomfort (Photo D). Advanced progression under therapist’s guidance may include resistance from weight training equipment such as a Smith machine or a squat machine.

Feet and rock climbing

So you're out climbing, and you pull your climbing shoes out the bag. What size are they? One size smaller than your normal shoes? Maybe two? Well, this post is to discuss the links between feet, footwear and climbing, and other foot injuries/problems.

Do remember, however, that we aren't the only sport or hobby to do this to our feet.....

In a study of 104 rock climbers, Killian et al (1998) found that 81% suffered from an acute or chronic pain or pathology in the foot and/or ankle during or after rock climbing. They suggest that this is in relation to the biomechanics of wearing small rock shoes.

First, as always, I will discuss the anatomy of the foot.

Ligaments

Muscles

Tibialis anterior is also the main dorsiflexor of the ankle.
The gastrocnemius, soleus and plantaris are the plantarflexors of the ankle (there are more muscles involved with platarflexion due to needing to lift the entire body weight, whereas dorsiflexion only consists of lifting the foot.)

Movements of the foot

Feet position within climbing shoes

Arches of the foot

Forces through feet when climbing

Robert Bradshaw-Hilditch and Gary Gibson (yes, THAT Gary Gibson) are both podiatrists who have been conducting some brilliant studies in collaboration with Staffordshire University regarding the forces that are exerted through climbing shoes, and where. 

Their research has found that the forces when front pointing on the hallux (big toe) during climbing causes more force through the metatarsal head, and puts the plantar fascia under tension.

During edging, the forces through the hallux again puts most of the force through the hallux metatarsal head, and stresses the plantar fascia, but also places the foot in a supinated position.

This is just the tip of the iceberg for this research, and Rob and Gary are looking at expanding this much further, as this was only looking at the plantar aspect of the foot in an indoor climbing situation.

But what does it mean?

This means that the feet are more prone to ankle injuries due to the supinated position (see below), and this increase in pressure on the plantar fascia could cause plantar fasciitis (see below as well). The forces being placed through the metatarsal head will change the biomechanics of the foot through the strength of certain muscles, and could cause problems with the arch of the foot (see below) and these problems will surpass what happens on the rock alone. 

So what can be done? 

Read on...

Problems with the feet

Hallux-Abducto Valgus (commonly known as bunions)

Hallux valgus is defined as a 20 degree difference between the axis of the first metatarsal and the axis of the proximal phalanx of the toe, and was noted in both feet in 53% and in one foot in 20% of climbers participating in the sport for more than 5 years and climbing UIAA degree IX. (Peters 2001)

Bunions are not actually caused by wearing tight shoes, but climbing shoes can worsen the deformity. Bunions are most often caused by an inherited faulty mechanical structure of the foot. 

Treatments include wearing bunion pads, orthotics or different footwear and pain killers, or there is the surgical route if the pain is severe. There is no physiotherapy intervention that can help here, therefore prevention is the best cure, by avoiding wearing tight shoes and decreasing the effect of escalating the problem. 

Vessel Compression

65% of sport climbers have found to have tingling and/or pins and needles in their feet, thought to be caused by medial to lateral compression of blood vessels and nerves of foot by smaller climbing shoes. This usually dissapates quite quickly once the shoes are removed. If it doesn't, I'd get it checked out by a professional fairly quickly.

Arch Disorders

Rock climbing has been found to have a beneficial impact on longitudinal arch of the foot (due to strengthening), but does cause an increase in frequency in transverse arch disorders such as tansversal platypodia (flat foot),and an increased frequency of abnormal toe-to-surface adhesion.

Both these problems affect the frontal areas of foot, caused by climbing footwear - changes in the biomechanics of the foot, can cause weakness in muscles controlling 1st metatarsal head extension.

Ankle sprains

Ankle sprains are an injury that don't just affect rock climbers, as you may well realise. They are much more likely to affect other sports persons such as fell runners, however, with climbing, due to the already supinated/inverted (turned inwards) position of the foot means that there is an increased risk of an ankle sprain, normally due to jumping/falling off (this has happened to a few friends, one bouldering in Font, the other trad climbing at Stanage – and both those walks out seemed to take forever!) Hochholzer & Schöffl (2006) found that 24% of climbers have suffered from an ankle sprain.

Ankle sprains are normally caused because the muscles around the ankle don't act quick enough to stop the ankle surpassing it's normal range of movement and the ligaments have to take the brunt of the force.It is normally when the ankle is inverted.

Therefore, the preventative measures you can do to improve the acting of your muscles around the ankle would be to improve the proprioception of the ankle (knowledge of where your body is in space).

To do this, you can use the use of a wobble board or wobble cushion. Stand on the board/cushion on one leg until you can do it for 1 minute. Then close your eyes and try to reach one minute. This can also be used as late stage rehab for an ankle sprain.

 

 Early stage treatment for an ankle sprain would be to follow the management of acute injuries, along with maintaining range of movement in a non-weight bearing manner.

Taping can also be used to support the ankle if injured, such as the technique below, to prevent further inversion:

To read more about ankle sprain and preventative measures, check out Global Therapies recent blog.

Plantar Fasciitis

Plantar fasciitis is heel pain that is caused from an inflammatory process of the connective tissue, the plantar fascia. 
It is commonly caused by long periods of weight bearing and flat feet, as well as poor footwear, poor biomechanics, high arches, and/or running/walking long distance on hard surfaces.
The treatment is normally rest, ice, reduce inflammation and swelling, calf stretches, and finally, correcting what caused the problem in the first place, be that poor footwear, muscular imbalances etc. 

Achilles Tendinopathy

This has already been covered by a separate post here.

Ankle fractures

So, an ankle fracture, as you'd have guessed, is when a bone involved in the foot or ankle gets broken. There is no real preventative measure for this, and will normally occur from a fall. Therefore, the approach for a fracture is surgical intervention, or conservative treatment (which normally involves just casting the foot and ankle in plaster and waiting it to heal).
The time frame and approach is entirely dependant on where the fracture etc is, and what other structures are involved.
Post op/plaster, you should be referred to physiotherapy for rehab anyway.
So I'm just going to leave you with a tasty X-ray of an ankle fracture and repair!

Other problems

There are also other non-musculoskeletal problems hat can occur with the foot, such as corns, cuts, toe infections etc which just needs you to look after your feet!

Prevention

Just a few tips to try and prevent foot and ankle problems:

As previously mentioned, use of the wobble board or cushion can help prevent some ankle injuries.

Ensuring you have appropriate sized climbing shoes, or if not possible, remove them at all opportunities, or alternate your shoes for different routes

Parallel training to strengthen the muscles around the foot and ankle

Appropriate sized normal footwear

Foot hygiene

If you are a diabetic, please please please avoid tight shoes!! This is because of change in the sensation in the feet (neuropathy) that can be caused by diabetes, and can cause much more serious foot problems!

To avoid some ankle injuries, have some (decent!) spotters when bouldering, and try to have dynamic belay techniques when roped climbing, to avoid clattering into the rock and giving you time to slow down the motion with your upper legs rather than at the ankle!

However, the main take home message is that with footwear, pain is insane! here possible, make your climbing shoes fit properly, feel comfortable, and look after your feet!

Kids feet and climbing shoes

This will be covered in the next post, just to break up the amount of information I'm giving you! 

References

Peters P 2001 Orthopedic problems in sport climbing. Wilderness and Environmental Medicine, 12; 100-110

Morrison A 2009 Climbing shoes: is pain insane? BMC

Killian RB, Nishimoto GS, Page JC 1998 Foot and ankle injuries related to rock climbing. The role of footwear. J Am Podiatr Med Assoc. 88(8):365-74.

Morrison AB, Schoffl VR 2007. Physiological responses to rock climbing in young climbers. Br J Sports Med 41;852-861.

Compartment Syndrome

So we all get pumped when we are out climbing, in our forearms. This is natural, but we expect this pump to ease after the route, or at the very most the next day. 
So what happens when it doesn't go the next day, our even gets worse? Then it's quite possible that you're suffering from functional compartment syndrome of the flexor muscles, otherwise known as chronic exertional comparment syndrome (CECS).

Chronic exertional / functional compartment syndrome is much more common in the tibialis anterior muscle compartment in runners and walkers, but has recently been reported in the forearms of those requiring strong grip, such as climbers, motocross riders and rowers.

Physiology and Anatomy 


Within the forearm, all the muscles are surrounded by a thin sheet of fibrous tissue called fascia, which holds all the muscle fibres together in their bundle.

CECS occurs when there is an increase in muscle mass but not in fascia that envelops the muscle tissue, which happens with high intensity training resulting in hypertrophy of the muscles) i.e. muscles grow quicker than the surrounding fascia).
The only space left is veins and arteries and so the vessels become constricted by the muscle mass and creates a back flow of blood and an "instant pump" The muscle still creates lactic acid, but the blood supply cannot remove it, resulting in the pump/burn, that can take days to recover. 

This process can also occur after infectious disease compromises an athletes immune system, but much less common.

Acute compartment syndrome normally occurs post fracture or crush injury, and requires urgent medical attention. This is not the focus of this post.

Symptoms

Pain in forearms during and after stress
Pumped sensation that does not decrease in the usual time frame 
Pump reached way lower than your normal peak levels

Diagnosis

Diagnosis of CECS is using inter-compartmental pressure measurement during the sport specific stress (i.e. climbing) using the devices similar to below.

Schoffl et al (2004) set an algorithm as below for diagnostic of CECS dependant on the pressure found within the muscle compartments.

Differential diagnosis for the symptoms of CECS could be ulnar stress fracture or nerve entrapment

Treatment

• stress reduction i.e. cease to perform the activity, but I know climbers, and they won't stop climbing!
• stretching
• massage
• ice
• anti-inflammatories
• activity modification - analyse your climbing, change your climbing style, crimp less etc.
• surgical procedure - fasciotomy

Fasciotomy

A fasciotomy is one of the surgical options to reduce CECS. It consists of two incisions into each of the different forearm compartments to reduce the pressure within the compartments. They may require a skin graft if the muscle bulk is still too large to close the skin around it.

Outcomes

Painful sensations in the forearm were reduced from 53 to 7 VAS, and more than 95% (23/24) of the motocross patients were satisfied with the postoperative result of a fasciotomy after 5  follow-up. (Winkes et al 2011)

Post fasciotomy of 12 patients reported percentage improvement after surgery was 88%. Median time to return to full activity was 9 weeks. 
(Brown et al 2011)

In 8 post fasciectomy patients, all had resumed their sport in the 6 weeks after the surgery, and 3 returned to their previous level, 5 improved their level. No complications and no recurrences were reported during an average 2-year follow-up. (Croutzet et al 2009)

Physiotherapy post operatively would be to follow the post op guidelines to regain range of movement and strength.

Although surgery is highly effective for most people, it's not without risk. Complications of the surgery can include infection, permanent nerve damage, numbness and scarring. 

Pre and post fasciotomy

Prevention

Unfortunately, there is no real prevention for CECS except to remember that it is really important to build up training and intensity slowly and steadily to ensure all structures within your body adapt to the changes at the same rate, as muscle bulk grows quicker than tendon strength, fascia; and this can lead to problems, imbalances and injuries.

This doesn't mean that all the usual advice doesn't apply, such as warming up and cooling down properly, keeping well fed and hydrated, and "no pain, no gain" is a myth, if your in pain, stop! 

References

Am J Sports Med. 2012 Feb;40(2):452-8. doi: 10.1177/0363546511425647. Epub 2011 Oct 26.
Long-term results of surgical decompression of chronic exertional compartment syndrome of the forearm in motocross racers.
Winkes MB, Luiten EJ, van Zoest WJ, Sala HA, Hoogeveen AR, Scheltinga MR.