CASE REPORT Water and land based rehabilitation for Achilles tendinopathy in an elite female runner

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. Chronic painful conditions located in the Achilles tendon are relatively common, especially in runners. The cause of such conditions is not known, but they are often associated with repetitive loading and overuse. Achilles tendinopathy is difficult to treat. Most recommend a conservative regimen as the initial strategy. Non-surgical treatments include a combination of rest, antiinflammatory 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. 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 midportion of the Achilles tendon. 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. 7 In addition, over the last two decades there has been a considerable increase in the incidence of Achilles tendon rupture. 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. 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. 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. CASE REPORT 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.