ACC Sports Sciences Main Page

Anne Bradley, ATC-L
Chad Ezzell, M.D.
Wake Forest University Sports Medicine

To achieve success in the sport of tennis, an athlete must be able to run, stop, back pedal, move laterally, and change directions quickly. It is not surprising that over the course of a long competitive season, these activities may predispose tennis athletes to lower leg injuries. Achilles tendinitis is one of the most frustrating injuries that can plague an athlete and prevent them from enjoying a healthy season.

The Achilles tendon is the largest and strongest tendon in the body. It plays an important biomechanical function in positioning of the foot as the leg moves forward while walking or running. The calf muscles (gastrocnemius and soleus) function with the Achilles tendon to flex the foot downward (plantar flexion.)

Achilles tendinitis involves inflammation of the tendon or its tendon sheath. The most common symptom is pain after exercise or after a prolonged rest, such as getting out of bed in the morning. Other symptoms of Achilles tendinitis include a pain along the course of the tendon when pressure is applied; a thickened tendon appearance compared to the other side, swelling, and decrease in ankle strength and range of motion.

Prevention

There are several effective strategies that can be used to prevent Achilles tendinitis. Athletes should ensure that they are properly warming-up before each practice and game. A good warm-up routine should include jogging, skipping, light jumping and hopping activities to gradually introduce the activities that the legs will undergo during the course of a tennis match.

It is also important to make sure that an athlete has proper court and running shoes for their foot type. If the sole of the shoe is too rigid, it may not allow for enough motion of foot and shock absorption. This could place additional stress on the Achilles tendon. Another common problem is a shoe that fits too small and creates friction between the Achilles tendon and the heel counter of the shoe.

There are anatomical factors that have been identified as contributors to Achilles tendinitis. Many individuals with Achilles tendinitis have limited calf and hamstring flexibility. Fortunately, these issues can be addressed through a good stretching program. Structural problems in the lower leg may increase stress on the Achilles tendon.

Examples would be problems commonly known as "knock knees", "bowlegs", and flat feet. Referral to a sports medicine physician or podiatrist may be helpful to determine if orthotics would be appropriate in order to promote better foot mechanics.

A carefully planned training program may be the most important prevention strategy. Any sudden changes in the duration, intensity, and frequency of training sessions often lead to injury. Changes in surface type, such as workouts on a grass field versus a tennis court, may also precipitate injury.

Finally, in some cases Achilles tendinitis can develop secondary to another injury, such as an ankle sprain, when an athlete returns too soon to competition. They may subtly change their mechanics with running or jumping, or favor the non-injured leg, and place extra stress on their calf muscles and Achilles tendon.

Treatment

Treatment protocols depend on factors such as severity of the injury, time in the competitive season, and the previous injury history of the athlete. Initially, rest or modification of activity is necessary to protect the Achilles tendon from further injury. A heel lift in the athlete's shoe is commonly used to alleviate stress on the Achilles tendon.

Two treatment options that are no longer popular are cast immobilization and cortisone injections. Lengthy immobilization made it very difficult to regain full range of motion and strength, while cortisone injections have been associated with an increased risk for an Achilles rupture.

There are several therapeutic modalities available that can reduce the pain and swelling associated with tendinitis. Ultrasound, iontophoresis, and ice massage are all effective.

Once tolerated, range of motion exercises are necessary to regain normal mechanics of the lower leg and ankle. Passive stretching of both gastrocnemius and soleus is essential. Stretching should be done with the affected leg placed slightly behind the other, keep the heel on the ground, and then lean forward. It is helpful to use a wall for balance. This stretch should be done both with the knee straight and then again with the knee bent to stretch all of the muscles of the calf. Stretches should be held for 10 seconds, 10 repetitions, and done two to three times a day.

Strengthening exercises are also important in treatment. There are various methods that can be used. Standing calf raises are done standing on one leg and slowing flexing the foot up and down. Seated calf raises usually require the use of a resistance machine and strengthen a different portion of the calf muscle.

Rubber tubing or elastic bands are important in strengthening the side to side motions of the ankle. Single leg balance exercises should also be performed in both a straight and bent knee fashion. As the athlete is able perform exercises without pain, they should gradually resume tennis-related activities.