Updated: Nov 26, 2019
This is a part 2 of a 4 part series. In my previous post we covered Iliotibial Band Syndrome. Check them all out at www.breakoutppt.com/blog.
The Achilles is the thickest and strongest tendon in the human body. Tendons are tough bands of fibrous connective tissue which anchor muscles to bones allowing movement, in this case the calf muscles to the heel (calcaneus). This specific attachment allows for plantar-flexion of the foot which is needed for activities such as walking or running.
Despite the Achilles being the strongest tendon in the human body, it is also the most commonly torn or ruptured. Ruptures can occur when tension on the achilles is too high such as forceful jumps or sudden accelerations. Often when this happens, you’ll know right away. Popping sound can be heard with severe pain and swelling in the area, walking will be very difficult. Earlier and less dramatic signs of high strain on the achilles are tendinopathies.
Tendinopathy is a general term for tendonitis (inflammation) and tendinosis (thickening + weakness). Dull ache and stiffness is often felt at the start of movement, first thing in the morning or after prolonged periods of sitting, but will decrease as the area warms up. Pain can return if training intensity increases with progression to sharp pain if you continue to push through it. Pain is often felt either in the midpoint or insertion of the achilles. Depending on the location, the enlarged tendon may also begin to irritate the underlying bursae.
This occurs when excessive strain is repeatedly placed on the Achilles Tendon. Factors to consider are calf muscle weakness, weight- shifting/leg bias, exaggeration of ankle pronation, poor ankle range of motion, poor hip extension range of motion. This strain begins to disrupt the collagen fibers which normally ran parallel but due to insufficient healing time form in unorganized patterns.
In order to help the collagen fibers heal properly we need to carefully select what stimuli we provide the tissue. While stretching can help alleviate pain, aggressive stretching is thought to hinder recovery. Due to poor orientation of new fibers aggressively stretching will tighten undesired knot-like fibers. Instead, eccentric heel raises have been found to help selectively damage the tendon to encourage proper alignment. This exercise is thought to break apart misaligned fibers and allow the body to lay down new ones in the proper alignment.
Eccentric heel raises should be performed in both knee straight and knee bent positions. Starting with both feet on the floor, push yourself up onto the ball of your feet. Make sure not to allow your foot to supinate taking advantage of mechanical leverages of foot bones rather than relying on musculature. Simple cue is maintaining pressure on your big toe. Now, lifting one foot off the ground allow the other to drop towards the floor in a slow and controlled manner. Begin by performing 1 set of 12 repetitions with each foot in both knee positions, over time work your way up to 3 sets. Further progression can be completed by using a step (if steps are not available get creative, maybe use a book) and allowing your heels to dip below the edge to allow deeper ROM.
Remember to look at the entire kinetic chain and maintain sport specificity. The calves are most active during landing and hip extension. Factors such as running mechanics, hip extension mobility and strength play a role in achilles strain. Over-reaching will cause your leg to land to far in front of your center of gravity. This means your calves in stay under tension for a longer period of time as it covers the extra distance to get behind your hips. The hamstring is also placed in a passive insufficiency position hindering it's ability to pull you forward. Even if mechanics are solid, strengthening the hamstrings and glutes to better withstand demands of running and offload your calves/achilles can be a game changer.
The arches in your feet play a vital role in shock absorption during running. The arch shape allows for your foot to stretch out during weight-bearing and then recoils after you’ve propelled forward. You have bones, muscles (eg Tibialis Posterior) and ligaments working together to help maintain these arches. The long plantar ligament, spring ligament and plantar aponeurosis (fascia) run from your heel to the front of your feet to help maintain your foot’s arch.
Plantar fasciitis is an inflammation and subsequent adhesions of the plantar ligaments. Much like Achilles tendinopathies, plantar fasciitis will hurt early in the morning, “first step pain”, or after prolonged periods of inactivity. Pain is often reported on the medial portion of your heel by the start of the arch and can run down to the front of the foot. The pain will often decrease as the tissue warms-up but can return with an increase in intensity, end of run, or with very flat shoes/barefoot.
When reporting these symptoms you’ll often hear recommendations such as wearing orthotics or more support footwear, arch taping, rolling foot with frozen water bottle and reducing time on your feet. While these all can play a big role in reducing symptoms they do not correct the problem. Calf and plantar stretches should be completed. Night splints can often be prescribed for chronic suffers. Strengthening exercises should also be included in treatment to offload strain on ligamentous support. During a visit with your Physical Therapist, they can also utilize IASTM for more aggressive disruption of any adhesion.
Calf stretches can be performed by leaning forward against the wall with your hands. Place your feet in a staggered position so the front knee is bent and the back leg remains in an extended position. Lean forward until you feel a stretch and hold for 30 secs and then switch. Plantar stretches can be performed seated by pulling all your toes back towards your shin. This can be completed as 10 repetitions for 10 seconds each. Strengthening exercises can be as simple as practicing your single limb stance, ensuring your big toe stays down on the ground. Several variations exist to progress this exercise. Finally, resisted foot adduction is a great way of training Tibialis Posterior muscle in isolation.
Next week we will cover Patellofemoral Pain Syndrome/Chondromalacia patella, Patellar Tendonitis, and Muscle Strain