December 10, 2009

That Troublesome Achilles Tendon

The Achilles Tendon is made up of two major muscles and one insignificant muscle. The two muscles are the Soleus, which does not cross the knee and the Gastrocnemius which does cross the knee. The distinction is important because most people only stretch the Gastrocs (see the typical runners stretch with the knee straight). Very few people I treat regularly stretch their Soleus. The best way to do this is to be on the floor in a sprinters start and you will feel the stretch in back of the calf in the forward leg- this will be the Soleus that is stretching.


Sometime in middle age, around age 35 or so, I often see calf strains. The situation is typically one where the muscle is fatigued, and the person steps backwards, like on a tennis court or basketball court, and they feel like they have been hit or kicked in the back of the leg. Typically, it is the medial third of the Gastrocs that gets strained. this is a muscle/tendon junction injury and can be easily treated, with a good outcome for return to sport.

At other times, the tendon actually ruptures. This can be the same move that causes the muscle strain, but the injury is felt further down, and feels more like a gunshot to the leg. The rupture of the tendon is the last event following many more minor events that lead to the gradual thinning and weakening of the tendon.

A rupture such as this requires surgery for repair. Then the PT that follows the surgery needs to both restore ROM, and also balance as well as explosive strength.

For whatever reason, I have several Achilles tendon injuries in the clinic at the moment. Among my present population is an acute Gastroc strain, a very irritated and strained tendon, a recently ruptured and repaired tendon and a tendon that was repaired a long time ago. Each of these situations offers lessons for prevention and for recovery.

The medial third Gastroc strain illustrates the importance of both stretching and hydration. Not hydration in therms of how much water you drink, but hydration at a tissue level. More on this later. Pre-game stretching will help prevent this injury as will stopping when you have become fatigued before the injury stops you!

The pre-failure tendon illustrates the consequence of multiple injuries to the tendon that lead to a thinning of the tendon (called “necking” in the physiology text books). The progressive failure of a dense connective tissue goes through several stages before a rupture. One of the last stages before the rupture is this necking stage. If you grab your Achilles tendon and pinch it, and it hurts, then damage has occurred in the tendon to the dense connective tissues and you are on the way to further damage that might eventually lead to rupture.

The recently repaired tendon needs good rehab to stimulate the best and strongest possible repair. The rehab needs to take into consideration the repair characteristics of the scar that is growing. Then the strength needs to be restored. My patient with recently had a repair, for instance, cannot actively recruit the Soleus at the moment. This will pass, but we need to pay attention to the restoration of strength as well as to the other issue such as balance and ROM before we start thinking about activities like running and certainly before sprinting.

The post surgical tendon – a year or two out, reveals that not enough energy was spent in the rehabilitation cycle. The loss of power of the injured leg has left the leg in a state of sub-optimal performance ability. We now need to help this person build muscle mass and restore the Type II muscle mass especially.

I think that the best treatment for the Achilles Tendon is prevention of injury in the first place. So three things come to mind:
– Stretch the Gastrocs AND the Soleus
– Strengthen the two muscles as well. to strengthen the Gastrocs, do heel raises with a straight leg. To strengthen the Soleus do heel raises with your knees bent. You should do 40 continuous heel raises on both legs with both positions and then do 40 continuous on EACH leg.
– Use THE STICK to work the tissue regularly.

stick your calf

Finally, a word about water binding in the dense connective tissues. If you are middle aged, you need to take a supplement like COSAMIN DS or MOVE FREE that provides molecular support to the production of GLUCOSAMINOGLYCAN – a long mucopolyscharide that binds water in the connective tissues and makes it both more elastic and also tolerant of tensile forces.

July 14, 2009

The Case for Barefoot Running

As an orthopedic physical therapist who builds custom orthotics and provides custom orthotic therapy, one might be surprised that I am also an advocate of barefoot running.

I believe that running around barefoot forces the foot into an ideal posture for running unlike the sophisticated running shoes on the market today that allow and even encourage   running.rearfoot strike

The runner who is a “heavy striker” is a great candidate for barefoot running. While there have not been many studies examining the benefits of barefoot running compared to shod running, the fact is that there is a lower incidence of chronic injuries associated with barefoot running. In fact, an article in Sports Science notes that “running barefoot is associated with a substantially lower prevalence of acute injuries of the ankle and chronic injuries of the lower leg in developing countries”.

The heel strike is a normal    part of the normal gait cycle in walking, but in running, it is preferable to be a mid-foot striker rather than a rear foot striker.  Heel strikers are “puling themselves along” while mid foot and fore foot  strikers are “pushing themselves along”.  I encourage heavy plodders to try to run on their toes in order to move the strike toward the forefoot. In contrast, look at this image and see both the body posture of the runner and how by leaning forward his strike is naturally more underneath him, and as such, is naturally more of a forefoot or even mid foot strike. forefoot strike

I have found that one of the best ways to do this is to run barefoot. By running barefoot, there is a tendency to stay off the heel because excessive heel strike is actually painful, which should tell us something about the way the foot is designed. Remember, there is good evidence from at least a couple of world class runners, that barefoot running does not interfere with performance and, it may be argued, that barefoot running might even enhance performance.

I also want to promote a great new shoe to assist one in their barefoot running efforts. The Vibram Five Finger Classic Water Shoe, shown below is a really useful way to get into barefoot running so that as one does so the risk of injury to the sole of the foot is minimized.

Vibram Five Finger Classic Water Shoe

Vibram Five Finger Classic Water Shoe

The shoe is available at REI for example, and costs about $75.00. Pretty good value. The people I know who are wearing the shoe are very impressed with the feeling they have about the shoe and how it gets them onto their toes during their runs.

So the take away is this: If you are having trouble as a runner with chronic injuries, or if you are a really heavy striker and you can hear your self running, or if you describe yourself as a really “heavy” runner, then you might be a really good candidate for barefoot running to help you re-educate yourself to be more of a forefoot or even a mid-foot striker.  If you go in this direction, then the Vibram Five Finger Classic Water Shoe might be a good solution for you.

December 14, 2008

Achilles Tendonitis Rupture?

The Achilles Tendon often ruptures somewhere around age 40 – I usually see this injury in men, but as Misty May, the US Beach Vollyball Star learned, women experience this injury as well.

The Achilles tendon, like all tendons, is a dense connective tissue made up of microfibrils of collagen, the most prevalent protein in the animal kingdom. As we age, little by little, the tendon fails microfiber by microfiber, and while this is not a serious issue on a microfiber level, at a certain point, the number of microfibers that have failed starts to interfere with the function of the tendon, usually felt as stiffness in the tendon.

When the tendon reaches a level of weakness that it starts to feel poorly, the tendinitis, there is usually already irreversible damage to the tendon with sufficient microfiber failure that leaves the tendon vulnerable to further damage and eventual rupture.

When the tendon ruptures, it often sounds like a gunshot and feels like you have been kicked on the back of the leg. I often hear stories about the person going down and looking back to see who kicked them, only to find that there is nobody there. The tendon usually ruptures when the foot is placed on the ground while moving backwards, when you plant the foot for example.

The best thing to do to avoid a rupture, and even Achilles tendinitis, is to a. stretch regularly, and b. Strengthen the muscles of the calf, and c. avoid overuse of the tissue if you can help it.

As far as strengthening and stretching are concerned, you need to remember that there are two muscles that could in fact be stretched and also strengthened. The Gastrocs and the Soleus. The Gastrocs cross the knee and the Soleus does not, so in strengthening the Gastrocs for instance, you need to keep the knee straight, while on the other hand, strengthening or stretching the Soleus, you need to keep the knee bent. I believe that most acute strains of the Gastrocs affect eh medial third of the muscle, but most ruptures of the tendon are caused by lack of stretching of the Soleus especially. So give attention to this muscle and I think that a lot of trouble can be avoided.

As for strengthening, my suggestion is that you work up to 40 continuous heel raises off a step so that the heel drops down, with both a bent leg and also a straight leg to ensure strong muscles.

As far as overuse is concerned, this is especially an issue for runners who allow their shoes to deteriorate excessively while putting on the miles, and also for basketball and tennis players, for some reason, who step backwards a lot. I think a good strengthening and stretching program will eliminate most trouble.

One thing to think about is that if you have had a lot of pain and or stiffness in the Achilles tendon over the years, you are at risk for rupture, especially if you can actually feel the tendon get a lot thinner as you palpate along its length. In that case, I suggest you perhaps avoid activities like basketball or tennis, and treat the tendon to reduce inflammation as much as possible.