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Wednesday, January 3, 2018

Eccentric Training of the Achilles: How Low to Drop the Heel?

Hi Rich:

I hope this finds you well.

My feet are holding up OK. Left ankle is still funky, as are some toes on the right. But nothing worse. And I did two marathons in four weeks at the end of this year (New York and CIM), so I can’t complain. For a while, I was feeling that no matter what shoes I tried, I couldn’t avoid neuroma pain and started to wonder if it was time for new orthotics. But things seem to be stable now.

I have a question about calf raises. I know you have cautioned against calf exercises that have one lowering past level. I know you didn’t want me doing that when my plantar fascia was healing from the tear. But, if I’m not mistaken, I think you aren’t a fan of that altogether (and would instead recommend, say, keeping one’s heel on the ground, or even doing downward dog). But I am checking.

I noticed my online running coach had these two videos linked on his site as part of his foot/ ankle/strength routine. I wonder whether you would recommend these exercises or caution against them?

Eccentric calf straight leg x 25 reps each foot

Thanks, and be well,

Why did the calf muscle pull? Typically fatigue and some element of the soft sand allowing the heel to drop too low or the knee extending too much. 



Dr. Blake's comment: Thanks for the nice email. I will use it on my blog today because it reminds us of many points. When you are strengthening a muscle and its tendon, you have to think not only about concentric strengthening (where the muscle shortens doing its typical job) but also eccentric strengthening (where the muscle is in a controlled lengthening). Ask your therapist how to do each. I do not believe in pushing through pain when doing exercises, but some tendons have so much nerve innervation like the posterior tibial tendon with the posterior tibial nerve that we have to allow some pain as long as it does not affect the next day. 
     When you do calf eccentrics, which are wonderful exercises, you do not have to lower the heel past the level of the forefoot. So, in the two videos above that you sent me, I would have the patient just come back to ground level. You can get very very strong this way, and it is safer. Here is my original video after the article on eccentric strengthening. 

https://academic.oup.com/rheumatology/article/47/10/1444/1787695


     So, when you put the heel lower than the forefoot, with all your body weight coming down, the Achilles and plantar fascia are getting abnormal stresses. Do everyone need to avoid negative heel positioning? No!! But we all have weak spots (Achilles issues, scar tissue from an old injury, knock-knees, unstable ankles,etc.) that come and go during our lives, and that we have to be diligent of and work towards making less vulnerable. If you have old Achilles or plantar fascia injuries, or perhaps an MRI for some other reason showed some degenerative changes in these areas, then it is prudent not to intentionally place your weak spot under high stresses. People do not injure their Achilles running uphill on their toes, they hurt the Achilles when they are tired or untrained for the activity and their heel keeps dropping below the forefoot. 
     I am sorry if this is hard to explain so I am trying various explanations. The body can be worked for the positive (hooray!!) and overworked for the negative. What can make an exercise have a negative impact on you? The common components are a poor technique in general, stressing the tendon/tissues in abnormal positions, the stresses overload the tissue by jerking too much, too much weight, holding too long, starting out too tight, etc. The list goes on. The stress may be to the tissue being exercised directly or a byproduct of the exercise (like the plantar fascia being torn while doing eccentric negative heel Achilles strengthening). 
     I think your plantar fascia, from your previous injury, is a weak link, therefore, overstressing, when you can avoid it, is preferable. I think the downward dog pose is probably fine now since your injury has healed, and your weight is so forward (versus the vertical column of weight crashing down on the plantar fascia in the 2 videos above. 
     I have to finish the conversation by emphasizing the normal ways to strengthen the Achilles in my practice to see if you are doing all of these:
  • 2 positional Achilles stretching and other warming up exercises (like bike riding)
  • Straight leg two-sided heel raises 20 rep warm up, slow going up as high as possible concentrically and slow bringing the heel down to the ground eccentrically
  • Bent knee two-sided heel raises 10 rep warm up, slow going up as high as possible  concentrically and slow bringing the heel down to the ground eccentrically
  • Straight leg two-sided up 20 reps, then with right off weighted, and lowering the left side slowly bringing the heel to the ground
  • Straight leg two-sided up 20 reps, then with left off weighted, and lowering the right side slowly bringing the heel to the ground
  • Bent knee two-sided up 10 reps, then with right off weighted, and lowering the left side bringing the heel to the ground
  • Bent knee two-sided up 10 reps, then with left off weighted, and lowering the right side bringing the heel to the ground
  • Straight leg right off weighted, maximal left one-sided heel raises (until pain or burning or just can not do it more)
  • Straight leg left off weighted, maximal right one-sided heel raises (until pain or burning or just can not do it more)
  • 2 positional Achilles stretching 
You can then slowly build up to 50 one-sided straight knee and 25 one-sided bent knee over time. It is fun to chart the numbers. These exercises are done in the evening at best to allow the most rest after (in the 2 hours before you go to bed). With the one-sided Achilles, the numbers will vary from day to day, but you should see improvement each week with the total done. For example, I also mark the calendar Right Straight Right Bent Left Straight Left Bent so it would be an entry 10/4, 13/6. Anyone looking at the calendar would not know what they are looking at. Build up to every other day 50/25, 50/25. This can take a year, and longer if there are setbacks. Remember, never through pain, and rest day in between. 
There is more, but I can not remember anyone going through this program having too much strength issues. The slowest part, and sometimes the part that takes the most time, is when you can do 2 sided, but not one-sided (at least on one of the sides). Then you have to do many other things like toe walking, pool walking, first build to 100 two-sided, etc. I can get in more depth if someone is interested and emails me at drblakeshealingsole@gmail.com. 
Hope this all helps. Happy New Year again. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.