Heel Raises: So Important for Seniors and Overall Health

https://youtu.be/0r6w8K6ckQk

     This video highlights one of the two most important exercises in the lower extremity and is well done. The end of the video discusses negative heel positions and this is where I would differ as I prefer to have my patients stay away from negative heel positions. However, the logical progression to this video of gradually adding more difficulty is wonderful. The goal standard in sports medicine is 25 single leg heel raises, and the video shows you how to get there. The video also does not delve into the complexity of separating the gastrocnemius and soleus muscles, but again it is a great starting place. You want to gradually, probably on a weekly basis, add 2 more repetitions from her starting point of 1 set of 5 repetitions. Work your way through two sided heel raises, to two sided up and one down, to single sided (one up and down). Have fun getting your achilles tendons stronger. 

My new video on Achilles Strengthening

https://youtu.be/53AXlas2q6s

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

https://www.youtube.com/watch?v=d3YKlGdWni0

Eccentric calf bent leg x 25 reps each foot

https://www.youtube.com/watch?v=JTQeyikbo4Y

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. 

Achilles Injury: Always think about the Soleus

http://www.runnersworld.com/injury-prevention-recovery/soleus-strength?utm_source=t.co&utm_medium=social&utm_campaign=sharebutton

https://youtu.be/xjsYz_YFGyY

The Importance of Calf Stretching

http://www.anklefootmd.com/regular-calf-stretching-prevent-need-foot-surgery/

https://youtu.be/0eAqJ4-oKTM

Achilles Tendinitis: Email Advice regarding strengthening and running

Hi Rich;

I'm not up to 100 stretch sessions yet but I'm getting close (at which point I will make another appointment with you).

In the meantime, I just wanted to keep you abreast of what's going on.

I've been running every other day and doing the stretching regularly and leg strengthening exercises faithfully. I am now up to 50 straight leg both legs/25 bent legs, as well as 50/25 on each leg separately. I do, however, break the individual legs into sets. 25 straight leg on my right, 25 on my left, second set of 25 on my right and left, the 25 bent knees on both. My calves really start to burn at about 21 but I have the strength to power through them. I feel like they're really helping me with some burst energy when I run,which is good news.

Dr Blake's comment: I am having this patient each evening do two sided calf raises both straight and bent knee to warm up, and then straight and bent knee single leg calf raises to tolerance (pain in the calf/achilles, or burning. She has slowly worked up to this level. Sounds like she is successfully squeaking in a few more after the burn. She is also doing more since she is breaking them up into 25s for the straight knee. The goal in rehabilitating achilles is to build up to 50 one side straight knee, and 25 one side bent knee. 

This past weekend, I deviated from the "run only every other day" by running two days back to back. I ran 7.5 miles on Saturday at a relatively fast click (for me) and then a little slower on Sunday for 6 miles. I found after yesterday's run that my achilles reminded me that I needed stretching (we sat in the car a while) so I made sure to stretch whenever I could.

This morning, I felt the normal tightness in my achilles, but after my regular morning calf stretch routine it feels completely fine.

Question: I have a half-marathon coming up in 7 weeks and I would like to start being able to incorporate two things:

Running 4 times a week rather than 3

Running longer runs.

I want to get a sense from you whether those would be OK. The 7.5-miler was a test; I felt fine afterwards but I made sure to ice and stretch afterwards.

No crazy big miles for any of the runs but I would like to be able to run at least a couple of 12 milers in the next 5 weeks. Do you think that's reasonable?

By the way, I have started taking a yoga class once a week and I find that it is very helpful.

Thanks.

Dr Blake's comment:

     Sounds great, but you can do the 1/2 marathon better with every other day runs when you are recovering from an injury. That gives you 4 times one week, and 3 the next. It will honor the recovery phase better, and when you are increasing mileage (especially the long runs), it makes a big difference. Hope it makes sense. Keep up the hard work. With 7 weeks to go, run 8 miles the first weekend, 9 miles the next, 10 the next, 11 the next, and 12 the next. You will be more than ready.  Rich

Saturday's Exercise of the Week: Eccentric Strengthening of the Achilles Tendon

The video below shows how I love to teach my patients eccentric strengthening of the achilles tendon. Eccentric strengthening is when the tendon is lengthening at the same time you are contracting it. Concentric strengthening is the classical toe raise where the tendon is shortening while strengthening. It is vitally important to strengthen a muscle/tendon complex both concentrically and eccentrically. I hate eccentric strengthening where the heel is lowered below the front of the foot, like off a stair. This is okay at times with healthy tendons I am sure, but I am treating patients with achilles problems already, and that position is a very vulnerable place for the achilles and can cause injury. 

http://youtu.be/hjNWF7QelNY

Achilles Tendon Flexibility Measurement and Strength Daily Routine

I hope you enjoy my new video on the Achilles Tendon

Dangerous Achilles Strengthening Exercise

The video above has two basic parts to it. The first part is the stretching part. As long as the heel is on the ground, the stretch is safe and should produce excellent flexibility. The second part however is the strengthening part. This is very risky since a Negative Heel Effect is created when the heel comes off the ground. Negative heel is when the front of the foot is higher than the heel. This is a very unnatural position and definitely the cause of many injuries. Avoid at all costs. The same exercise starting with the heel and front of the foot at the same level is much safer.

Achilles Tendon Strengthening: Video on Resistance Bands and 2 Positional Weight Bearing Exercises

     This new video is on achilles tendon/calf strengthening. With the achilles tendon being the strongest tendon in the body, this is a vital area to re-strengthen after injuries or prolonged inactivity. The reader is encouraged to read the previous post on strengthening exercise in the article on Treatment of Tendinitis (the link is below). Thera Band type strengthening used in this video is also called Progressive Resistive Exercises. You gradually work through a varying resistance based on the variable resistance placed in the multi-colored bands, but also the resistance is variable since it is coming from you. You supply the power to move the band which will resist you back. As the patient works from 2 sets of 10 reps in the lightest band to 2 sets of 25, usually add 5 more reps per week, they then move to the next color starting again at 2 sets of 10. Every advance should be pain free and feel easy to the patient. Strengthening at a low level can be done daily, and I prefer my patients to do them in the evening. In this way, if you fatigue the calf muscles and achilles tendon, they have all night to rest before you stress them the next day. Gradually, as you advance to the weight bearing gastrocemius and soleus strengthening exercises, you should switch to the normal strengthening regimen of three times per week.

     I can not emphasize enough how neglected the Soleus muscle is in achilles rehabilitation. These weight bearing achilles exercises are so important. All achilles injuries must be rehabilitated to be able to do 2 sets of 25 single leg gastroc, and 2 sets of 15 single leg soleus. Without restrengthening this vital muscle, reinjury will occur, and injury to surrounding muscle/tendons with various tendinitis will occur. Physical Therapists these days love the Weight Bearing exercises demonstrated since it is Functional. But the resistance bands can play a big role in regaining lost tone in the gastroc and soleus. It has been said that the gastroc and soleus lose 3-5% of their strength per day in an injury, and gain it back less then 1% per day. Do the math to see how long it may take you to regain achilles strength if you are injured and need to be in a cast for 3 months.

     Good luck with your Rehab!!


http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html