Achilles Tendinitis: Yes it can get better!!!

This email is from one of my favorite long distance patients. I treated her for achilles tendonitis last year with activity modification, icing, stretching and strengthening. The email shows that this basic approach was successful. She also found a wonderful video on self deep tissue mobilization of the calf, but not to be done if your knee cartilage is suspect at all. The technique requires your knee to be too bent forcifully for too long. But, given good knees, and given a calf or achilles problem, you may want to add this to your regimen. Another example of how I learn more from my patients than medical seminars some times. Rich

Hi Rich;

I meant to make a follow-up appointment with you for earlier this spring, and I got caught up with stuff and never did. Part of the problem (if you want to call it that) is that my Achilles was feeling much better... which meant I wound up putting off making an appointment to see you.

I think I don't need to make another appointment at this time, but I thought it would be good to send you an update.

I kept up with my calf stretches regularly (and heel lift exercises not-as-regularly but still every so often), to where my Achilles no longer bothered me. I stopped wearing the support boot at night. I also felt like I could finally start pushing off with my left foot and I didn't feel any sort of strain.

The big news is that I ran the Mountains 2 Beach Marathon (from Ojai to Ventura) this past May, and qualified for the Boston Marathon! Not only did I BQ; I did so with 5 minutes 12 seconds to spare, essentially guaranteeing a race spot by being able to register during Week 1 (with the rest of the "fast runners"). I have a friend of mine who only made her qualifying time with a spare 100 seconds, who was shut out for the 2016 race because the cutoff was 2 minutes 38 seconds (I assume you know how that two-step process works for Boston).

I have registered and been confirmed to run Boston next April. I also won the "Boston 2 Big Sur" lottery so I will be running the Big Sur International Marathon down in Monterey a week after that.

Things got a little dicey after the marathon. Just a few weeks later, we took a vacation to Grand Teton and Yellowstone, where we ran two half marathons. Since we were doing a lot of hiking and also some camping, I actually didn't stretch as much as I should have... and so June/July was a little concerning because my Achilles tightness came back. I restarted working on them with diligence, and the issue has resolved itself now.

Now that I no longer feel gimped, I find that being able to push off with healthy feet/legs has made a tremendous help in my speed. This past weekend, I ran the inaugural Yosemite Half Marathon, and had I been suffering from Achilles tendinitis that course would have had me howling in pain; the course is 10 miles of downhill, with a leveling off/rolling streets for the last three miles.

However with my healthy Achilles, I was able to just remove my brakes altogether. I finished with a time of 1:40:51.9 and broke my previous PR by 10 minutes. My husband joked that I should put an asterisk on it because it was a gravity-assisted course, but I also came in first in my age group... THAT's legit, since everyone else in my age group also ran the exact same downhill course.

One quick question. A friend of mine forwarded me this video, and I'm wondering what you think. It makes sense; it's essentially like having someone press down on your knots while you try to work them out.

http://mobilitymastery.com/learn-the-one-stretch-that-relieves-plantar-fasciitis-shin-splints-achilles-pain-heel-pain-and-compartment-syndrome/

Cheers!

PS: Sorry about the Giants. The A's sucked this year, too.

Achilles Tendinitis and The Tip of the Iceberg Concept

Are You Looking at the Tip of the Iceberg?

Each week I have patients that present with their first foot or ankle injury and I wonder whether I am looking at the Tip of the Iceberg of this and other future injuries. No matter how minor the injury appears, I wonder if it will be followed by another and another and another. What can I do as a healthcare provider to eliminate or at least minimize the onslaught of future injuries? How serious should I take these initial injuries which will heal relatively quickly? Should I always follow the KISS Principle and Keep It Simple Stupid when I think some of these injuries are definitely the Tip of the Iceberg? More pain is on the way. What goes into the thought process of deciding who should get more treatment when relatively simple injuries present into my office? The treatment of any overuse injury (without an acute single episode) should always be directed at the one or two common causes, or the several possible causes for this individual patient. Take Achilles Tendonitis for example. The common causes of Achilles Tendonitis are:

1. Straight overuse situation in which the Achilles Tendon is put in major stress (i.e. stair running for the first time, or working out too many days in a row, etc.)

2. Very tight Achilles Tendons.

3. Worn out shoe gear with lack of stability or cushion at impact.

4. Unstable shoes, or excessive wearing of shoe gear with inadequate support (i.e. too much time in the flip flops, etc.)

5. Short leg with compensation of early heel lift.

6. Excessive pronation of the foot/ankle with excessive torque on the Achilles (as seen in the left foot of the photo below).

7. Excessive supination of the foot/ankle with lateral instability and over firing of the Achilles Tendon to stabilize the ankle joint complex.

8. Very loose Achilles Tendons from over stretching or patients with loose ligaments in general. This produces a weakness in the tendon (see future post on the force/length curve).

9. Weak Achilles Tendons from many reasons (just returning to regular exercise program, following prolonged casting, aging process, genetics, dietary, etc.)

10. Achilles Tendonitis secondary to another problem (heel spurs, ankle injuries, sciatica, tibial stress fractures, etc.)

After performing an initial history and physical examination, and making the diagnosis if possible, the clinician will try to assess the reasons this individual patient developed their injury. It is the experience of the clinician that separates them from other health care providers in getting to the cause(s) of some injuries. Some “reversal of cause” treatment must be initiated in all cases. But for some patients, looking below the surface level of water, below the Tip of the Iceberg, is really what is crucial. What factors could lead, if not addressed, to either prolonged injury/treatment, or frequent recurrences of the symptoms. This is so crucial, but in a busy medical practice, often times not proactively explored. The patient and clinician only stumbles into the discoveries.

When a ship’s captain looks at the iceberg approaching, the captain scrutinizes the situation, assesses the severity, and then makes an appropriate plan. Health care providers, and proactive patients, can be slower than the sea captain at finally making these decisions, but must look at possible severity of the injury, and severity of the cause of injury, to come up with an appropriate plan. Since we can grade the severity of anything 3 typical ways—mild, moderate, and complex—let us look at these 2 factors in injury treatment from this angle. Perhaps then you can understand when under the Tip of the Iceberg danger may be lurking in the forms of prolonged treatment, possible incomplete healing, and frequent recurrences of the symptoms. After the initial assessment (history and physical), and perhaps after several follow up visits, the clinician will place the patient in one of 9 categories. These are:

1. Mild Injury/Mild Severity of Cause

2. Mild Injury/Moderate Severity of Cause

3. Mild Injury/Complex Severity of Cause

4. Moderate Injury/Mild Severity of Cause

5. Moderate Injury/Moderate Severity of Cause

6. Moderate Injury/Complex Severity of Cause

7. Severe Injury/Mild Severity of Cause

8. Severe Injury/Moderate Severity of Cause

9. Severe Injury/Complex Severity of Cause

With the Severe Injuries, the treatment is usually prolonged enough that the patient and doctor/therapist gradually work at recognizing and correcting all possible causes of the injury along the way. It is the Mild and Moderate Injuries, that the KISS principle and Tip of the Iceberg principles must be reconciled. It is when the injury is classified as mild or moderate that the health care provider must decide when to look under the Tip of the Iceberg and explore the depths of moderate to complex causes. It is in the 4 categories below that I find most problems in dealing with these injuries. These are:

1. Mild Injury/Moderate Severity of Cause

2. Mild Injury/Complex Severity of Cause

3. Moderate Injury/Moderate Severity of Cause

4. Moderate Injury/Complex Severity of Cause

In these cases, I see the most patients for 2nd opinions. Why is the injury not healing? Why does the injury keep coming back? The mild and moderate nature of the initial injury makes the healthcare system relax and not look too deep into cause of injury.

I will end this discussion with one example of this dilemma. Since I already used Achilles Tendonitis above, I will finish using an example of Achilles Tendonitis. The patient had pain in the Achilles for 3 months prior to seeing the initial doctor. The patient was a runner who pronated too much, rarely stretched the Achilles, when stretching only did Negative Stretching off a curb (which I do not encourage), was a vegetarian (not to pick on you guys too much!) but ate well, ran a lot of hills after moving from Dallas to San Francisco, and was told he had one leg shorter but never did anything about it. The initial treatment addressing the possible causes of the injury were Orthotic devices for the pronation, new motion control running shoes, power lacing, Achilles stretching 3 to 5 times a day, and running on flat ground, not hills until the symptoms got better. The doctor had categorized the patient mild injury/moderate cause of injury and had addressed the causes on the surface well. Was he/she just looking at the Tip of the Iceberg? What was below the surface that needed to be addressed? The patient after six months of treatment still was not much better in function. Running was still very limited. The initial treating doctor told him to stretch more and give it more time at their last visit (of 6 visits overall). This patient then sought a 2nd opinion.

    On review of the injury itself, the right diagnosis had been made. The plan of treatment initiated was good, but never improved upon when the patient was struggling. Each of the treatments initiated were subpar in retrospect. The pronation was only partially corrected with the new Orthotic devices (but they were easy to modify to greatly improve their function), the running shoe store had convinced him to not get a motion control shoe since he had Orthotic devices (and the doctor never evaluated his running after the first visit), the power lacing has been done incorrectly (and was also modified), diet counseling came up with non optimal protein intake (something that will help the patient forever), measurement of his flexibility showed him off the charts in over flexibility (too flexible means too weak and this was improved with 6 weeks of no stretching at all—he thought I was crazy when I proposed that one), and exact measurement of his legs showed over ½” short leg on the injured side (treatment with heel lifts helped him immensely). Within several weeks, he was feeling much better, and by 8 weeks was back running regularly with a better diet, heel lift for the short leg, sensible stretching routine before and after exercise, no negative achilles stretching, stable Orthotic devices, stable shoes, proper power lacing, and a gradual re-strengthening home program under a physical therapist with 6 one/month visits to up the ante. Yes, under the Tip of the Iceberg for this athlete was a considerable short leg, a considerable dietary problem, slightly harder to treat pronation, and an Achilles that could become over flexible too easily. His mild injury did not initially respond since the cause of injury was misread as moderate, when it really was complex.

The Golden Rule of Foot: When treating athletic injuries, if the symptoms and function plateau, look under the Tip of the Iceberg to a deeper level of possible answers.

Top 10 Treatments for Achilles Tendinitis: A Starting Point

Golden Rule of Foot:  Look at the Achilles Tendon Wrong and it will be sore for 9 months.

Introduction to Achilles Pain

    Treating achilles tendon problems can be very challenging and frustrating. So, it is so important to understand the basic rules of rehabilitation so you can get ahead of the problem as soon as possible. If I was to tell you two things to take to heart regarding achilles injuries, they would be “do not ignore achilles pain for it is not like other injuries, and begin working on controlling the swelling the day before it hurts”. Swelling is the deal breaker with achilles since it cuts off the normal circulation to the tendon and stops any chance of healing in it’s tracks.

    It is so important to know how to stretch the achilles tendon safely. I love the 3 positional achilles stretches I also teach for plantar fasciitis to be done 5 times daily, as long as there is no pain. Stretching the achilles tendon should give you instant and temporary help where you feel better. If this is not the case, you may have an over stretched tendon, a nerve problem, or a partial tear of the tendon (plus a few other things).

The top 10 treatments for achilles tendinitis are:

1. Stretching 3-4 times per day (see chapter 3)

2. Icing 2-3 times per day (see chapter 3)

3. Heel lifts in all flat shoes, or an elevated shoe like Dansko clog or heels/cowboy boots

4. Orthotic devices if over pronating or over supinating

5. Use activity modification to avoid “bad pain” (see post on Good Pain vs Bad Pain)

6. Begin calf strengthening as soon as pain free

7. If cannot walk, you need a removable boot with EvenUp on the other side and probably MRI

8. If symptoms are significant or persist, use PT or acupuncture, but consider an MRI to really see the 3D images.

9. Calf massage with massage sticks (always emphasized if you go to PT)

    10. Avoid activities that are too explosive or over stretch the tendon, or modify activities like

          staying on the seat of the bike in spin class, or not lifting your heel on the elliptical

Below is a few further thoughts on achilles stretching. These are all enclosed in the posts on stretching principles and achilles stretching.

Achilles Stretching Technique

    Proper Stretches for the Achilles Tendon are a vital part of every pre and post activity, and especially with injuries to the achilles, calf, plantar fascia, and hamstrings. There are two muscles, gastrocnemius and soleus, that make up the achilles tendon. These two muscles can be stretched separately by first having the knee straight (gastroc stretch on the left photo above), and then having the knee bent (soleus stretch on the right photo above). It is the back leg that is being stretched. The soleus stretch is being done incorrectly (on purpose) to demonstrate that the heel should be on the ground the whole time. With both stretches, it is important to keep the heel on the ground. Hold each stretch for 30 to 60 seconds, or 8 deep breathes. Deep breathing gets oxygen into the stretch, a good yoga principle. Do not bounce, called ballistic stretching. It is never good to jerk the muscle or stretch through pain. You want that good ache feeling. Try to stretch several times a day to actually gain in flexibility, even on days you do not do your normal activities. When non-athletes complain of cramping in their calves, often low potassium or dehydration is blamed. Have them try stretching 2 or 3 times a day and many will experience complete elimination of the cramps.

Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)

A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. The photo above shows a very powerful achilles and plantar fascial stretch. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch, called Negative Heel Stretching, can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of Foot: Avoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas which will be handled in other posts.

Achilles Tendinitis: Email Advice

Hi Dr. Blake;

I'm a marathoner who has been suffering from chronic Achilles tendonitis (from February 2013). Without going into a lot of details, let's just say I've seen podiatrists, sports therapists, etc. in the past year+, but the condition never healed because I refused to stop running. I slowly saw that my left foot was losing push-off strength and it was affecting my speed, so I've essentially been off running for the past month. I do stretching exercises twice a day and I've seen a marked improvement, but I still feel tightness, and it's likely going to take another month or two to heal...

I'm contemplating going to a running injury clinic for comprehensive evaluation, but I've been putting it off figuring there isn't a whole lot more they can do for me right now. However, as I get closer to the point where I feel like I'm healed, I want to start back slowly so I don't reinjure myself. Do you think I should be working closely with a sports physician (such as yourself) or a running injury clinic? Or would I be OK by myself, taking it slowly?

I've been spinning for exercise but I miss running SO MUCH!!! It's just killing me.

Regards,
Laura (name changed)

Dear Laura, 

     Thank you Laura for the email. I hope the following advice is helpful. Glad you finally were forced to let yourself heal, but you could have produced permanent damage. It is generally hard to treat this yourself, but you are also the best judge on how treatments effect you as an individual. There are 3 phases of injury rehabilitation: Immobilization/Anti-Inflammatory (which you have placed yourself into), Restrengthening and Return to Activity. Typically the bullet points below are best helped by a trained physician, PT, and yourself as the Sports Medicine Team. You, at least, need someone at times to decide on whether or not to get an MRI, what is the exact diagnosis (could it be something more than just achilles?), how to safely strengthen the Achilles and lower extremity, should you actually be stretching at all,  is your gait off enough for shoe change/orthotic devices/gait changes, and how to safely return to activity. This is my normal day, and the day of most sports medicine specialists. From a podiatry standpoint, if you look in the member list of the American Academy of Podiatric Sports Medicine you can usually find a good one close to you. 

     For now, consider the following:

1. Do two sided toe raises every evening until you can comfortably do 50 at a time without pain and with relative ease. Then slow start doing one sided toe raises. Do both straight knee and bent knee.The goal is 50 straight knee and 25 bent knee without pain. See my video below. Start with therabands if the toe raises are painful. 

http://youtu.be/xjsYz_YFGyY

      2. Avoid Negative Heel Stretching which can overstretch the tendon. Did anyone say you were either tight or over flexibile? If they said over flexible, minimize your stretching, and use a massage stick twice daily for any calf tightness. 



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

      3. Run every other day until soreness develops, even if that is 1 minute, once you can walk briskly for 30 minutes without any problem. Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point. 

      4. 3 times daily do either 20 minute ice pack or a full 20 minute contrast bath. This helps to manipulate the swelling within the tissue, and swelling which cuts off normal circulation within the tendon is our enemy!!!

http://youtu.be/rRt5hC24Afg



      5. Diagnostically, if you can get an MRI, get one. Knowing exactly what is going on can be a tremendous help to us. You can definitely wait as long as month by month you are gaining strength and activity.

      6. Set Benchmarks for activity--you definitely want to do more this month than last, but it can not be alot too quickly. To re-strengthen the achilles, it can take 6-7 more months. I would be gentle to yourself these next two months adding alittle to the toe raises each week, alittle to the time at spin class, alittle more walking, etc. By the end of July you will have a strong sense of what you can and can not do, and then set new Benchmarks for toes raises, walking, cycling, elliptical, and hopefully gentle running. 

I sure hope this helps you. Rich

The patient's response:

Oh, I meant to ask for a clarification. You wrote:

"Run every other day until soreness develops, even if that is 1 minute, once you can walk briskly for 30 minutes without any problem. Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point."

I wasn't clear on what this meant. Did you mean:

#1 If you can walk briskly for half an hour without any pain/discomfort/limping, then every other day, as a test, try to run until your Achilles feels sore.
Dr Blake's comment: Yes, runners need to run, even if it is a little bit, as part of their rehab. 
Somehow the text was lost here!!
Dr Blake's comment: Definitely. Most of my patients walk or run a stationary bike to limber up before running, then normal stretching, then run. 
How should I define "soreness" for this test? Discomfort that makes me adjust my gait? And since this is a test, I assume I want to immediately stop running when I feel soreness? So this is just to check on my healing progress? ("I had to stop after 70 seconds yesterday, but today I could go for 75 seconds"?)
Dr Blake's comment: Definitely, that is the right logic. See the Good Pain vs Bad Pain post. 
http://www.drblakeshealingsole.com/2013/12/foot-pain-dilemma-of-good-vs-bad-pain.html

#2 when you say "Substitute biking, with resistance and seat height modifications, 4-5 times per week at this point." do you mean that my exercise of choice right now should be biking 4-5 times a week, as a replacement to my running? I think that's what you mean, but I'm just making sure.
Dr Blake's comment: Definitely, biking is the best non weight bearing exercise that helps runners. 

I've been taking spin class and I have a smartphone app so I can essentially get a spin workout in by myself (the app has an audio cue from a coach so I just follow along).

Finally, I have a 10K next weekend I already registered for that I'm hoping I will be OK for (no plans to set any PRs). I also have a marathon for September but I can knock that down to a half marathon I also have half-marathon in mid-November, and then a half and and 10K in mid-January. I don't want to cancel any of those (they are big marquee events) but I can knock the September full down to a half. I don't think I have enough time to correctly train for a full marathon for September.

Thanks again!

Saturday's Exercise of the Week: Soleus Roll for Achilles Tendinitis

Achilles Tendon Injuries are very common. This is a wonderful video to help work out the muscle tension in the soleus muscle just above the tendon itself. There are many versions with massage sticks, foam rollers, and tennis balls, so please feel free to experiment. I personally like the wine bottle with warm water roll to get heat into the tissues while you massage, then an ice pack for 10 minutes after if you have mucho inflammatio!! Have no idea what I just said. Good luck. Dr Rich Blake





http://youtu.be/DgHoePuZaPw

Varus Wedging for Excellent Pronation Control

Achilles Tendinitis: Avoid Cortisone Injections

This was a comment posted today on 6/28/13.

First I want to say that I've had Achilles tendonitis in both ankles for the past 5 years. I've had cortisone injections every 6 months for the first 2 years from my local Doctor then went to a Physiotherapist and had 6 months of Shock Wave treatments that didn't help.

Dr Blake's comment: Please try to avoid any type of cortisone injection around the achilles tendon. I am so hopeful that ultrasound guided injections will be the wave of the future, but it will take many years to prove that any injection of cortisone around the achilles tendon is not potentially dangerous. Remember health care providers: do no harm. Use physical therapy, acupuncture, body work, orthotics, stretching, strengthening, etc to help the achilles. 

 I then went to a Specialist and received more injections which only helped for about a month each time and then I was back again for more. Then on the 24th September 2011 I sprained my ankle as I was getting out of bed - yes, before I even touched the floor with my foot. I heard a very loud crack and it hurt really bad - even my husband heard it! It started swelling and aggravated my Achilles tendonitis to the point where I couldn't wear my shoes.

Dr Blake's comment: This is probably a partial tear of the tendon causes or aggravated by the cortisone. 

 I had to buy a pair the next size up if I wanted to go somewhere. It stayed very sore and swollen for months until I had a intensive set of cortisone injections in February 2012. It helped (until now) and the ankle swelling and tendonitis went away but I still have a strange swelling on the top of my foot. It starts where my toes join and then goes up the foot almost to my ankle. It swells and hurts more if I'm on my feet a lot or even just a few hours so I'm going to try your hot and cold bath method to see if it helps.

Dr Blake's comment: This was a comment from the contrast bathing post.

I still have the Achilles tendonitis (in both ankles now again) and was referred back to a different Physiotherapist. After 5 treatments he said I had too much inflammation in my body and couldn't treat me - the more he and I worked on it, the worse it got. The strange thing is, all my doctors etc. have told me doing The Negative Heel Stretch is the only way it will help it but in one of your videos, you say they should be avoided.

Dr Blake's comment: Here is the video associated to that comment.

 I've tried doing them (because my doctors have told me) but I had excruciating pain and had to stop. It only makes my problems worse and for some reason they don't believe me. Anyway, I'm going to follow your advice with the calf, ankle and foot stretching instead and hope it works.

Dr Blake's comment: Definitely push to get an MRI so that we can analyze the 3D of the tendons. Please stay away from cortisone and let the MRI put us into a specific direction.