Achilles Tendons Survive Hill Workouts, but there is a Catch!!

This is a great article stating that well trained achilles tendon survive the stresses of running hills (like in my beloved San Francisco). However, achilles and other body parts for that matter, do not like sudden changes in workouts (like adding hills, speed, or distance). So, make each transition gradually and you will do fine!! 

http://www.runnersworld.co.uk/training/hill-running-poses-no-extra-risk-to-achilles/14047.html?utm_content=buffer58a99&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

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

Achilles Tendon Injury: Email Advice

Hi Dr. Blake,

I wanted to ask your opinion about which direction I should next take with my treatment.

I am a junior college lacrosse player. Last february (9 months ago now) during our preseason my achilles tendon was stepped on during practice. It hurt at the time, I had my trainers look at it but it didn't seem like anything serious so I did the usual treatment options, especially ice and anti-inflammatories. As the season went on, however, the pain got worse and worse. I saw our team doctor who said it was the sheath around my achilles that was inflamed, so he had my trainers place a heel lift in my shoes. But the pain didn't subside and by the end of the season I was placed in a walking boot for 3 weeks to calm the pain down.
Dr Blake's comment: Typically achilles tendinitis is an overuse injury, so your description of being stepped on makes it harder to get a read on. Putting yourself in the Immobilization Phase was the right idea, and it should be coupled with anti-inflammatory treatments as well. 

Over the summer I continued to work out but focus more on weights and cycling/swimming as running continued to be painful (although I did continue to run some). In addition, over the summer I began to do strengthening exercises.

Dr Blake's comment: This was the right order---Immobilize, Cross Train, and strengthen. You were beginning the ReStrengthening Phase of Rehabilitation. 

 When I came back to school in August I continued the strength exercises and lots of stretching but the pain didn't improve. We had a month long fall season and by the end of the month I was back in a walking boot as it was nearly impossible to walk because of the pain. 

Dr Blake's comment: The Immobilization Phase should take you to Pain Levels 0-2. I am not sure of your pain, but it sounds worse. You should stay in this Phase for 2 weeks longer than you think you need to. The restrengthening should continue, as well as the cross training as long as all of this can be maintained in that 0-2 pain scale level. If not, you are just fooling yourself that you are progressing. 

I had an MRI recently and our team doctor said that, while we had thought it was mostly achilles tendinitis, it appeared that while I did have some achilles tendinitis it was mostly bursitis that appears to be the issue.
Dr Blake's comment: Bursitis in front or behind the achilles is a common side effect of achilles tendinitis swelling, or the bursitis was the only source of pain from the beginning. Bursae are fluid filled sacs that collect fluid in the wrong place and act as an irritant to the surrounding tissue. Bursitis elsewhere is treated with cortisone shots, but these are risky close to the achilles. I prefer electrical stimulation with contrasts, or iontophoresis, while going to PT. 

 He checked by strength and noted that my left gluteus (it is the left achilles that is the problem) was weak. My trainers switched up my strengthening program to include more gluteus exercises to improve this.

At this point my doctor also prescribed a topical anti-inflammatory saying that if that didn't work we could consider doing a  cortisone shot into the bursa, but that after the shot I would be in a boot for a month as to avoid rupturing the tendon.

My question to you is that it has been a month and the topical anti-inflammatory doesn't seem to be doing anything (it hasn't helped with the pain or decreased the amount of swelling at all) would you recommend considering the cortisone shot as the next treatment option or do you think that custom orthotics might be able to provide some assistance? Clearly I would like to avoid the cortisone shot.

Dr Blake's comment: Definitely the shot is risky, but I like the idea of a boot for 1 month afterwards. I would not like to do a shot anytime soon. Consider an 8 day Prednisone Burst to reduce the bursitis, while you are doing iontophoresis in PT (transdermal cortisone). 

http://www.drblakeshealingsole.com/2010/12/oral-cortisone-king-of-anti.html

Follow up the oral cortisone with voltaren or another NSAID with a good daily dose. Do Contrast Baths, the best way to reduce bursitis swelling, twice daily and remain in the removable boot for the next month. If you are not significantly better in one month, send me the MRI to look at because something will not make sense. Hope this helps. 

Thank you so much for you advice.

Dr Blake's comment: Tendinitis treatment follows the BRISS formula and The Good Pain vs Bad Pain formula. Memorize well. Good luck!!

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

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Best,

Gretchen (name changed)

Insertional Achilles Tendinitis: Email Correspondance

Julie is a patient I saw yesterday (name changed for privacy). She has Insertional Achilles Tendinitis and came in for a second opinion. This was the outcome of our visit where I found extremely tight achilles tendons and a prominent heel bone that can get easily irritated by the back of a shoe. Xrays did show some bone spurs which may or may not be part of the pain, but definitely influence how the medical world treats this. 

Both posterior heel spurs (where achilles attaches) and plantar or bottom heel spurs note

Back of Heel Bone Showing Boney Growth

Dr. Blake,

Thanks for taking time to answer questions and share information this afternoon.

Below is my understanding of our discussion. I have a couple of question marks where I would appreciate your confirmation/clarification.

1.       Stretch the calf 4-5x’s/day – I don’t have to try to get it stretch all the way to the bottom where it starts to hurt, don’t do stretches that lower the heel (off the curb), pulling with a towel is OK

2.       Ice 4-5x’s/day  and within 2 hours?? of activity that might aggravate the Achilles

Dr Blake's comment: Definitely a 10-15 minute ice pack within 2 hours of an activity that would predictably irritate it will allow overall less inflammation to collect and cause activity reduction over the next few days. 

3.       Use the heel lifts in the running shoes – icing can be wrapped around foot, it does not need to be localized/massaged.

Dr Blake's comment: I gave her several 1/4 inch heel lifts to use in non heeled shoes, like her running shoes, to take some tension off the back of the heel where the achilles attachs. It also changes the position of the heel against the back of the shoe, and sometimes helps take some pressure off (and sometimes puts more pressure and has to be removed). 

4.       Avoid  explosive (jumping /bootcamp type) activities for a few weeks

5.       Ok to run 4x’s/wk – Sat and Sun can be consecutive days because I will have more time to ice on the weekend

6.       Increase running methodically – flipping run/walk ratio by a minute, if the pain is flared up, I don’t need to go backward on the time flip, just hold off on running until it settles down.

7.       Try the Achilles sock

called Achilles Gel Pad made by Silipos

8.       If I do any strengthening for the calf, such as the calf raises, do it in the evening then ice and rest overnight.

Dr Blake's comment: When strengthening an injured area, at the same time allowing activities which will stress the area, it is important to do the strengthening in the evening 1-2 hours before bed to avoid weakening the muscles/tendons and then having to use them. 

9.       OK to continue ART (Active Release Technique not drawing lessons!!)  with Dr Jess

10.   Request MRI from HMO doctor

Dr Blake's comment: If you read my blog, you probably know I love MRIs. There are too many generalizations being used to treat patients, and MRIs are a great way to individualize the treatment more and understand just what is going on causing this pain. The MRI can help differentiate partial tears, excessive scarring, bursitis, bone edema, and achilles calcifications from the more common plain old ordinary once around the block standard double play achilles tendinitis. 

11.   If an activity hurts, stop, unless the pain is letting up, including running.

Dr Blake's comment: Julie has a high pain level which can work against all rehabilitation programs. Getting her to understand Good vs Bad Pain is crucial. Pain at the start of a workout that looses up and disappears is typically Good Pain. But if the pain comes back while in the workout, you have reached your physiological threshold, and you must stop. Pushing through that pain is BAD!!

12.   Cortisone injection is not recommended, topical might be OK.

Dr Blake's comment: There is four ways to administer cortisone in this patient if we are having trouble getting ahead of the inflammation. Topical with Iontophoresis in Physical Therapy, Short Acting Cortisone Injection, Oral Cortisone in a 7-8 day tapering dose, and Injection of Long Acting Cortisone. Only the Long Acting Cortisone Injection could produce some series damage including tendon rupture, but the other 3 must accompany 2 weeks off athletics which stress the tendon. 

13.   OK to check back via e-mail in a couple of weeks

A couple of other questions I did have are:

1.       If I have flared it up, do you have any concerns with taking some Ibuprofen for inflammation?

Dr Blake's comment: Ibuprofen is fine for flareups, just never take so you can mask pain before working out. 

2.       Do you think there is any benefit to using products, such as BioFreeze?

Dr Blake's comment: I think biofreeze or topical voltaren gel (by Rx) or Flector patches (by Rx) or zyflamend (OTC) are great adjuncts to the above treatments. 

Thanks! Julie

Achilles Tendinitis: Email Advice

Hi Dr. Blake,

I think the orthotics are working well.  If you wouldn't mind making me another pair (maybe with a longer pad this time), and mailing it to me.

Btw, I noticed that my left Achilles is a bit sore/tight so I started wearing my night splint at night, in addition to stretching.  Do you think that will be enough to prevent Achilles tendinitis?

Thanks for everything.

Beth

Beth, I will go ahead and design another pair. When you are dealing with any tendinitis, the acronym is BRISS--Biomechanics (what causes it and what can help it), Rest or Activity Modification (to avoid irritating daily), Icing, Stretching, and Strengthening. See the link below to give you the generalizations. You can also explore the blog for more specifics on each area. In summary, the treatment should be well rounded, and not just limited to stretching. Hope this helps, Rich. Please feel free to email with other thoughts. 

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

And here are 4 videos from my YouTube channel (drblakeshealingsole) which also may help.

Tip for Adding Lift/Stability to an Orthotic Device

When Adding Lifts for a short leg or some other purpose to the bottom of some custom made devices, and most over the counter insoles,  consider making the lifts like the insert on the left. First you glue on 1/8th inch rubber cork from JMS Plastics or another supplier to both sides, then you cut and smooth (if you have a method of grinding). See the photo below.

This nice young lady has achilles soreness on both sides. Her inserts were wearing down slightly allowing more motion in gait. I placed the medial and lateral heel buttresses to both sides for extra side to side stability and also to achieve the heel lift effect to relax the pull of the achilles. A straight heel lift can produce more instability as it lifts the patient out of the shoe slightly. 

Podiatry Video Quiz #1: Why can swelling around the achilles tendon cause an Injury to the Achilles Tendon to become difficult to treat?

Podiatry Video Quiz #1: Why can swelling around the Achilles Tendon cause an Injury to the Achilles Tendon to become difficult to treat?

Achilles Tendon/Plantar Fascia Injuries: Role of Calf Tightness

Calf Tightness is an often missed as the cause of achilles or plantar fascial injuries. This short video demonstrates one of the techniques used in breaking down tightness in the calf that can cause achilles tightness. Self massage with ethaform roller, rolling pins (yes used for cooking), or other devices like the Stick should be implemented if you note that the sore side is also tighter when stretching the achilles tendon.

http://www.amazon.com/s/ref=nb_sb_ss_c_1_9?url=search-alias%3Dhpc&field-keywords=the+stick&sprefix=the+stick

http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dhpc&field-keywords=ethafoam+roller&rh=n%3A3760901%2Ck%3Aethafoam+roller&ajr=0

Achilles Tendon Injuries and Zone of Ischemia

This short video introduces the importance of immediate treatment of achilles tendon pain especially when swelling is noted. The area 2 to 5 cm above the attachment of the achilles tendon in the body of the tendon is called "The Zone of Ischemia". It is an area of relative poor blood supply. When an injury to the achilles tendon occurs, if there is swelling in this zone of ischemia, the normal circulation is cut off and healing potential comes to a halt rather quickly. This is why athletes fear achilles tendon injuries since they can be so chronic. It is vital to work on the swelling with physical therapy, accupuncture, ice packs, heat in careful amounts, and contrast baths.

Plantar Fasciitis/Achilles Tendinitis: Stretches To Do and Not To Do

This short video demonstrates the 4 common weight bearing stretches for plantar fasciitis and achilles tendinitis. The Gastroc Stretch, the Soleus Stretch, and the Plantar Fascial Wall Stretch are all safe and can be done multiple times throughout the day to improve flexibility. The final stretch demonstrated called the Negative Heel Calf Stretch is potentially dangerous and places too much abnormal stress on the plantar fascia, heel, achilles tendon, and midfoot areas. The first 3 safe stretches have one major safety valve. That is that the stretch is done with the heel on the ground in a stable position. Please see the links below for other posts on these important exercises.

http://www.drblakeshealingsole.com/2010/08/plantar-fasciitis-all-important-wall.html

http://www.drblakeshealingsole.com/2010/08/video-plantar-fascial-am-stretches-for.html

http://www.drblakeshealingsole.com/2010/08/video-on-plantar-fasciitis-big-3-weight.html

http://www.drblakeshealingsole.com/2010/05/quick-tip-6achilles-stretch-to-avoid.html

http://www.drblakeshealingsole.com/2010/05/quick-tip-7-rolling-ice-stretch-for.html

http://www.drblakeshealingsole.com/2010/08/video-plantar-fasciitisachilles.html

http://www.drblakeshealingsole.com/2010/07/video-7-generalizations-for-stretching.html

I sure hope these help!! Dr Blake

Plantar Fasciitis/Achilles Tendinitis Rest Splint Video

The use of a posterior sleeping splint for plantar fasciitis or achilles tendinitis was first introduced I believe by a physical therapist Don Chu, PT, in the San Francisco Bay Area in the 1980s. It has become a mainstay in the treatment of plantar fasciitis. The Bird & Cronin one is dispensed in our practice (and demonstrated in the video above), but I have used many. This is the basic style that I like. It can take 1 or 2 weeks before you can wear all night, so there can be some interrupted sleep initially. Patients, like my son Steve the attorney, who sit alot all day, can wear during the day also. It is better called a rest splint than a night splint. Anytime you can wear it for 30 minutes, go for it. You want the splint to hold your foot near a right angle with the ankle, and the side strips for pulling your foot upwards flexing the ankle, should be very loose. Many of my patients never need to pull any tighter. When you start wearing the splint, keep the side strips very loose, and be ready to take off the splint at 1 or 2 am for a week or so, especially if you are a light sleeper. The gentle prolonged stretch on the plantar fascia or achilles tendon is felt immediately with relief of the classic morning stiffness. This pain relief tends to carry on with less pain throughout the day also. It should be worn 1 month longer after the symptoms of plantar fasciitis and/or achilles tendinitis has resolved. When asking patients particularly about their treatment of plantar fasciitis, 20% responded that the splint was the most important factor in their treatment, and 60%+ responded it was helpful. It may be very helpful for you. Good luck.