Achilles Rehabilitation: Great Discussion of Mid Tendon vs Insertional Achilles Tendon Rehab Differences in Tensile Loading

https://youtu.be/FaCWTC408ys

Plantar Fasciitis and Achilles Tendinitis: A Common Duo

Dr. Blake, I found your blog online and found them a fascinating read. I wonder if you can shed some light on my foot problem. I have plantar fasciitis on both feet and Achilles tendon insertional micro tear (insertional Achilles tendonitis?). I have had them for more than a year, been seen by my podiatrist 4 times. I am still in pain from both problems.

• Nov. 2011.       started noticing pain in bottom of right heel at the first steps of the morning

• Nov. 2011.       took Ibuprofen for 2 weeks per primary doctor’s advice and stopped daily 2-mile run since then on

• Jan. 2012,       while the condition of right heel is getting worse to 8 out 10 pain scale, I started noticing pain in bottom of left heel at the first steps of the morning. I started wearing orthotics since then.

• Feb. 2012.       seen by a Podiatrist. Was told to do regular stretching.

• Mar. 2012.       over stretched the Achilles tendon/heel bone insertional area. Having pain in the insertional areas of both feet since then. Stopped stretching since then.

• April-Sept, 2012, elevate my feet as much as I can during the day. Ice them before I go to bed at night. Symptom is getting better. Pain level improved 5 out of 10 scale.

• Dec. 2012.       Started arch stretch. Plantar fasciitis pain appear to get better, but very slowly

• Feb. 2012.      Started to massage calf muscles, plantar fasciitis pain appear to get better, but very slowly

• March, 2012. Started to have a lot more pain, new pain, in the lateral side of the heel of both foot.

• My doctor told me to stretch the calf muscle. But even a very gentle stretch will cause the insertional area quite painful.

I wonder whether there is any cure for me? Thank you.

Dr Blake's comment:

     Thank you so very much for your email. I am gradually catching up from before my little Hawaiian vacation, so I apologize for my delay.

Sunset from Waikiki Beach, Oahu, Hawaii

Most people know that the plantar fascia on the bottom of your foot originates from the achilles tendon fibres that engulf the heel bone. If you are lower on the evolutionary change, there is a greater connection between these 2 structures. Apes can use their ankles like hands so need these two structures connected. So, no matter where you are at  in the evolutionary process, you can develop pain in one structure first, then another. This, in your case, is what is being treated. But, is it correct? You can consider the achilles tendon fibres grabbing the heel bone from the back, both sides, and bottom (like a hand), ready to lift the weight equivalent to 10 times your body weight. And, it is hard to stretch the insertional achilles fibres into the heel bone since they are attaching into the bone. Typically stretching and massaging, if not done perfectly, can irritate the fibres more than bring them relief.

As you are being treated for tendinitis/fasciitis, and it is not working well, there are 2 logical explanations. The treatment is just not tailored enough (individualized) to you or the treatment is not addressing the correct diagnosis. First of all, both the plantar fascia and the achilles tendon attach into the heel bone (calcaneus). This could easily be an injury to the heel bone with pain from protection or compensation in the  plantar fascia and achilles. So, I would look into obtaining 3 tests that can greatly help with the diagnosis: x rays, an MRI, and a bone scan. The x rays have the least likely chance of helping, but they may point to something important. Even if you had to self pay for these tests, the $1200 (San Francisco Bay Area prices) would be worth it. This would 100% rule in or rule out a bone problem that needs to be dealt with differently than you are treating yourself. 

Second of all, the plantar fascia and achilles have fibres of the sciatic nerve running through them. I have personally misdiagnosed sciatic nerve problems as plantar fasciitis and achilles tendinitis numerous times. It is easy to do, but when the patient does not respond to normal treatment, you look deeper. Neurologists and physiatrists are the nerve test people. See if they can make some correlation to your pain and the sciatic nerve. This may require a nerve conduction test. Treatment for this syndrome also quite different. The sciatic nerve hates to be stretched, but the technique of neural flossing may work. 

Finally, perhaps the treatment you are getting for achilles/plantar fasciitis is not correct. When you have any type of tendinitis, see my post on BRISS. This stands for Biomechanics, Rest, Ice, Stretch, and Strength. It is the 5 areas that should be addressed simultaneously in treating any tendinitis like achilles tendinitis and plantar fasciitis. You make changes in the biomechanics of shoe gear or activities, you use rest or activity modification principles to keep the pain level between 0-2, you use ice and other anti-inflammatory measures to calm the tissue down, you do pain free stretching, and you begin arch and achilles strengthening the day you begin to have pain. Go back to square one with your rehabilitation. See the link on BRISS. Read all the posts regarding achilles and plantar fascia. Get some of the above mentioned tests to rule in or out other causes of heel pain. I sure hope this points you in a good direction. Rich

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

     

Video on Calcific Achilles Tendinitis

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