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***Subjective Asterisks***
• 55 year old male UVA Law Professor
• Pain non Insertional aspect Achilles, Insertional at
posterior Calcaneous
– Dull ache
• 8 year history achilles pain with running
• Run – pain – rest – Run – pain- rest
• Increased running train for 10 Miler
• Aggravating Factors: AM/following sitting; Run – initially
(first ¼ mile), > 3 miles, Faster; Stretching
• Easing Factors: Rest, Run < 2 miles
• PMHx: HTN, Elevated Chol; Achilles; Medial menisectomy
with knee OA.
• Activity Level : Intermittent Gym (cardio/wts); Softball;
Run as able***Objective Asterisks***
Slightly tender Achilles (non insertional); sharp lateral aspect posterior calc at insertion
• Thickened non uniform tendon – nodules (non
mobile)
• Varus rearfoot, tibia; PF 1st Ray
• LQ mobility Deficits: Hip – Flexion, ADD, IR, EXT, ER;
Ankle/STJ – EVR
• Flexibility Deficits: HS, HFs, Hip ERs, TFL/ITB
• Ankle DF > 25 degrees
• Bilateral Squat: Limited Hip flexion ROM, Varus knee
• Single leg Squat: Varus knee, LOB medially
• Step down: > Frontal plane excursion – varus –>
dynamic valgusPhase 1 – Pain Reduction
Phase 2 – Improve Biomechanical Efficiency
Phase 3 – Strengthen the Complex
Phase 4 – Progress the Load
Phase 5 – Sport Specific/Functional Training
Phase 6 – Maintenance LoadingTreatment for each phase to follow soon.
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Phase 1 of Rehab
Modification of current program
-Cross-training (biking, swimming, anything not running/jogging/walking/etc.)
-Assess gym program and modify any Achilles exercises to mid-range and avoid ECC
-No stretching of Achilles tendon/gastric-soleus complexInitiate isometric program for Achilles tendon
-In neutral or into slight plantar flexion
-With total gym or seated with powerband or theraband
-5 reps at 45 second holdsSchedule
-Day 1 – isometric exercises
-Day 2 – cross train
-Day 3 – Gym exercise without exercise involving Achilles
-Day 4 – rest
-RepeatPhase 2 of Rehab
Assessment
-Ankle position
-In prone
-In standing (ankle and globally)
-Squat (ankle and globally)
-SLS (ankle and globally)
-Swing test (ankle and globally)-Based on findings assess
-Core strength/endurance
-Hip mobility
-Hip strength
-Knee strength
-Ankle mobility
-Ankle strength
-Rear- and midfoot mobility
-Intrinsic muscle activationIntervention based on assessment
-Could include flexibility and/or strength training throughout core and LE
-Most likely will include motor control intervention for functional activities and impairments found-
Phase 2 based on OBJ
Don’t stretch the AchillesFlexibility training 3x30s 2-3x/day
-Hamstring stretching
-Thomas stretch
-ITB stretch with pro stretchStrength
-SLR 4-way or hip machine 4-way if available to allow weight bearingMotor Control
-Squats
-Focus on maintaining medial foot loading in hopes to prevent knee varus and improve force distribution through Achilles
-Side steps with resistance to improve strength/activation of hip ERs
-Trying to prevent varus to valgus seen at step
-SLS – with rotational challenge if possible to involve hip ERs/IRs
-Progression to step down as intervention as bio mechanics improve with previously listed interventions
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Phase III:
Continue activities and exercises from phase II but begin to increase direct strength of achilles complex to improve tolerance to load.
Progress from isometrics to concentrics. If necessary, start in open chain with a theraband or power band but progress to closed chain. Start with a tolerable load. Could be using a total gym or leg press with decreased weight. The research shows that he should avoid tendon compression; therefore, avoid dorsiflexed position during these exercises to start (will progress to this position in phase IV). Perform the exercises in mid range to reduce stress and compressive load distally. Some discomfort with these exercise are expected but increased pain following exercises is not. Higher repetitions of these exercises are what have been shown to be effective in the literature. Allow adequate rest days in between tissue loading days as there is a loss of collagen production for 24-36 hours post exercise. This means the pt should allow at least 1-2 days between exercises.
Phase IV
Phase 4 is a progression of phase III; progressing the acceptable load on the achilles. Exercises from phase III can now be progressed from mid range to full range and from concentrics to eccentrics (or heavy slow resistance as both have been shown to be equally effective in the literature).
Example of gradual heavy slow resistance could be:
-Heel rises with knee bent on calf raise/leg press machine, heel raises with knee straight on leg press machine, and heel rises with straight knee standing on a disc weight with the forefoot (to allow some DF increasing load and tension) with a barbell on shoulders.
-These exercises would be performed 3x/wk to allow for adequate rest time on achilles
-These would be progressed weekly by decreasing repetitions and increasing weight.
ie (from Beyer et al):
3 times, 15-repetition maximum (15RM), in week 1
3 times, 12RM, in weeks 2 to 3
4 times, 10RM, in weeks 4 to 5
4 times, 8RM, in weeks 6 to 8
4 times, 6RM, in weeks 9 to 12The Alfredson study study requires a very high number of repetitions and therefore can be very painful due the exercises being unilateral. The heavy slow resistance prescription allows for the patient to perform less repetitions and increase wt to increase the vigor; likely increasing the compliance of performing the exercises.
Strengthening the achilles appropriately to gradually increase its load tolerance can take several months and this should be made clear to the patient. Following Phases III and IV the patient’s achilles should be strong enough to begin a return to run program in phase V.
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Phase V
– No more than 3 high intensity/high energy storage workouts within a week, with this principle continued on for a year following the initial injury (Malliaras 2015)
Strength and power (initial transition from phase IV)
– Leg press calf raise with fast concentric and slow eccentric 3×15 (initially avoiding dorsiflexion in order to not over compress tenon insertion, as tolerance allowing transitioning into full range). Weight at or near body weight
– Leg press calf raise with fast concentric and eccentric
– SL lateral step down with heel raise on return 3×20 (focus on maintaining contact with the first ray and step)
– Sport cord high knees and push off 2 min x5 in order to introduce greater degrees of freedom and tendon loading with speed, in addition to working on running form issues
Plyometrics (prior to return to run)
– Dbl leg forward/backward hops x30 seconds
– Single leg hopping in place x30 seconds
– Single leg forward/backward hop x30 seconds
– Quadrant hop single leg x30 seconds CW/CCWReturn to run
– Running form analysis: assessing presence of possible altered ground reaction forces, potentially due increased vertical excursion, decreased knee flexion at heel strike. Assessing presence of trendelenburg gait. Because of the presence of knee varus into knee valgus with the step down task at initial evaluation, assessing the presence of this pattern with running. Assess the patient’s loading through the foot at heel strike, and whether they began in an excessively inverted position before transitioning into excess pronation throughout mid stance.
– With good response to increased difficulty of gym routine, transition into running x2 days per week and gym routine involving tendon loading x1 day per week.
– Graduated running progression attached below (Warden 2014) with at least 2 days off between running sessions. Once the patient has been painfree through the initial progression a secondary progression can be made with the patient in order to increase their mileage (10+ miles)Phase VI
– Importance of continued loading due to potential heterogeneity of tendon structure
– Continue Phase II stretching and CKC strengthening x2/wk in order to continue to resolve ROM restrictions and deficits in SL squat form. Progress with the following: SL squat on 1/2 foam roll, SL anterior/posterior/lateral foot taps on 1/2 foam roll, side step with band around feet while maintaining loading through entire foot, SL step down from greater height and on Airex/foam, contrakicks on half foam roll
– Running x1/wk 3-6 miles in order to maintain optimized load
– Running form/mechanics: utilize metronome app on phone to continue to train cadence, utilize mirrors around TM to increase feedback of running form-
In regards to cadence and shoe wear in return to run phase. Would you want the pt to run in less of a minimalist shoe (zero drop)? With this shoe, he would likely adopt a forefoot to midfoot strike pattern – increasing the stress at the achilles complex. Therefore, it makes sense that a higher drop shoe would promote heel strike and decreased stress.
Same goes for retraining cadence. Would you potentially want their cadance to be decreased (depending on their “norm” obviously) to lower the potential for a forefoot/midfoot strike pattern, subsequently decreasing stress through the achilles complex?
I’m curious because I see very few of these patients in clinic. Just throwing out some thoughts I had. Let me know your thoughts.
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Great job everyone – I hope this was helpful for clinical reasoning/decision making with tendinopathy patients.
As for the Gait retraining questions – that is always a challenge .
Mid/fore strike definitely loads more of the achilles complex; but rearfoot striking typically means runners are on the ground longer with pronation into terminal stance, and the achilles works obliquely at propulsion.
So some trial and error, and decision making based on individual foot/gait mechanics.
I’ve had successes and failures with gait re training with this population – but if a larger frontal plane deviation (excessive pronation at terminal stance), they usually do better with cadence/strike pattern cues/changes, just have to progress slow. If less of a frontal plane issue, then they do less better with cadence/foot strike cues.
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