Mid-portion tendinopathy does exactly what it says on the tin effects the mid portion of the achilles typically 2-7cm above the calcaneus heel bone (Maayke et al. When the Achilles tendon becomes injured, the structure of the collagen near the injury site becomes disrupted.
A big thank you to Peter Thain and James Welch for their help sourcing research for this article.
Further studies are needed to explore the role of this promising intervention in all phases of tendinopathies.". Next week I will shoving this piece in the face of my 4th different physical therapist asking them why we’re not following it (Yes, I’ve seen three separate outfits over the last year for this problem, and my mistrust and skepticism of physical therapists couldn’t be greater than it is now). The available literature would suggest that in the absence of an overt inflammatory process, there is no rational basis for the use of NSAIDs in chronic tendinopathy, because they are unlikely to change its still ill-defined natural history. This year, I made two changes: (1) instead of doing 3 sets of 15 reps, bent and straight, twice daily, I gradually increased to sets of 30, but usually only once daily; and (2) instead of doing the heel drops in a single plane of motion (straight forward and straight back), I tried leaning left and right (as well as straight) as I did the drops to work the AT in a pronation and supination position. Even within this the evidence to support specific approaches is limited.
Do you know if:1) It's possible/probable to have both insertional and midpoint tendonitis?2) Assuming you can have both, would doing all the heel drop variants (flat ground, step straight leg, step bent knee) be helpful are is the step variant harmful to the insertional type?I definitively have pain in the heel and in the bursa at the insertion point, but I also feel tightness and mild pain an inch or two up from the heel.
The best advice? Hi John, very good review. Dr Thomas C. Michaud, writing at Competitor.com, says “Another factor to consider when managing insertional Achilles injuries is that the heel counter of the running shoe should not contact the damaged portion of the Achilles insertion. Everything was perfectly fine, except that the area where I had the injury felt sensitive (it still does). Very useful and interesting article, thanks. Your Physio should guide you in terms of reps and sets. If you have this deformity, a bump at the rear of your foot, and/or your shoe’s heel pocket is stiff or presses into your achilles, there could be major problems. It seems like it would be POSSIBLE, although the lack of anything in the literature about it makes me think that, at the very least, it'd be rare. These are sort of the opposite of calf raises, where you perhaps hold some weight and slowly raise up onto your tippy toes (dorsiflexing). I haven't seen anything in the research about this—usually studies classify Achilles tendonitis based on where the pain occurs. As for whether you should also do the two exercises for midpoint tendonitis, I'm unsure.
Great question! What’s the bottom line? Although we have seen that inflammation is not a problem in Achilles tendonitis, applying heat will definitely increase blood flow and also the flow of lymph fluid to that area. Giving an update six months hence…I’ve been able to get back to some running with the help of physical therapist #4 (ran my first 10K on Thanksgiving!).
The information presented on this web site is not intended to take the place of your personal physician’s advice and is not intended to diagnose, treat, cure or prevent any disease. As usual, stellar article! In Jonsson et al. This comment has been removed by the author.
They’ll probably try to make me do some ‘core strengthening’ exercises too, which I’ll do but see as irritating busy work more than anything else. A look at extreme aerobic fitness and longevity. Because of Achilles tendonitis was thought of as an inflammatory injury for a long time. A key difference is that compression is considered a key factor in insertional tendinopathy. Pronation, along with forefoot varus, are the most common causal factors for Achilles tendonitis cited in review articles and medical textbooks. Forefoot varus is a "tilt" of the metatarsal heads where the outside of your forefoot naturally rests lower than the inside. Forefoot varus coupled with pronation on impact, The proposed "whipping motion" of pronation. So haven’t run in about 8 months and have been doing eccentric work for about the same time. PS : I had tried conventional methods (inserts, NSAIDs, isometric exercises etc.,) and since there was no luck, I had the growth on my left heel removed surgically.
Still sore to squeeze the tendon - in fact no progress there at all. A bent-knee heel drop involves keeping the knee bent upon descent (thereby strengthening the soleus muscle), as illustrated below. Personally and nonscientifically speaking, I am not a fan of stretching an already-injured area, so calf stretches are not something I would do for Achilles tendonitis. (2007) included patients with at least a 2 month history of mid-portion achilles tendinopathy, which is perhaps a little more representative of the majority of people with this condition. Finding the root cause of the problem is really important (if possible). This goes away after I do the protocol. Our previous article on the staging tendinopathy and role of tendon compression discusses these important concepts more detail. Healthy collagen fibers are parallel, wavy structures at the microscopic level (bottom left and bottom right). In addition our piece on tendinopathy rehab covers phases of progression. Gradually progress your load to the point where you can only manage around 12 reps with good technique. James (@Ablefeet) is a top podiatrist and my go to guy for anything feet related. (2008) who used an eccentric programme with similar approach to Alfredson et al. Ultra sound will give you an absolute answer for this. So far (about 3 weeks in) the stiffness in the morning has reduced - I am aware of the achilles but walking feels free free of discomfort.
It wasn't clear exactly what brought it on. VEGAN Research: Pea vs Whey Protein, Legumes, Veg vs Animal Burgers, Protein Quality. If this is the case, it would explain the poor results of the traditional eccentric heel drop protocol for patients with insertional Achilles tendonitis: because the heel drop is done on a step (bringing the ankle into dorsiflexion), and the maximal force on the Achilles tendon as a whole occurs when the downward motion is stopped, the exercise does not effectively stress the insertion point of the Achilles—it is under compression, not tension…
used a progressive loading programme (in patellar tendinopathy) which started with 15RM and progressed to 6RM over a period of 12 weeks.
drops hurt in the same way running does and the mild soreness persists for a day or two. Thanks to its history in treating heart disease, the effects of nitroglycerin patches on the body are relatively well-known; when used to treat tendonitis, the only major side effect appears to be headaches due to nitroglycerin's potent vasodilating properties.
This should be based on each individual and requires detailed assessment from a physiotherapist or health professional…as ever on RunningPhysio if in doubt get checked out! Malliaras et al. I went back to running in December. and this is the first place I’ve seen a routine articulated that MIGHT allow me to get back to doing anything active outside again. Performing a proper warmup before a run and icing the area after a run can be helpful. When evaluating possible treatments, we'll have to use more general principles about reducing stress and healing tendon injuries when we consider how to treat and prevent Achilles tendonitis. I had AT soreness for several years, and after starting the Alfredson protocol a couple years ago, it helped very much, but did not prevent my AT from acting up when hiking on steep trails.
It can ache at different times such as before, during, and/or after a run.
1998) and just 28% of their patients reported complete recovery or significant improvement. Did you finally get rid of your pain? Thoughts and comments on long-distance training, injuries, and more from a student of the sport. The calf complex is composed of 2 main muscles – gastrocnemius and soleus – both need to be strengthened. Let's talk about that 'strength', and what eccentric heel drops are -really- … We've teamed up to put together some additional information to compliment our previous article on this […]. Eccentric exercises will load the elastic component or the spring of the tendon. Maybe someday heating WILL be part of Achilles tendonitis rehab, but until then I don't want to recommend something that has the potential to throw off the rehab protocols that we KNOW are useful (i.e.
It’s been incredibly depressing to realize how little the medical profession knows about tendons and how to alleviate their pathies and osises. If it is possible to have both, how would you treat since many of the approaches for mid-portion tendinopathy seem to involve exercises that are contraindicated for insertional tendinopathy. It's important to note that there are several limitations of our recommendations that have been highlighted by a recent systematic review. Your Physio should guide you on when to progress your rehab. After this 67% of patients were satisfied with their outcome and had returned to their sport. In an injured tendon, the collagen fibers appear disorganized, damaged, and degraded (top left and top right). In these cases progression through the phases or tendinopathy rehab to include functional strengthening, correction of movement dysfunction, power training, plyometrics to engage the Stretch-Shortening-Cycle and sports specific rehab may be indicated. Insertional Achilles tendonitis is characterized by a similar aching, painful sensation, but it is very near where the tendon attaches to the base of the heel, and sometimes can extend into the bottom of your foot. Heavy loading is thought to stimulate the most adaptation from the muscle and tendon. This image from Dixon and Kerwin demonstrates how the peak force in the Achilles tendon varies when the seven subjects wear heel lifts. I will see a Doctor, orthopedic surgeon , who deals only with foot and ankle problems, in a large university center, see what’s her opinion. 3) single leg calf raises with the leg straight 15 reps x 3 sets with 2 min recovery 3 times a week
More recently, researchers suggest that only part of the achilles tendon takes the majority of the stress while running.
I’ve been suffering from IAT (I think) for almost 1.5 years. I am working at the heel drops and could do with some advice on doing it correctly and assessing progress. Most studies on nitroglycerin patches to date have used sections cut from circular nitroglycerin patches for chest pain, which are applied directly over the most painful area of the tendon.
However, they were told to stop the exercise if the pain became disabling.
So yes, I think you can have the two ‘types’, as it were, but I think the treatment has to be for insertional initially, which may enable you to progress onto dorsiflexion for the upper portion later on. Eccentric exercise was first examined as a possible treatment for Achilles tendonitis in 1992, but the value of an eccentric exercise rehab program didn't make waves in the scientific community until a landmark 1998 study by Håkan Alfredson and other researchers in Sweden.