Running Foot Pain or Stress Fracture?

Running Foot Pain or Stress Fracture?

Pain is often a runner’s most loyal training partner, free from the busy social calendars or alarm clock failures that leave you pounding the pavement solo during those early-morning 5 milers.

Differentiating “normal” pain from one that merits a visit to your local sports medicine specialist is the tricky part of that relationship.  Let me help you address this problem to keep you healthy and happy…and running pain-free.

The Inside Scoop on Foot Stress Fractures

Stress fractures located in the foot are usually characterized as an overuse injury to weight-bearing bones.  High-impact sports that involve running and jumping contribute to simple foot pain and, if left untreated, can lead to a more serious problem like stress fractures.

Bones generally respond to stress by hardening along their outer margins.  When suddenly exposed to strong forces or ongoing stress, there is little time for bones to adapt. Meanwhile, muscles associated with the feet lose their shock-absorbing capacities when fatigued. These uncontrolled forces inadvertently transfer to nearby bones, possibly resulting in small cracks that are better known as stress fractures.

Stress fractures commonly occur in distance runners along the outer ridge of the forefoot over the fifth metatarsal bone. This is often referred to as either a Jones fracture or a Dancer’s fracture, depending on location.

Statistically, women are more prone to stress fractures than men due to biomechanics, nutrition and possibly menstrual cycles. Running an excessive amount of miles in a short time span with insufficient rest increases the risk of generalized foot pain, plantar fasciitis, turf toe, metatarsalgia and stress fractures.

Obviously, any underlying bone disease or disorder will drastically increase one’s risk for these conditions. Outlined below are key characteristics and recommendations with respect to these aches and pains:

Signs & Symptoms of Stress Fractures in the Foot
  • Localized foot bone pain that is dull, aching or sharp and occurs during activity (especially running) and/or periods of rest
  • Mild widespread foot swelling and tenderness
  • Pain that worsens with prolonged exposure to ice and during sleep
  • An initial sensation of sharp pain followed by intensifying aching
  • Related lower-extremity symptoms such as lateral thigh/knee pain, low back tightness and/or Achilles tendonitis due to altered foot mechanics sometimes observed in runners
Professional Treatment for Foot Pain in Runners
  • Get plenty of rest and apply ice.
  • Avoid placing excessive weight on the affected foot.
  • Wear shock-absorbing footwear, and if symptoms worsen, use a walking boot to help mitigate stress on the injury site.   
  • Eat healthy and ingest the Recommended Daily Allowance (RDA) of calcium and vitamin D to help restore bone integrity.
  • Engage in strength training for the arch, toe flexors and weak muscles, which may have contributed to the initial injury.
  • Maintain an ideal range of motion for surrounding muscles and joints, specifically the Achilles, calf, plantar fascia, great toe and ankle joint.
Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask a sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

  1. What do you believe is the main reason(s) why this injury occurred?
  2. How can I best manage this pain and safely return to running?
  3. Do I need orthotics and if so, which foot doctor(s) do you recommend I discuss treatment with, specifically as a runner?
  4. Should I concern myself with any potential long-term issues associated with this pain?
Elite Sports Medicine Tips from Mike Ryan
  • Time is of the Essence – Visit a sports medicine specialist as soon as symptoms appear to best manage foot pain from the onset.
  • Rest Rocks – It’s boring, but REST is the #1 tool to tame a stress fracture.  For how long, you ask?  Prepare yourself for 2 to 6 weeks of inactivity if symptoms persist.
  • Be a Turtle, Not a Hare – Resume your running regimen slooooowly. Include pool running, run/walk routines and off-road routes while increasing your miles by no more than 10% per week.
  • Mix It Up – Cross training is king. Add varied activities such as biking, swimming, yoga, strength training and elliptical training to stay in shape and save your “marriage” during this break from running.
  • Smooth and Steady – Wear stable and proper-fitting shoes to protect your feet.
  • No Big Break – Stress fractures can easily develop into typical bone fractures if left untreated.  Setting limitations from the get go can help you avoid the “big break.”

Tame Heel Pain Flareups From Plantar Fasciitis

Tame Heel Pain Flareups From Plantar Fasciitis

 

Understanding Plantar Fascia Strains

Plantar fasciitis is a condition that causes localized pain in the backside portion of the arch that attaches to the underside of the heel bone, or calcaneus.  It often results from overstretching, overloading or tearing in the arch origin that runs from the heel to the front portion of the foot, under the toes.

This band of tissue helps stabilize and propel the foot forward during movement and stretches each time weight is applied to the foot when standing or walking. Plantar fascia strains occur when the band experiences excessive trauma or if the arch is exposed to persistent stress over time. A plantar fascia strain usually gives rise to sustained inflammation in the front of the heel and back portion of the arch.  This results in a high level of localized pain, particularly after a prolonged period of rest during non-weight bearing activities such as sleeping and sitting.  The band simply tightens when not in use, and if left untreated, a plantar fascia strain can become a chronic and troubling ailment.

Causes: The most common cause of plantar fasciitis is wearing inadequate footwear while running, walking and/or jumping. Additionally, beginners who go overboard performing new physical activities may inadvertently overstretch the band while doing so.   Additional factors include obesity, sudden weight gain, flat feet, and excessive exercise with insufficient levels of progression.  Heel bone spurs may also result as the band of tissue continues to pull on the heel bone in some chronic arch pain conditions.

 

Signs & Symptoms of Heel Pain From Plantar Fasciitis

  • Burning, stabbing, or dull aching pain in the front of the heel and along the band of tissue in the backside of the arch
  • Difficulty placing weight on the foot while barefoot
  • Arch pain that occurs with heel raises or flat-footed squatting
  • Localized swelling and tenderness under the heel and arch

 

Professional Treatment for Plantar Fasciitis

Plantar fascia strains usually respond well to conservative treatment methods. However, recovery time does vary from individual to individual. Be sure to:

  • Rest and avoid weight-bearing activities to lessen heel pain.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Ice the arch and toe flexor tendons in a stretched position on a consistent basis to reduce inflammation and pain while elongating the sore plantar fascia tendon. 
  • Always wear the proper footwear for your sport(s).
  • Tape the foot to assist in arch support, reduce inflammation and decrease the risk of further injury.
  • Apply progressive, aggressive transverse-friction massage techniques for the posterior arch, along with more moderate massage for the ankle and lower shin.
  • Perform strengthening and stretching exercises for the neighboring arch and calf muscle.
  • Buy arch support shoe inserts.
  • Properly tape the arch to provide effective support and reduce heel pain when performing weight-bearing activities.
  • Minimize weight-bearing activities.
  • Work to shed excess pounds, if overweight or obese.

 

Ask the Right Questions like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1)   Is this heel pain related in any way to my pelvis, lower extremity or foot alignment?

2)   Which types of physical therapy are best to quickly resolve this problem so I can get back to my sport(s), pain-free?

3)   Are non-surgical treatment options available?

4)   Can this problem cause any long-term complications?

5)   Will anti-inflammatory medicines provide relief?

6)   Is my painful heel a result of some other biomechanical abnormality that must be addressed?

 

Elite Sports Medicine Tips from Mike Ryan

  • Fast Treatment=Fast Recovery: The sooner you address plantar fascia sprains, the sooner they resolve.  Seek treatment quickly to avoid a chronic problem.
  • Defy Sir Isaac Newton: Aggressive weight-bearing activities prolong recovery time and increase the risk of long-term complications.
  • Embrace that Après Workout Life: Immediately following your workout (or related treatment):
    • Elevate your foot for 3 minutes
    • Stretch for 5 minutes
    • Ice your arch and heel for 7 minutes
  • Unleash Your Inner Gumby: Aggressively stretching your calves, arches, big toe and toe flexor tendons will go a long way toward maintaining healthy tissue in the entire foot.
  • Eat and Drink Right: It’s easier and safer to control inflammation and promote healing by staying well hydrated and maintaining a healthy diet rather than popping pills to manage the problem.

Solving the Stop and Go Issue of Sinus Tarsi Syndrome

Sinus Tarsi Syndrome is a rather common foot injury for stop-and-go type sports, which can leads to pain in the sinus tarsi region of the foot. Some refer to this area in front and slightly below the lateral malleolus as “the eye of the foot”. The sinus tarsus is a bony canal located on the outer (lateral) surface of the foot between the talus bone and midfoot.

Understanding Sinus Tarsi Syndrome

Sinus Tarsi Syndrome is a rather common foot injury for stop-and-go type sports, which can leads to pain in the sinus tarsi region of the foot.  Some refer to this area in front and slightly below the lateral malleolus as “the eye of the foot”. The sinus tarsus is a bony canal located on the outer (lateral) surface of the foot between the talus bone and midfoot.

The sinus tarsus contains the talo-calcaneal ligament, which spans between the talus and clacaneus bones. Injury to this ligament is commonly a result of an inversion mechanism, as with a lateral ankle sprain.

In 1957, Denis O’Connor was the first to use the term “sinus tarsi syndrome” to describe an injury which is characterized by pain, limitation of movement and instability in the hind portion of the foot. At the time, O’Connor treated the injury with a local injection of anesthetic agents into the sinus tarsus.

Common causes of sinus tarsus are inversion ankle sprains, chronic ligament instability and poor foot biomechanics.

The diagnosing of this injury is typically based on the mechanism of injury, the location of the symptoms, palpation findings in this area and the MRI findings.

Signs & Symptoms of Sinus Tarsi Syndrome

  • Pain just anterior to the lateral malleolus, which is the bony prominence on the outer border of the ankle. Prolonged standing usually aggravates the pain.
  • Point tenderness anterior to the lateral malleolus, which is typically aggravated by excessive ankle inversion and/or excessive eversion of the forefoot.
  • Instability and looseness of the lateral ankle and/or midfoot joints.

Professional Treatment for Sinus Tarsi Syndrome

  • Immediately ice the entire ankle and forefoot to help reduce inflammation and control pain.  Ice bags are good but an ice bucket is much better.
  • Mild anti-inflammatory medicines are sometimes prescribed by the treating physician to minimize the pain.
  • Immobilization of the ankle joint, the sub-talar joint and forefoot is a key early step to promote healing. This is best accomplished with a walking boot or a removable splint.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Assess and correct biomechanical problems related to the entire lower extremities if necessary with orthotics and postings.
  • Utilize a physical therapist to assist you with range of motion, manual strengthening and proprioceptive strengthening ankle exercises with tools such as a wobbles board.
  • Surgery is quite unusual and should only be considered for sinus tarsi syndrome cases that fail to respond to all other conservative forms of treatment.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Have I developed sinus tarsi syndrome and what structures have been injured?
  2. Do I need to have an MRI or any other special test to confirm this diagnosis?
  3. Do I have any biomechanical concerns or previous injuries contributing to this injury?
  4. Will I need orthotics and if so, where can I have them made correctly with free adjustments for less than $300?

Elite Sports Medicine Tips from Mike Ryan

  • Bottom Line – The bottom line of your standing body is your foot.  Gravity is going to bring fluids to that foot.  Early and aggressive ice therapy and elevation is key.
  • Contol Your Weight – Rest is needed.  If the doctor gives you crutches, use them.
  • Proper Footwear – Check with the people that know and make sure you are wearing the proper shoes with the right fit for your sport.
  • Trust the Experts – If this is a chronic issue, the reasons can be many.  Take the time with the best physical therapist or certified athletic trainer available to learn from the best how to put this injury in the rearview mirror.

Metatarsalgia: Foot Pain’s Evil Brother

Metatarsalgia is a general term relating to forefoot pain secondary to inflammation in the area of the distal foot and toes.

Metatarsalgia: Foot Pain’s Evil Brother

Metatarsalgia is a general term relating to forefoot pain, secondary to inflammation in the distal foot and toe area.  Joints that connect metatarsal foot and phalange (toe) bones become swollen, and the second, third, and fourth MTP joints are most often affected.  Additionally, Metatarsalgia is commonly found within the second, third, and fourth interphalangeal joints.

Morton’s Neuroma is a similar condition that presents with forefoot pain.  Unlike Metatarsalgia, Morton’s Neuroma pain is located between the distal metatarsal bones as opposed to within the forefoot and toe joints themselves.

Morton’s Neuroma is caused by pinched nerves located between the second, third, and fourth metatarsal bones, resulting in nerve inflammation.

Pain in the ball of the foot is not typically linked to either of these conditions, although it is not surprising to develop this symptom by compensating for lower extremity dysfunction.

 

Signs and Symptoms of Metatarsalgia

  • Forefoot and toe pain that increases with weight-bearing activities
  • Symptoms that worsen when wearing tight-fitting shoes or high heels
  • Point tenderness pain in the distal foot area and proximal toes
  • An excessive pattern of blisters, calluses and wear and tear in the forefoot and toes
  • Increased pain from passive toe bending and rotating
  • Pain in the ball of the foot (related to compensation mechanics that sometimes present with chronic foot pain)
  • A contributing factor of long-term abnormal toe alignment, such as claw toes or bunions 
  • Excessive skin or calluses underneath the foot due to excess pressure

 

Signs and Symptoms of Morton’s Neuroma

  • Localized pain between the third and fourth distal metatarsal bones and toes
  • An increase in weight-bearing symptoms, such as feeling as if you are  “standing on pebbles”
  • Increased pain with weight-bearing activities
  • Sharp pain, burning, numbness and/or tingling in the distal foot and toes
  • Increased symptoms between the metatarsal bones when squeezing the forefoot
  • Excessive callus and wear patterns under the distal forefoot and great toe
  • Pain in the ball of the foot (related to compensation mechanics that sometimes present with chronic foot pain)

 

Treatment for Metatarsalgia and Morton’s Neuroma

  • Aggressively ice the arch, foot and toes with ice bags, ice massage or (ideally) an ice bucket, for 10 to 15 minutes.
  • Wear the proper footwear for specific activities.
  • Minimize weight-bearing activities.
  • Massage and apply soft-tissue treatments to the arch, great toe, ankle joint and calf.
  • Perform a biomechanical evaluation to assess contributing factors such as a leg length discrepancy, hyper pronation/supination, tight ankles, restricted toe extensor tendons, hypomobile toes, or knee, hip or low back conditions.
  • Stretch your calves on a consistent basis.
  • Wear orthotics, ideally with a rigid steel insert, when experiencing pain in the ball of the foot.

 

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Are you concerned that I may have a stress fracture in my foot or toes?

2. Could my foot symptoms be related to nerves in my back or leg?

3. Will orthotics help, and if so, where can I find them at a reasonable price?

4. If faced with this same problem, where would you go for therapy?

 

Sports Medicine Tips

 

If the Shoe Doesn’t Fit, Don’t Wear It – It’s a fact that women’s shoe designs help keep foot doctors in business.  They may look sexy and stylish, but they are absolute killers for the health of your feet.  Ladies (and gentlemen) – rid your closet of any ill-fitting shoes ASAP!

Do Some Sole Searching – Assess the overall health of your shoes in addition to your feet. Wearing old, “expired” shoes with worn soles is a common factor that leads to foot and arch pain.

(Another) Test with a #2 Pencil – Using the eraser end, apply pressure between the metatarsal bones of the foot to help pinpoint the location of the pain and lead to a diagnosis.

Ice is Your Friend – I’m sorry, but it’s true – the bitter chill of ice is necessary to treat this injury.  The pros will tell you that ice is their best teammate.  Stop complaining and stock your freezer accordingly!

Sprained Ankle Management

Sprained Ankle Management

Year over year, ankle sprains are the most common lower extremity injury in all of sports.  From a minor “tweak” to a high ankle sprain, the range of symptoms and corresponding limitations vary greatly.  Ankle sprains are challenging due to the ankle joint’s inherent vulnerability years after the sprain and ligament instability that is common after a significant injury.

The term “sprain” refers to an injury that involves ligament damage.  Ligaments connect bones to bones, while tendons connect muscles to bones.  Ligaments help stabilize joints and are embedded within capsules surrounding most joints in the body.  The ligaments in a “normal” ankle provide static stability to lower leg and hindfoot bones.

A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that provide joint stability.

Lateral Ankle Sprain

When a lateral ankle sprain, commonly referred to as an inversion sprain, occurs, the majority of the ligament damage occurs along the lateral or outside part of the ankle joint.  This includes the following ligaments:

1.  Anterior Talofibular Ligament (ATF) – located in front of the outer distal Fibula (shin) bone

2.  Calcaneofibular Ligament – connects the fibula (shin) to the heel bone

3.  Posterior Talofibular Ligament (PTF) – located behind the outer distal Fibula (shin) bone

High Ankle Sprain

We often read about elite athletes who have an ankle sprain that keeps them from competing for 2-6 weeks.  This sparks immediate questions about why anyone would miss so much time with “just” a sprain (rather a more serious-sounding injury, like a break).  In most cases, this athlete has suffered a high ankle sprain, one of the most frustrating and difficult injuries to overcome.  Recovery is even more difficult when the athlete plays (what I refer to as) a “stop-and-go sport” that involves quick changes in direction.

With a high ankle sprain or interosseous ankle sprain, most damage is found in the anterior ankle and distal shin area.  These structures include:

  1. Interosseous Membrane – located between the two distal shin bones 
  2. Anterior Distal Tibiofibular Ligament – located at the front of the two distal shin bones, just above the ankle joint

 

Ankle sprains cause damage to surrounding bones, tendons, capsules and joint surfaces, but the most serious ones can lead to a rupture of lateral and anterior ankle ligamentous structures, including the capsule.  Ankle joint dislocations and fractures can also occur, which I personally suffered as a collegiate athlete, resulting in two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms of a lateral ankle sprain vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from one to three depending on their laxity, or looseness of the ligaments.

Grade 1 Lateral Ankle Sprain:

  • Mild pain
  • Mild joint stiffness when walking or running
  • Minor stretching of the lateral ankle ligaments
  • Minimal joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Minimal swelling around the bone on the outside of the ankle

 

Grade 2 Lateral Ankle Sprain:

  • Moderate stretching and tearing of the lateral ankle ligaments
  • Moderate joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Moderate swelling on the outside, front and back of the ankle
  • Moderate bruising of the lateral ankle and mid-foot
  • Moderate-to-severe pain and difficulty walking
  • Significant stiffness of the ankle and mid-foot

 

Grade 3 Lateral Ankle Sprain:

  • Complete tearing of the lateral ankle ligaments
  • Significant joint instability with a soft end-feel or tautness of the ligaments when stressed
  • Significant pain
  • Significant swelling throughout the outside, front and back of the ankle and mid-foot
  • Significant bruising of the lateral ankle and mid-foot

 

Treating a Lateral Ankle Sprain

  • Rest the distal leg with Ice, Compression and Elevation (RICE).
  • Leverage the power of ice as a valuable tool for a fast recovery.  Placing ice bags on the outside and inside of the ankle joint for 15 minutes each day is a good way to reduce pain and swelling.  The best way to aggressively treat the entire ankle/foot/distal shin area is to immerse it in an ice bucket for 10 minutes.  Placing a rubber glove or insulated sock over only the toes will make this significantly more tolerable.
  • Depending upon the grade of the sprain, adhere to weight-bearing limitations.  Utilize a walking boot and/or crutches to help gradually reduce symptoms while still allowing for normal activities of daily living (ADLs).
  • Gradually perform range-of-motion (ROM) activities with elevation.  Use only upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Use compression to control swelling and pain in the ankle joint and surrounding tissue when performing weight-bearing activities.  Mixing compression with rest is also helpful for acute sprains.
  • Massage the arch, ankle joint, Achilles and calf to help reduce swelling and enhance blood flow to the injured tissue.
  • Ride a bike using compression, which can be started early on.
  • When the swelling is 50% improved, perform strengthening exercises with manual resistance.  Start with upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches, as inversion motion is the typical injury mechanism that causes ligament damage in the outer ankle.
  • Use a slant board to aid in stretching the calf and posterior ankle joint as it becomes more comfortable.  Include calf-strengthening heel raises when tolerable.
  • As you prepare for your return to sport, perform balance activities, which are great exercises for the final stages of treatment. 
  • Begin sport-specific activities when back to 75% strength and if swelling does not significantly increase with activity.
  • Call on a certified athletic trainer to tape your ankle joint, a smart way to minimize the chance of re-injury.

 

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Is my ankle sprain classified as Grade 1, 2 or 3?

2. Is an X-ray required to rule out a fracture?

3. What do I need to accomplish in rehab to safely return to my sport?

4. Should I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid a Bum Ankle – Trust me: A chronically loose ankle can ruin your confidence and your game.  Without proper treatment, ankle sprains can result in a “bum ankle” that rolls over while performing simple actions such as walking across the yard or stepping off a curb.  Prioritize treatment to tighten affected ligaments and prevent becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – Partnered with loose calves and Achilles, your ankle will enjoy a great range of motion and function normally.

Compression is Your Friend – Employing compression on the ankle joint and distal calves will help maintain congruity of the lower leg long after the sprain has healed.

Get Back to Basics – Other then Michael Jordon, none of us were born with sneakers on our feet.  Bust out of those tight shoes and spend more time barefoot to strengthen your arches, foot muscles and ankle ligaments.

How To Recognize And Treat Achilles Tendon Ruptures

Achilles Rupture

Your Achilles tendon is a strong tendon in your body.  It connects the calf muscles (made up of the gastrocnemius and soleus) located in the back of the lower leg to the back of the heel. The Achilles tendon can partially tear or completely rupture. It is more common for individuals over the age of 35 to suffer a complete rupture of their Achilles tendon than a younger athlete.

Achilles tendon ruptures are frequently associated with a previous history of a prolonged inflammatory condition.  Significant Achilles tendon injuries are commonly the result of an aggressive acceleration movement using the lower leg and/or rapid change of direction activities.

Signs & Symptoms of an Achilles Tendon Rupture

  • A sudden sharp pain as if something hit you in the back of the leg.
  • A sudden snapping sound accompanied by an intense but short-lived pain.
  • The inability to push your foot downward or raise yourself up on your toes while walking.
  • The presence of a divot or gap felt along the usual location of the tendon.
  • A significant amount of swelling and surprisingly, minimal pain, in the back of the lower leg.
  • A positive result for Thompson’s test.

How to Treat a Torn Achilles Tendon

  • Apply ice to the area with an ice bag, ice massage or, ideally, an ice bucket.
  • Avoid walking on the ankle.  Until the severity of the injury is determined, walking on this injury may result in additional damage which can significantly prolong the recovery time.
  • Elevation of the ankle and lower leg will limit the swelling and decrease the pain.
  • Seek sports medicine consultation immediately. Confirming the diagnosis early is very important.

Questions to Ask About Your Torn Achilles Tendon

Even if you’re not a professional athlete, your goal should be to treat your torn Achilles tendon both safely and efficiently. To emulate the smart professional athlete with an Achilles tendon injury who wants to safely return to his/her sport, ask your sports medicine specialist the following questions:

  1. Are you certain of the diagnosis and do we need to do an MRI to determine the extent of the injury?
  2. What are my options with a conservative (without surgery) rehab plan and with a surgical approach?
  3. With both options, what can I expect for the next 3, 6 and 9 months?
  4. If your son or daughter where in my situation and had the exact same injury as I do, what would you recommend them to do?
  5. If surgery is my best option, how many of these types of surgeries do you do per year?  Who do you consider to be the expert Achilles surgeon in this area?
  6. Who do you consider to be the expert Achilles rehab specialist in this area?
  7. Will I be given a detailed rehabilitation protocol to direct my rehab for both my therapist and me?

Elite Sports Medicine Tips You Can Apply to Recover More Quickly

  • Know what you’re dealing with – To quickly get a clear diagnosis and plan, it’s better to have this type of an injury evaluated by an orthopedically-oriented medical specialist compared to a general medical professional.
  • Start treating it early – There are many factors such as walking boots, surgery and early weight bearing plans that must be addressed within the first couple of days after an injury if a full recovery is expected.
  • Know Your Plan for Today & Tomorrow – Be realistic about your activity plans for both your short term and the long term.  Being on crutches for a month or two is never ideal for anyone but if in doing so it considerably improves the likelihood that you will be a happy and active athlete for the rest of your life, DO IT!
  • Think like a Pro – Most high-level athletes with a complete Achilles tendon rupture decide to have their tendon surgically repaired.  The outcome is usually better than the conservative approach, which usually takes longer to heal along with a slower rehabilitation schedule.
  • Expect a Marathon Recuperation Period– The recovery time is considerable for this type of an injury.  Generally speaking, with a surgical repair the recovery time is approximately 6 months.  With the conservative or non-surgical approach, the recovery time is usually closer to 9 months.

Achilles Tendonitis

Understanding Achilles Tendonitis

Common Location of Achilles Tendonitis

Achilles tendonitis is a common injury associated with the presence of inflammation and scar tissue of the largest tendon in the body. The Achilles tendon is located above the ankle in the back of the lower leg. It connects the large calf muscles (Gastrocnemius and Soleus) to the heel bone (calcaneus). Its main function is to transfer power to the ankle during the push off phase of the gait cycle while both walking and running.

Achilles tendonitis is commonly described in the literature as Achilles tendinopathy. The presence of scar tissue and degenerative changes of the tendonous tissue often accompanies the inflammation. A decrease in the elastic qualities and a reduction of the tendon fiber strength is a common finding with athletes older than 30 years of age with Achilles tendonitis.

Achilles tendonitis can be either acute, meaning occurring over a period of a few days, or chronic, which occurs over a longer period of time.

The location of the inflamed tissue can be anywhere along the tendon form the calf muscle or where it attaches to the heel bone or calcaneous bone. Because of the daily stresses place on that area of your body during a normal day of walking and being active and a less than adequate blood supply, the healing of the Achilles tendon is often slow.

Expanding on what was stated earlier, it’s important to understand that the two muscle of the “calf” merge together to form the Achilles tendon before it anchors or inserts into the calcaneus bone. The Gastrocnemius in the larger and more superficial muscle and it originates above the knee. The Soleus is the deeper and shorter muscle that does not cross over the knee joint.

Therefore, whenever Achilles heel pain is being treated, the two calf muscles need to be involved if long-term pain control is the objective.

Signs & Symptoms of Achilles Tendon Pain

  • With milder cases of Achilles heel pain, the localized pain in the Achilles at the beginning of exercise will decreases as the athlete warms-up.
  • The onset of pain can be as fast as within minutes or a gradual increase in symptoms over a period of days or weeks.
  • Symptoms such as pain, stiffness and calf weakness typically decrease with rest.
  • Tenderness noted anywhere along the tendon with palpation and with activities.
  • Prolonged period of inactivity such as in the mornings or after sitting for a long period of time will result in significant Achilles tendon pain and stiffness.
  • Palpable knots or lumps in the Achilles tendon are common.
  • Tendon “squeaking” can often be felt with ankle motion.
  • When performing a one-legged toe raise with the knee completely straight, pain in the tendon, weakness in the calf and limited range of motion in the ankle is demonstrated.
  • Swelling or thickening within the tendinous sheath is common.

Causes of Achilles Heel Pain

Achilles tendonitis is typically an overuse injury. The basic cause of an overuse injury is when a person does “too much to soon”. With that being said, other factors can contribute to inflammation of the largest tendon in the human body:

  • Altered or improper footwear for both activities and work environments.
  • Changes in training surface firmness and inclines such as hills.
  • Rapid increase in activity volume and/or intensity.
  • Insufficient recovery time between workouts.
  • Various arch and foot pathologies such as fallen arches, excessive pronation, hyper-supination or poor toe alignment.
  • Weak calf muscles
  • Tight calves and Achilles tendons
  • Stiff ankles due to arthritic changes.

Professional Treatment for Achilles Tendon Pain

  • Avoid the activities and footwear that are linked to the symptoms. These two issues are classic factors with Achilles tendonitis.
  • Place a ¼ – ½ inch heel lift in both shoes whenever walking more than 50 yards.
  • Avoid prolonged barefoot walking.
  • Massage of calves, arches and front of ankles to promote a decrease in Achilles tendon and ankle stress with motion.
  • Improve arch and toe flexor strength with activities such as marble or rock pickups and towel curls in a seated position.
  • Perform daily calf rolling treatments for the calf and peroneal tendons (lower outside of the shin) but not on the Achilles tendon itself is a beneficial way to promote the healing of Achilles tendonitis. The most effective technique is to warm up the tissue prior to treatment and while slowly rolling the areas noted above, slowly breath comfortably while consistently moving the foot in a large circular pattern.
  • When at least 75% of the pain is eliminated with walking, initiate toe raises to strengthen the calf muscles. Start with double legs on a flat surface and progress to single legs on an uphill incline. Between strengthening sets, perform a 20 second “duck walk” which is a straight legged walking technique on the heels with the front of the foot off the ground. This crazy looking exercise an effective drill that I like to use to both enhance the strength in the front of the ankle and prolong the stretching of the Achilles tendon and calf.
  • Stretching of the two calf muscles is important for long-term reduction of Achilles tendon pain. Wall pushes or slant-board stretches should be performed with both the knees straight and the legs bent to address both muscles and the Achilles tendon. Key Tip – Adjust the angle of your foot to keep the stretch pain-free while performing five (5) slow breaths to promote a relaxed elongation of all the tissue being stretched.
  • Compression of the calf during activities to maintain warmth and improve blood flow.
  • Ice your Achilles tendon and calf muscles in a moderately stretched position. Ice bags/veggie, ice cup or ice bucket will work.

Questions a Pro Athlete Would Ask

A smart professional athlete with Achilles Tendonitis who wants to safely return to his/her sport will ask his sports medicine specialist the following questions:

  1. What are the main factors to why I have Achilles tendon pain?
  2. Do I have abnormal foot/arch/subtalar joint biomechanics that need to be addressed with an orthotic?
  3. Do I have a leg length difference of greater than 1/4 inch?
  4. Am I a candidate for a cross friction massage on my Achilles tendon or will that form of treatment be too aggressive?
  5. Who is the best physical therapist in this area to rehab with for my Achilles heel pain?

Elite Sports Medicine Tips

  • Look Around – This Achilles tendon pain is probably more a result of somethingelse than just an isolated inflammatory issue with your tendon. Look at everything from your shoulder levels to your core strength to your ugly toes for clues.
  • Why Now? – What triggered the flare-up now, Detective? List the activities and factors that you changed in the last month and you may be shock to see the reason(s) looking right at you!
  • Rubberband Man NOT – I watch my young son stretch and bend like Stretch Armstrong. We are probably not as flexible as we need to be so do something every day to stretch your shoulder, back and legs.
  • Check Your Sole – Compare the wear pattern on your favorite shoes. Do the soles look different from one side to the other?
  • Avoid Hills…For Now – As you return to your activities avoid hills for the first couple of weeks. Whether running, walking or on a bike, hills will apply excess stress on the calves and Achilles tendon.