Running Foot Pain or Foot Stress Fracture?

As a runner, pain is often your most loyal training partner.  Pain has no social calendar to work around or a sleep disorder to leave you pounding the pavement all alone during those early morning 5 milers.

Determining which pain is your friend and which one merits a visit to your local sports medicine specialist is the difficult part of that relationship.  I’d like to help you with this problem to keep you healthy and happy….and running pain-free.

The Inside Scoop on Foot Stress Fractures

Stress fractures in the foot are usually characterized as an overuse injury of weight bearing bones.  High impact sports involving running and jumping contribute to simple foot pain and, if left untreated, it can contribute to a stress fracture.

Bones generally respond to stress by hardening along the outer margins of those bones.  When bones are suddenly exposed to great forces or repetitively exposed to increasing stress, there is insufficient time for those bones to adapt.  Meanwhile, when the muscles associated with the feet become fatigued, they lose their shock absorbing capacities. These uncontrolled forces are inadvertently transferred to the nearby bone and possibly resulting in small cracks in the bones, better known as stress fractures.

A common location for stress fractures for distance runners is along the outer ridge of the forefoot over the 5th metatarsal bone.  This is often called either a Jones Fracture or a Dancer’s Fracture, depending upon the location of that metatarsal fracture.

Statistically, women are more prone to stress fractures than men.  The reason for this increased risk factor is based on biomechanics, nutrition and possibly menstrual cycles. Excessive miles in a short period of time with insufficient rest will increase the risk of generalized foot pain, plantar fasciitis, turf toe, metatarsalgia and stress fractures.

Obviously any underlying bone diseases or disorder will drastically increase the risk got a painful foot.

Signs & Symptoms of Stress Fractures in the Foot

  • Localized pain on any bone of the foot, especially during running.  The pain can be dull aching or sharp, occur during activity and may persist with rest.
  • Mild widespread swelling and tenderness over the foot.
  • The pain may worsen with prolonged exposure to ice and during sleep.
  • An initial sensation of sharp pain followed by intensifying aching is common.
  • Associated lower extremity symptoms such as lateral thigh/knee pain, low back tightness and/or Achilles tendonitis due to an alteration of a runner’s foot mechanics.

Professional Treatment for Running Foot Pain

  • Rest and Ice.
  • Avoid excessive weight bearing on the affected foot.
  • Wear shock-absorbing footwear with walking and if symptoms worsen, a walking boot is a great tool to help control the stress on the injury site.   
  • Eat healthy and ingest Recommended Daily Allowance (RDA) amounts of calcium and vitamin D can help restore bone integrity.
  • Strength training for the arch, toe flexors and weak muscles, which may have contributed to the initial injury.
  • Maintain range of motion of the surrounding muscles and joints.  This especially relates to the Achilles, calf, plantar fascia, great toe and ankle joint.

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. What would you consider to be the main reasons why this injury occurred?
  2. How can I best manage this pain and to safely return to running?
  3. Do I need orthotics and if so, who is the very best foot doctor for runners to discuss this option?
  4. Do I need to be concerned with any long-term issues with this foot pain?

Elite Sports Medicine Tips from Mike Ryan

  • Reporting Time – See a sports medicine specialist as soon as symptoms appear to manage this foot pain quickly.
  • Rest Rocks – It’s the boring option but REST is the #1 tool to quiet down a stress fracture.  For how long?  It may be 2 to 6 weeks if the symptoms persist.
  • Return to Running – Resume your running slooooowly. Include pool running, run/walk routines and running off-road while increasing your miles by no more than 10% per week.
  • Cross Train – Cross Training is King. Adding biking, swimming, yoga, strength training, Elliptical trainer,…etc. are great ways to stay in shape and to save your marriage during this “downtime”.
  • Stability – Wear stable and proper fitting shoes upon your return.  It’s not about needing a feather shoe, it’s about protecting your feet.
  • No Big Break – Stress fracture can easily develop into a typical bone fracture if gone untreated.  Limitations early can help you to easily avoid the “big break”.

Taming the Fire of a Painful Heel From Plantar Fasciitis

Understanding a Plantar Fascia Strain

Plantar fasciitis is a painful condition with localized pain in the backside of the arch where it attaches to the underside of the heel bone or calcaneus.  It is often the result of overstretching, overloading or tearing of the origin of the arch, which runs from the heel to the front of the foot under the toes.

This band of tissue stretches every time weight is applied to the foot with standing and walking.  It helps to stabilize and propel the foot forward in movement. Plantar fascia strains can result excessive trauma to the band or the result of culminated effect of repetitive stress placed on arch over time. A plantar fascia strain usually gives rise to sustained inflammation of the front of the heel and back of the arch.  This results in excessive pain in this location, especially after prolonged non-weight bearing inactivity such as sleeping and sitting.  This is based on the simple fact that the band tightens when you don’t move it. If left untreated, a plantar fascia strain can become a chronic and troubling ailment.

Causes: The most common cause of plantar fasciitis is doing too much running, walking and/or jumping in poor footwear. Also, beginners attempting to go overboard in their chosen physical activities are likely to stretch the band too much the first time.   Additional predisposing factors include obesity, rapid weight gain, flat feet, and excessive exercise with insufficient progression.  With some chronic arch pain conditions, as the band of tissue continues to pull on the heel bone, it can result in a heel bone spur.

Signs & Symptoms of Heel Pain From Plantar Fasciitis

  • Perception of burning, stabbing, or dull aching pain at the front of the heel and along the band of tissue in the backside of the arch.
  • Difficulty bearing weight on the foot without shoes.
  • Arch pain with heel raises and with flat foot 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 times do vary from individual to individual.

  • Rest in the form of avoiding weight-bearing will help improve heel pain.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Repetitive icing with the arch and toe flexor tendons in a stretched position will reduce inflammation and pain while helping to elongate the sore plantar fascia tendon.
  • Proper footwear for your sports.
  • Taping the foot will assist in supporting of the arch, to reduce inflammation and decrease the risk of further injury.
  • Progressively aggressive transverse friction massage to the posterior arch along with a moderate massage for the ankle and lower shin.
  • Strengthening and stretching exercises for the arch and calf muscles will help a painful heel.
  • Arch support inserts can be helpful.
  • Arch taping, if done properly, can effectively support the arch and reduce the amount of heel pain with weight-bearing.
  • Minimize weight-bearing activities.
  • Weight loss, if overweight or obese.

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)   Does this heel pain have anything to do with my pelvis, lower extremity or foot alignment?

2)   What forms of physical therapy do I need to do to quickly resolve this injury so I can get back to my sport(s) pain-free?

3)   What are my options besides surgery?

4)   Are there any long-term complications from a sprain?

5)   Will I benefit from the use of anti-inflammatory medicine?

6)   Is this painful heel a result of some other biomechanical abnormality that needs to be addressed?

Elite Sports Medicine Tips from Mike Ryan

  • Fast Treatment/Fast Recovery: The sooner you address plantar fascia sprains the quicker they resolve.  Don’t let it become chronic.
  • Minimize Newton’s Laws: Aggressive weight-bearing activities will prolong the time for recovery and increase the risk of long-term complications.
  • Template for Post-Workout Therapy:Immediately after all of your workouts or treatments do the following:
    • Elevate your foot for 3 minutes.
    • Stretch for 5 minutes
    • Ice the arch and heel for 7 minutes.
  • Stretch: Aggressive stretches for the calves, arches, big toe and toe flexor tendons will go a long way in maintaining healthy tissue involving the entire foot.
  • Eat and Drink Right: It’s easier and safer to control inflammation and promote healing by being well hydrated and with a healthy diet compared to taking all sorts of pain pills.

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.

No One Can Ignore Metatarsalgia Foot Pain

Metatarsalgia is a general term relating to forefoot pain secondary to inflammation in the area of the distal foot and toes.  The swelling involves the joints that connect the metatarsal bones of the foot and the phalanges (toe) bones.  The 2nd, 3rd and 4th MTP joints are most often stricken with this disorder.  With the joints of the toes, Metatarsalgia is commonly found within the 2nd, 3rd and 4th interphalangeal joints.

Morton’s Neuroma is a similar condition that demonstrates with forefoot pain.  Unlike Metatarsalgia, Morton’s Neuroma pain is located between the distal metatarsal bones where Metatarsalgia is typically pain within the joints themselves of the forefoot and toes.

Morton’s Neuroma is caused by a pinching of the nerves between the 2nd, 3rd and 4th metatarsal bone creating an inflammation of the nerves.

Ball of the foot pain is not typically linked to either of these condition although it is not surprising to develop such symptoms by compensating for any lower extremity dysfunction.

Signs and Symptoms of Metatarsalgia

  • Forefoot and toe pain which increases with weight bearing activities.
  • Tight fitting shoes and high heels increase symptoms.
  • Point tenderness pain in the distal foot area and proximal toes.
  • Excessive blistering, callus and wear patterns are commonly found in the forefoot and toes.
  • Passive bending and rotating of the toe will increase pain.
  • Ball of foot pain can be present which tends to be more related to compensation mechanics with chronic foot pain symptoms.
  • Long-term abnormal toes alignment such as claw toes or bunions may be contribute to the condition.
  • There may be excessive skin or calluses under the foot due to excess pressure.

Sign and Symptoms of Morton’s Neuroma

  • Localized pain between the 3rd and 4th distal metataral bones and toes.
  • Complains of increased weight bearing symptoms as if they are “standing on a pebble”.
  • Pain increases with weight bearing activities.
  • Symptoms into the distal foot and toes can include sharp pain, burning, numbness and/or tingling.
  • Increased symptoms between the metatarsal bones with squeezing of the forefoot.
  • Excessive callus and wear patterns are commonly found under the distal forefoot and great toe.
  • Ball of foot pain can be present which tends to be more related to compensation mechanics with chronic foot pain symptoms.

Treatment for Metatarsalgia and Morton’s Neuroma

  • Aggressive icing of 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 the activity you are performing
  • Minimize activities that include weight bearing.
  • Massage and soft tissue treatments to the arch, great toe, ankle joint and calf.
  • Biomechanical evaluation to assess contributing issues such as: a leg length discrepancy, hyper pronation/supination, tight ankles, restricted toe extensor tendons, hypomobile toes, knee, hip or low back factors.
  • Consistent calf stretching.
  • Orthotics with possible rigid steel insert of ball of foot pain is present.

Questions a Pro Athlete Would Ask

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

  1. Do you have any concern that I may have stress fracture in my foot or toes?
  2. Is there any chance that some of my foot symptoms are coming from nerves in my back or leg?
  3. Will orthotics help me and if so, where can I get them at a reasonable price?
  4. If you had this same problem, where would you go to do your therapy?

Sports Medicine Tips

If the Shoe Doesn’t Fit, Don’t Wear It – True fact:  woman’s shoes are the best invention for the foot doctor profession.  They look sexy and stylish but they are killing your feet.  Ladies or dudes:  You know that it’s true so get rid of any shoes that are creating foot problems.

Sole Searching – The shoes are typically the source of your problem.  Old shoes, improper shoes and worn shoe soles are common factors that lead to foot and arch pain.

#2 Pencil – Using the eraser end, use it to apply pressure between the metatarsal bones of the foot.  It’s a simple tool to help determine the location of the pain and the diagnosis.

Ice is Your Friend – It’s a reality check:  Ice hurts but it’s exactly what you need for this injury.  The Pros will tell you that ice is their best teammate.  Stop complaining and do what you know you need….ICE and lots of it.

Sprained Ankle Management

Lateral Ankle Sprain

Ankle sprains remain the most common lower extremity injury in all of sports.  From the minor “tweak” of the ankle to the high ankle sprain, the range of symptoms and the limitations vary greatly.  The challenging factor with ankle sprains remains the ongoing vulnerability of the ankle joint for years after a sprain because of the resulting ligament instability so common after a significant injury.

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

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 give stability to a joint.

Lateral Ankle Sprain

With a lateral ankle sprain, commonly called an inversion sprain, occurs, a majority of the ligament damage takes place along the lateral or outside of the ankle joint.  These ligaments include 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

Often we read about elite athletes with an ankle sprain that forces the athlete to be out of competition for 2-6 weeks.  Immediately, questions arise as to why anyone would miss so much time with “just an ankle sprain”?  In most cases, the reason is that the athlete has suffered a high ankle sprain.  The high ankle sprain is one of the most frustrating and difficult injuries for an athlete to recover from during a season.  This injury is even more difficult to overcome when the athlete is involved in what I refer to as a “stop and go sport” where rapid changing of direction is required.

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

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

Additional damage to the surrounding bone, tendon, capsule and joint surfaces can result from any ankle sprain.  A serious ankle sprain can result in complete ruptures of the lateral and anterior ankle ligamentous structures including the capsule.  Ankle joint dislocations and fracture often occur.  I suffered such an injury while in college resulting in two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms for a lateral ankle sprain will vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from 1 to 3 based upon their laxity or the ligament looseness.

Grade 1 Lateral Ankle Sprain:

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

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 to severe pain and difficulty walking.
  • Moderate swelling on the outside, front and back of the ankle.
  • Significant stiffness of the ankle and mid-foot.
  • Moderate bruising of the lateral 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).
  • Ice is a valuable tool for a fast recovery.  Ice bags on the outside and inside of the ankle joint for 15 minutes is a good way to reduce the swelling and pain.  The best way to aggressively ice the entire ankle/foot/distal shin area is to place the ankle into an ice bucket for 10 minutes.  A rubber glove or insulated sock covering only the toes will significantly help make the ice bucket more tolerable.
  • Depending upon the grade of the sprain, limitations in the weight bearing status may be necessary.  The use of a walking boot and/or crutches will prove to be helpful to allow for a daily reduction of the symptoms while still performing normal activities of daily living. (ADL’s)
  • Easy range of motion (ROM) with elevation can be started in a painfree range.  This motion should only be in the upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Compression when weight bearing and with activities is very helpful to control swelling and pain in the ankle joint and surrounding tissue.  Compression with rest will be helpful for acute sprains.
  • Massage to the arch, ankle joint, Achilles and calf will help reduce the swelling and enhance blood flow the injured tissue.
  • Bike riding with compression can be started early.
  • Manually resisted strengthening exercises can be started when the swelling is reduced by 50%.  Starting with resisted upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches.  Typically this inversion motion was the mechanism of injury resulting in ligament damage to the outside of the ankle.
  • Slant board can be initiated when stretching of the calf and posterior ankle joint is comfortable.  Include calf strengthening heel raises when tolerable.
  • Balance activities are great drills for the final stages of treatment to prepare you to return to your sport.
  • Sports specific activities can be started when strength is at least 75% and the swelling is not significantly increasing with activities.
  • Having your ankle joint taped by a certified athletic trainer is the smart way to minimize your chances of re-injuring your ankle.

Questions a Pro Athlete Would Ask

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

  1. What grade is my ankle sprain?
  2. Do I need an x-ray to rule-out a fracture?
  3. What do I need to accomplish with my rehab to be able to safely return to my sport?
  4. Do you recommend that I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid the Bum Ankle – Trust me: a chronically loose ankle can ruin your confidence and your game.  So many have a “bum ankle” that rolls over just walking across the yard or stepping off a curb.  Treat your ankle sprain right now will keep your ligaments tight and keep you from becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – If your calves and Achilles remain loose, your ankle will have great range of motion and function normally.

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

Back to Basics – Other then Michael Jordon, none of us where born with sneakers on our feet.  Get out of those hard shoes and spend more time barefoot.  It will 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.