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Introduction


Treatment of Achilles tendinopathy requires a comprehensive approach including pain control exercises, then strengthening followed by power and finally a well rounded return-to-play program to restore strength and function to this affected tendon.

In this blog, you will learn the main exercises we use with soccer player recovering from an Achilles Tendionpathy


Should I rest the Achilles or Loaded ?


Many soccer players may think that they need to ‘use’ the tendon ‘less’ in order to improve the pain and reduce the symptoms, so they rest or reduce the activity significantly and the pain usually gets better but here is the catch, once these players return to practice the pain comes back almost immediately

In our approach to Achilles Tendinopathy, the key is to fully rehabilitate the tendon by using the tendon more. More means progressive loading of the tendon to increase its resilience for the sport activity.


What are the best exercises for Achilles Tendinopathy?


Build plantar flexor capacity !!!! Do all types of calf raises


We discussed above that in Tendinopathies, loading the tendon is the way to improve this condition.


The goals is a progressive increase in loading the tendon through rehabilitation exercise that ultimately will include what is known as ‘heavy slow resistance’ work that typically is performed in a gym setting with appropriate resistance.


I like to see soccer players being able to do heavy gastrocnemius and soleus work in a gym (targets 1.5x body weight soleus seated calf raises & 0.3-0.4x body-weight standing calf raises aiming for 3x 8 reps with good control.


Of course even though the goal is to go heavy on the tendon, we cannot start with heavy stuff because it will most likely irritate the tendon and create more pain.


The logical progression for this exercises is to build up capacity with Isometrics first, then isotonics (full Range of movement) , then eccentrics (emphasis on the movement down of the calf raises ) and finally plyometric exercises with all types of jumps to challenge the super important and ultimate function of storage-release mechanism of the tendon )



Isometrics


Isometric contraction is a very powerful type of muscle activity in which the muscle contracts quite strong but there is no movement at the adjacent joint. Isometric exercises help with pain in the tendon as well as with the develop of force.

Isometric contractions are used early in the treatment process for these reasons.



Bilateral Calf Raises - Isometrics




Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Slowly raise your heels off the ground and hold that position. Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended .

As you get stronger you can add weight to this exercises with a vest or backpack



Unilateral Calf Raises - Isometrics



Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Raise your heels as high as you can then Bend one knee up to 90 degrees and hold the weight of your body on the opposite Foot raised , hold that position . Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended.



Isotonics Exercises


Once you are able to manage the Isometrics without a flare-up in pain or symptoms we start loading the tendon progressively in the full Range of motion available. Adding a step to the equation allows for more demand on the tendon fibers.

It is very important with these exercises below that you control the pace of the movement and go from one end of the movement to the other. This is how we will show the tendon where to align the newly formed fibers of collagen : “in line “ with the force which makes the tendon more resistant to the load.


Calf Raises on Step



Setup.

Begin standing at the edge of a step with your heels hanging off the edge. You may hold onto a stable object for support.

Movement.

Raise up onto the balls of your feet, then slowly lower your heels down off the edge of the step and repeat.

Tip.

Make sure to maintain your balance during the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.


Bent Knee Calf Raise on Step



Setup

Begin standing on a small step or platform with your heels off the edge, holding onto a stable object for balance.

Movement

Bend your knees, then raise both heels up, and lower them down slowly. Repeat these movements.

Tip

Make sure to keep your back straight and knees bent throughout the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.





Excellent… by doing calf raises Am I cured ? ….

The answer will be NO... YET....


Building plantar flexor capacity is just part of the treatment. Once you have more control of your calf muscles we need to reproduce the demands on the tendon. Tendons are like springs. Let’s say you are running and every step you take you absorb your own weight in the foot and then you push your body forward to continue running. This load absorption and release is the main function of the Achilles Tendon.






So in order to get completely better, strengthening only will not be enough and you need to reproduce and train this energy storage-release mechanism.

To recreate this, Therapists use what it is called Plyometrics exercises intended to simulate this function. Examples of Plyometrics are bilateral and unilateral leg jumps , quick calf raises , box jumps and other.

Plyometrics are high level exercises need to be done by a therapist to properly choose the right doses in order to avoid irritation of the tendon



Ankle Plyometrics - Double Leg and Single Leg Ballistic Heel Raises


Set Up

Stand up on the ball of your feet

Movement

Do Quick Rebounds mid amplitude

Then switch to one foot only and repeat mid amplitude heel raises

Sets of 10 reps


Load Management



When returning to the activity in this case playing soccer, you must do it gradually. Knowing exactly what brings out your symptoms will empower you to make the right adjustments for the healing process to take place.

Movements that create high loads and use the tendon as a spring (jumping or sprinting activities for example) increase cell signaling and can create the over-response that sparked the pain you are feeling. Therefore, start with walking and jogging session, followed by jogging only session, changes of speed (50-75-90 %), cuts 45-90-180 degrees, speed and agility drills, ball possession drills until you can practice a whole week without irritation of the tendon. If during the progression there is pain after the activity of the morning after it means the pain you’re experiencing is your tendon telling you it is not tolerating the loads you are placing on it. It is there for a reason. Listen to it.

For such cases, try changing one variable in your training program and see how your tendon responds. For example, if you currently train seven days a week, decrease the frequency by dropping one session. If you can’t sacrifice one day of training, you must make a change to either the amount of high intensity loads or the total volume of your training. Regardless of which variable you choose, only change one factor at a time and wait to see how your body responds (everyone will be slightly different so there is no golden rule).




Finally...Should I stretch Tendon Pain?

Despite what you may have learned elsewhere, we do not want to stretch an Achilles tendon injury!

No matter what form of tendinopathy you may be experiencing, stretching should not be a part of your rehabilitation program.

Remember that Insertional Achilles tendinopathy injuries occur due to high levels of compressive load to the tendon against the calcaneus bone. Stretching your calf muscles will only serve to add more compression (and lead to more pain) on the already injured area.

While there is less cause for concern for those dealing with a mid-tendon tendinopathy injury, research has not shown any benefits to stretching whatsoever.

Instead, if you do have limited ankle mobility or you feel tight in your calves, you can safely perform soft tissue mobilization to the calf muscles with a foam roller or massage stick. Foam rolling has been shown in research to improve ankle mobility without placing harmful compressive loads on the tend




Conclusion


  • Achilles Pain from Tendinopathy is very common in Soccer players (see statistics at https://www.ncbi.nlm.nih.gov/pubmed/23770660)

  • In this Tendinopathy there is an imbalance between the amount of load that the tendon in receiving and the tendon's capacity

  • Weakness in the calf musculature is the main reason for Achilles Tendinpathy.

  • Physical Therapy can help by building Calf Raise Capacity to improve the strength of the calf and reinforce the remaining of the healthy tendon.

  • A combination of Isometrics, Isotonics, Eccentrics and Plyometrics exercises is necessary for a safe and pain-free return to play process

  • Education in Load Management and a strategy to progressively load the tendon without (or minimal) irritation are also mandatory if you want to play pain-free



Do you have other questions about Achilles Tendinopathy?

Do you want to know if Physical Therapy can help your particular case ?



Give us a call at 754 244 2561 and we will help you answer these question and even we will schedule you a Free consultation


Visit www.wbsphysicaltherapy.com for more information

on how to talk to a Sports-Certified Specialist

and start getting better today...



#achillestendinopathy #achillespain #whitebayphysicaltherapy #calfpain #calfStrain #PulledMuscle #Soccerinjuries #Soccercalfinjury #westonsoccer #westoncalfpain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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  • Lionel Pannunzio PT / SCS


Introduction


Achilles tendinopathy is an irritation of the Achilles tendon, a thick band of tissue along the back of the lower leg that connects the calf muscles to the heel.

It affects Soccer players of all ages. In this blog, you will learn the main causes of Achilles Pain, the different types of injures and guidelines for recovering from this condition



Incidence


A total of 27 clubs from 10 countries and 1743 players have been followed prospectively during 11 seasons between 2001 and 2012.

A total of 203 (2.5% of all injuries) Achilles tendon disorders were registered.

A majority (96%) of the disorders were tendinopathies

A higher injury rate was found during the preseason compared with the competitive season

The mean lay-off time for Achilles tendinopathies was 23±37days

Players with Achilles tendon disorders were significantly older than the rest of the cohort, with a mean age of 27.2±4 years vs 25.6±4.6 years

27% of all Achilles tendinopathies were reinjuries.

Recurrence is common after Achilles tendinopathies and the reinjury risk is higher after short recovery periods.

(source: Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up of the UEFA Champions League injury study. Gajhede-Knudsen et al)





Anatomy of the Injury



Where is the problem?

Achilles Tendinopathy is an irritation of the Achilles tendon, a thick band of tissue along the back of the lower leg that connects the calf muscles to the heel.




What is a Tendinopathy?


The term “tendinopathy” refers to any problem with a tendon, either short- or long-term.

The Achilles tendon transmits force from the calf muscles down to the foot when a person pushes the foot off the ground (eg, runs or jumps), and helps control the position of the ankle when the foot touches back down on the ground (eg, lands).

Achilles tendinopathy results when the demand placed on the Achilles tendon is greater than its ability to function.

The condition can occur after a single incident (acute injury) or after repetitive irritation or "microtrauma" (chronic injury).

Most often, Achilles tendon pain is the result of repetitive trauma to the tendon that can result in chronic Achilles tendinopathy—a gradual breakdown of the tissue—and is most often treated with physical therapy. Please note that we don’t use the term tendonitis because “itis” means inflammation like in a acute ankle sprain. This is more a problem in the architecture of the tendon, a mechanical problem within the tendon and not an inflammatory process.

So in the tendinopathy there are mainly healthy fibers in conjunction with some “abnormal fibers”





Stages of the Achilles Tendinopathy


  • Normal Tendon

  • Reactive Tendinopathy: early stage of the tendinopathy, as a result of an excessive and rapid load. Thickening of the tendon. Painful . Reversible. Young -15-25 yrs

  • Tendon Disrepair: tendon unable to manage loads and architectural changes occur inside the tendon. Trying to repair . Less painful. Less reversible. Young Adult - 20-35 yrs

  • Degenerative Tendinopathy: Late stage of Tendinopathy, tendon gives up on healing. Degeneration of parts the tendon. Non-reversible. Older - 30-60 yrs

  • Reactive on Degenerative Tendinopathy: acute exacerbation of a Degenerative Tendon







Types of Achilles Tendinopathy

Pain can be present at any point along the tendon; the most common area to feel tenderness is just above the heel (known as mid-portion Achilles tendinopathy), although it may also be present where the tendon meets the heel (known as insertional Achilles tendinopathy).






Causes of Achilles Tendinopathy


Achilles tendinopathy is linked to several different factors, including:

  • Calf muscle tightness

  • Calf muscle weakness

  • Abnormal foot structure

  • Abnormal foot mechanics

  • Improper footwear

  • A change in an exercise routine or sport activity

  • Obesity



Symptoms


With Achilles tendinopathy, you may experience:

  • Tenderness in the heel or higher up in the Achilles tendon with manually applied pressure

  • Pain and stiffness with walking, at its worst with the first several steps, especially worse in the morning upon stepping down from bed or after being sitting for +20-30 mins

  • Tightness in the calf

  • Swelling in the back of the ankle


The Pain cycle and the road to a Chronic pain


In the early stages of the Tendinopathy Achilles Pain typically warms up as the athlete starts to exercise, feels okay during exercise, then aches again following activity.

As time goes on, there is often less of a warm-up effect and the pain persists during exercise. Patients will often also complain of morning pain and stiffness which warms up over a few minutes. Tenderness and swelling are also common complaints.


That’s how this Tendinopathy becomes Chronic and from there it can last forever without proper treatment



How Physical Therapy can help me get better from Achilles Pain?


At White Bay Physical Therapy, we will review your medical history and complete a thorough examination of your heel, ankle, and calf. We will assess your foot posture, strength, flexibility, and movement. This process may include watching you stand in a relaxed stance, walk, squat, step onto a stair, or do a heel raise. The motion and strength in other parts of your leg also will be assessed.

We may also ask questions regarding your daily activities, exercise regimens, and footwear, to identify other contributing factors to your condition.

Imaging techniques, such as X-ray or MRI, are often not needed to diagnose Achilles tendinopathy. Although it is unlikely that your condition will ultimately require surgery, your physical therapist will consult with other medical professionals, such as an orthopedist, to determine the best plan of treatment for your specific condition if it does not respond to conservative care.



Treatment Guidelines


Seth O’Neil a physiotherapist from UK and one the Achilles Tendinopathy “Gurus” resumed the guidelines for treating Achilles Tendinopathy in 5 points


1. Reassurance

One of the common incorrect beliefs is that tendinopathy needs to be rested to get better. In actuality the tendon needs to be used ‘more’ but in the correct manner (ie loaded rehab exercises and progressive running)


2. De-threaten the condition

Many people can fear loading the tendon for concern of ‘tears’ or ‘rupture’. The therapist’s job is to show the tendon-pain-sufferer of the very high loads that tendons endure day to day (eg 4x Body-weight intra tendon loads with walking, 6x BW with running) so loading the tendon with just your body at the beginning it is not a high demand activity so you are safe to do it.


3. Educate on load management

The soccer player needs to appreciate that loading tendon correctly is the pathway forward, how to monitor increases in workload based on the pain response, the required time to allow tendon to adapt to loading, why ‘flare ups’ can be expected.

Build plantar flexor capacity: I like to see soccer players being able to do heavy gastrocnemius and soleus work in a gym (targets 1.5x body weight soleus seated calf raises & 0.3-0.4x body weight standing calf raises aiming for 3x 8reps with good control

Return to full practice : this must be staged & I normally suggest returning to practice progressively with days in between to rest



Conclusion


  • Achilles Pain from Tendinopathy is very common in Soccer players.

  • In this Tendinopathy there is an imbalance between the amount of load that the tendon in receiving and the tendon's capacity

  • Weakness in the calf musculature is the main reason for Achilles Tendinopathy.


Next post will be about what exercises you can do to self manage Achilles Pain, stay tuned.



Do you have other questions about Achilles Tendinopathy?

Do you want to know if Physical Therapy can help your particular case?



Give us a call at 754 244 2561 and we will help you answer these question and even we will schedule you a Free consultation


Visit www.wbsphysicaltherapy.com for more information on how to talk to a Sports-Certified Specialist and start getting better



#achillestendinopathy #achillespain #whitebayphysicaltherapy #calfpain #calfStrain #PulledMuscle #Soccerinjuries #Soccercalfinjury #westonsoccer #westoncalfpain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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  • Lionel Pannunzio PT / SCS

Introduction


Plantar fasciitis is a condition causing heel pain. It affects players of all ages and when it becomes chronic it can be very debilitating even prevent you from playing soccer .

Learn how this condition develops and more important how to treat it.





What is Plantar Fasciitis (The Correct name is Fasciopathy)?


Plantar Fasciopathy is a condition causing heel pain. Supporting the arch, the plantar fascia, a thick band of tissue connecting the heel to the ball of the foot, can become inflamed or can tear.


The condition develops when repeated weight-bearing activities put a strain on the plantar fascia.


Plantar Fasciopathy is a degenerative Process characterized by Collagen Breakdown, nerve and vascular ingrowth.


In late stages of the condition it can progress to Calcifications .


The correct term for this condition should be Fasciopathy instead of Fasciitis since there is no real inflammatory process involved. As with the Achilles Tendinopathy, there are structural changes in the Fascia as a result of collagen breakdown that cause pain rather that inflammation.



Incidence and Causes of Plantar Fasciopathy


Incidence


Plantar fasciitis occurs most frequently in people in their 40s but can occur in all age groups.

The condition can develop in athletes who run a great deal and in non-athletes who are on their feet most of the day, such as police officers, cashiers, or restaurant workers.


Plantar Fasciopathy is a common foot condition. It occurs in as many as 2 million Americans per year and 10% of the population over their lifetimes.

Plantar Fasciopathy affects people of all ages, both athletes and non-athletes. Men and women have an equal chance of developing the condition.



Causes of Plantar Fasciopathy


Factors that contribute to the development of plantar Fasciopathy include:

  • Age (over 40 years)

  • Rapid increases in length or levels of activity, such as beginning a new soccer season or preseason program

  • Decreased calf muscle flexibility

  • Reduced ankle dorsiflexion in combination with reduced Great Toe Extension.

  • Reduced Toe flexor and evertor strength and decreased Hamstring Flexibility ( Sullivan et al 2015)

  • Increased body weight (Body Mass Index greater than 30)

  • Tendency to have a flat foot (pronation)






Plantar Fasciopathy highly related to Tightness in Calf muscles ?



In the picture above you can appreciate how the ankle and the great toe work together to push the body forward when walking or running . You can also see how a normal combined movement between Ankle Dorsiflexion and Great toe Extension are necessary to avoid excessive tension in the fascia. Any restrictions in these joints or their surrounding muscles will create excessive loading in the fascia creating the Fasciopathy if the movement is not restored.


Signs and Symptoms


People with plantar fasciitis may experience pain:

  • In the morning, when stepping out of bed and taking the first steps of the day

  • With prolonged standing

  • When standing up after sitting for awhile

  • After an intense weight-bearing activity such as running

  • When climbing stairs

  • When walking barefoot or in shoes with poor support

As your body warms up, your pain may actually decrease during the day but then worsen again toward the end of the day because of extended walking. Severe symptoms may cause you to limp.


How Physical Therapy can help ?


First of all, Plantar fasciopathy should ruled-in and other conditions like fat pad irritation, stress fractures, nerve entrapment or arthropathies should be ruled-out .

Once you are diagnosed with plantar fasciitis, your physical therapist will work with you to develop a program to decrease your symptoms that may include:

  • Improve the flexibility of your ankle and the plantar fascia

  • Use of a night splint to maintain correct ankle and toe positions

  • Selection of supportive footwear and/or shoe inserts that minimize foot pronation and reduce stress to the plantar fascia

  • Iontophoresis (a gentle way to deliver medication through the skin)

  • Taping of the foot to provide short-term relief

  • Increase Plantar Flexor capacity

  • Increase Great Toe mobility and Range of movement

  • Increase strength and flexibility of the Lower Extremity as a whole.

Research shows that most cases of plantar fasciitis improve over time with these conservative treatments, and surgery is rarely required.

Plantar Fasciopathy is a self-limiting condition of variable duration

With treatment symptoms usually improved in 3-6 months (some cases up to 9 months)



Stages of Rehabilitation


Pain Dominant Phase


Plantar Fascia becomes sensitive to load. Pain and stiffness when stepping out of bed and taking the first steps of the day. Pain with activities like walking long distance or prolonged standing. This phase can last 2-8 weeks.


Interventions


  • Control pain by reducing or modifying aggravating Activities: load management , reduce running distance or frequency of games played. For example if you are playing soccer 2 o 3 times a week this is the time where you only play once a week to allow time to recover from game to game.


  • Improve the flexibility of your ankle and the plantar fascia: mobility work for ankle and foot with emphasis on reducing tightness in calf and posterior chain.


  • Increase Plantar Flexor capacity: mainly Isometric strengthening progressing to light Isotonic strengthening as tolerate.


  • Increase Great Toe mobility and Range of movement: big emphasis on Improving Great toe extension to help with shock absorption and power generation in the stride.


  • Increase strength and flexibility of the Lower Extremity as a whole: quadriceps and Gluteal muscles assist with load absorption during the run so by strengthening these muscles group we help unloading the fascia.


  • Bicycle is a good option to maintain some aerobic capacity while allowing the fascia to heal . Players should avoid running or walking long distance during this phase.



Plantar Fascia Mobilization - Stretch



In sitting with the foot resting on your opposite knee, bend the ankle and big toe up holding for 10 -15 seconds and repeat 10 times



Ankle Strengthening




Turn the ankle out against the band and then in . 8-12 reps to each side




Isometric Toe Flexion



Push the big toe down as hard as possible and tolerated, Hold the contraction for 3-5 seconds . Repeat 5-10 times each foot.


Also in the Pain Dominant Phase we must address any excessive foot deviation by using over-the-counter orthotics or Taping for short-term pain management. If these help it may grant the investment in custom-made orthotics down the road.




Load Dominant Stage


We can move to the next phase once the Pain at 1st step in the morning improves and increases walking tolerance. Symptoms remain stable unless the fascia is overloaded ( runs or games) .


Interventions:

  • Increase Plantar Flexor capacity: progressing from Isotonics to Eccentric movements of the calf

  • Interval training to increase load capacity to develop calf endurance and Power : plyometrics.



Some exercises we like to use during this phase are shown below which are intended to create ankle Dorsiflexion and Great toe extension and at the same time mobility and strengthening of the plantar fascia and calf-ankle-foot- Toe complex muscles


Great Toe sliders




Great Toes - Plantar Fascia Strengthening - Push off




Double leg Heel raise with towel





Once the patient can do the above exercises and pain remains at a minimum or has disappeared we start thinking and the Return to Play Strategy: start with light jogging, increasing time and distance as tolerated and with no irritation (or minimal irritation). Then from there to sprinting , cutting and jumping. This stage must be guided by a Physical Therapist to assure a safe return to Play .





Conclusion


  • Plantar Fasciopathy and heel pain affect a large population of soccer players

  • Conventional physical or chiropractic treatment usually fails to address all the possible causes of this condition

  • Improve and restore plantar fascia length and Plantar Flexion Capacity with emphasis on Great Toe strength are the main goals of the treatment.

  • Our comprehensive approach is backed-up by the most recent research. Once you resolve the root of the problem the Plantar Fascia becomes pain free

  • Education and load management are key factors for people with Plantar Fasciopathy


White Bay Sports Physical Therapy is a Sports-Injury clinic that specializes in Plantar Fasciitis treatment .

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Players and Athletes of all ages



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