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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 - What are Shin Splints?




Medial tibial stress syndrome (MTSS) is a condition that causes pain on the inside of the shin (the front part of the leg between the knee and ankle).

MTSS is commonly referred to as “shin splints” due to the location of pain over the shin bone; pain can be felt on the inside or the front of the shin bone.


The pain is non-focal but extends over “at least 5 cm” over the shin  and is often bilateral


MTSS is one of the most common athletic injuries. It affects both the muscle on the inside of the shin and the bone to which it attaches, causing the connection between them to become irritated or even develop minor tears due to overwork. .


The two main muscles relating to shin splints are tibialis anterior muscle (located on the front of the shin bone), and posterior tibialis muscle (located inside and behind the shin bone). Overuse of these muscles is what creates the pain on the shin.


MTSS may affect up to 35% of athletes who run and jump, such as distance runners, sprinters, basketball or tennis players, soccer players or gymnasts. Military personnel, dancers, and other active people also can develop MTSS.


The most common complication of shin-splints is a stress fracture, which shows itself by tenderness of the anterior tibia.


Physical therapists help people who develop MTSS recover pain-free movement and learn exercises and tactics to prevent reinjury.






Shin Splints- Anatomy of the Injury




There are 4 muscle compartments in the lower leg:


1. Anterior: this compartment contains the tibialis anterior muscle, the extensor hallucis longus, the extensor digitorum longus and the peroneus tertius. This group moves the foot and toes up.


2. Deep posterior: this contains the flexor digitorum longus, the tibialis posterior and the flexor hallucis longus. This group moves the foot and toes down.

3. Superficial posterior: this is the gastrocnemius and soleus group; predominatly plantar flexors of the ankle.


4. Lateral: this compartment contains the peroneus brevis and longus, mainly foot evertors. This group brings the foot up and out .




Types of Shin Splints:


Anterior shin splints


The tibialis anterior is very important during the running stride.


This muscle has to work very hard in keeping the feet dorsiflexed (up) during every step and for that it needs to be strong to prevent your feet from slapping into the ground and producing excess stress to the lower legs.


Overstriding as a cause of anterior shin splints: the tibialis anterior tendon and muscle lengthen past their “normal” during over-striding which results in inflammation and pain.


Adding a hard surface, slapping too hard or improper shoe selection can add to the “overuse “ of the tibialis anterior and create shin splints .


Posterior shin splints.


With posterior shin splints pain is located on the inside part of the leg at the edge of the shin bone.


The tibialis posterior has a role supporting the arch as the body moves over the foot during the running stride.


Posterior shin splints in medical terms is known as medial tibial stress syndrome (MTSS).


The tendon will become inflamed and have micro-trauma if the forces applied to it are too great.


Runners who have high arches and supinate, are more likely to develop posterior shin splints.





Facts




Physical Therapy Treatment for Shin Splint


Rest and Load Management


Patients may require “relative” rest and cessation of sport for prolonged periods of time (from 2 to 6 weeks), depending on the severity of their symptoms.


Decreasing weekly running distance, frequency, and intensity by 50% is a good starting point when in pain.


Runners are encouraged to avoid running on hills and uneven or very firm surfaces


Use cross training with other low-impact exercises, such as pool running, swimming, using an elliptical machine, or riding a stationary bicycle.


Over a period of weeks, athletes may slowly increase training intensity and duration and add sport-specific activities, jumping exercises, and hill running to their rehabilitation program as long as they remain pain-free .


Athletes should scale back any exercises that exacerbate their symptoms or cause pain.




Physical Therapy - Modalities


Phonophoresis, electrical stimulation may be used in the acute setting to control pain.




Running Re-training:


Every  rehabilitation must include  reeducation of proper technique, gait retraining, and return to activity in a step-wise fashion.






Strengthening exercises:

Literature has widely supported a daily regimen of calf stretching and eccentric calf exercises to prevent muscle fatigue.

Other exercises focus on strengthening the tibialis anterior and other muscles controlling both inversion and eversion of the foot.

Patients may also benefit from strengthening core and hip muscles

Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries.

Developing muscle strength will improve endurance.

Other treatments:

Runners should also change running shoes every 250 - 500 miles.

Orthotics: Individuals with biomechanical problems of the foot may benefit from orthotics

Proprioceptive training:

Proprioceptive balance training in single leg balance




Shin Splints- Anterior Tibial Stress Syndrome


On this variation of Shin Splints, The muscle affected is the Anterior Tibialis in the front and outer part of the shin


These muscles function is to control the foot from "slapping" down on the ground as your heel contacts the ground with walking and running and also works to lift the foot up off of the ground so that it doesn't drag as you swing your leg forward for the next step.


As we mention before modifying your activity to decrease your volume and/or intensity of walking and running, and then gradually building back up again.


Landing with a more FLAT foot or FOREFOOT strike when running


Building up the strength of Tibialis Anterior so that it can handle the load better as you build up volume and intensity .


Here I show just a few ways to start working on the strength of these muscles:


1. Tibialis Anterior Isometrics - Static Holds , 2 Feet > 1 Foot


Isometric contractions help with controlling pain and buidling strength reason why this is our first choice of exercise.





2. Toe Raises off a Step - 2 Feet


Finally we need to work on strengthening of this muscle in the whole range of movement. We use a step to raise and lower the toes from one end of the movement to the other.





3. Walking Drills


First will be walking on the heels to increase strenth of Tibialis Anterior then progressing to a control downward movement of the foot .


We said above that slapping the foot on the ground was one of the reasons why a person can develop Shin Splints therefore controlling this movement is a must during the rehab process .


Start with the foot up and control the movement down slowly repeating the same step several times.




As a general recommendation perform 2-3 sets of 12-15 reps. See how it feels aftewards or the next morning after exercises. A mild increase in pain is allowed but it the pain gets irritated dial down in repetitions and sets.






Conclusion:


  • Shin Splints is a term used to describe pain in the front of the shin when running.

  • Solving this condition requires a comprehensive approach to correct all deficits that can be causing the pain .

  • The best approach to treating shin splints is to unload the tissue, increase the strength of the muscles affected ( Tibialis anterior and Posterior), as well as a well roundup hip and core strengthening program to finally load the tissue again with running program that progresses slowly to allow tissue adaption to the load of running

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 Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

#westonshinsplints #shinsplintpain  #runninginjuries #runningpain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston #whitebayphysicaltherapy




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  • Lionel Pannunzio PT / SCS



Introduction


Kneecap pain, also known as anterior knee pain or patellofemoral pain, is the most common injury seen in sports medicine clinics.


Expert clinicians and researchers reviewed about 4500 scientific articles about kneecap pain published between 1960 and May 2018. They chose the best research for the guidelines (271 articles) about the risk factors, diagnosis, examination, outcome measures, and nonsurgical treatment options for kneecap pain.

Here you have the conclusions and guidelines about Kneecap Pain





What is Patellofemoral syndrome?


Presence of Pain Around or Behind the Kneecap pain with squatting, stair climbing, prolonged sitting, running and jumping and change of directions

People with patellofemoral pain describe a gradual onset that typically occurs after a sudden increase in strenuous activities often involving running, jumping, or repetitive squatting.

Once a person begins experiencing symptoms, even simple activities, such as prolonged sitting or descending stairs, can be difficult.



Do I need a MRI for my knee pain ?

Imaging, such as knee magnetic resonance imaging, is not helpful in identifying patellofemoral pain.


How Physical Therapists can diagnose Patellofemoral Pain ?

Physical Therapist will  diagnose patellofemoral pain by assessing movements that are painful, such as squatting, and after ruling out other possible conditions, including iliotibial band pain and patellar tendinopathy.

Reproduction of pain with squatting and other functional activities that load the PFJ in a flexed position (eg, stair climbing or descent).

Patellar tilt test with presence of hypomobility





Classification of Patellofemoral Pain


Current recommendations on PF pain are to classify this condition in 4 categories

1. Overuse/Overload Without Other Impairment

History of an increase in magnitude and/or frequency of PFJ loading at a rate that surpasses PFJ recovery. This is a rapid increase in Activity ( pre-season training , Hill Running, Repetitive Jumping or Squatting) .


2. Muscle Performance Deficits

Lower extremity (LE) muscle performance deficits in the hip and quadriceps


3. Movement Coordination Deficits

Excessive/poorly controlled knee valgus during dynamic task not due to weakness


4. Mobility Impairment

Foot hypermobility and/or flexibility deficits of at least 1 of hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or iliotibial band








Facts, what we know about PFPS...


1. More common in Females than men

Physically active women are more likely to develop patellofemoral pain compared with physically active men.


2. Single Sport = ↑ risk x 2

Specializing in a single sport may double the risk of experiencing patellofemoral pain.


3. Quadriceps Weakness

↑ risk Thigh muscle weakness may also increase the risk of patellofemoral pain.


4. Height, body weight, and foot posture

No ↑ risk Height, body weight, and foot posture do not predict who will develop this pain.


5. Physical Therapy best Option for PF pain

Because patellofemoral pain typically does not resolve without appropriate treatment, people with this pain should seek appropriate care.




Treatment



The best treatment is a combined program of hip- and knee-strengthening exercises.

The combined strengthening exercises were better for reducing pain and helping people return to their normal activities than strengthening the knee muscles alone.



1 - Hip-Targeted Strengthening

Strengthening exercises that focus on your hip muscles, are more likely to get you back to feeling like yourself.

Hip-Targeted exercises will focus on the posterolateal hip muscles such as your Glutes , hip abductors and external rotators.

Video: Clamshells, Bridges and Deadlifts .





2 - Knee Targeted Exercises




Knee-Targeted Strengthening refers mainly to improve Quadriceps volume and strength

Video: Spanish Squats and Squats. Tip: When doing these exercises be sure they don’t cause any pain under your kneecaps. Spanish Squats are great for creating Quadriceps gains with minimal patello-femoral irritation reason why is one the first Knee Targeted exercises I choose with this type of patients . Back Squats are necessary at a later stage to restore size and volume in the Quadriceps .



3- Combined interventions




In the previous post, we stated that a combination of Hip and knee strengthening was the main treatment for PF pain .

In some cases exercise therapy alone will not be enough and it has to be combined with other interventions such as

  • Foot orthoses,

  • Patellar taping,

  • Running gait retraining

  • Patient education

Foot orthoses The new guidelines for PF pain recommended the use of Prefabricated foot orthoses for those patients that have greater-than-normal foot pronation with the goal to reduce pain in the short term (6 weeks). This intervention showed to be effective only when used in combination with exercise therapy. In this case the insoles are used at the beginning of the treatment to modify the pain and allow the patient to perform the exercises with no pain or less pain. Once pain improves it is recommended to discontinue using them .

Patellar taping and what about Knee Braces for patellar pain ? When Patellar taping was combined with exercise therapy for pain reduction , it showed enhanced exercise therapy outcomes in the short term (4 weeks). Same as with the Inesols , the taping is used at the beginning of the therapy session to modify the pain and allow the patient to perform the exercises with no pain or less pain. Some patients like to use taping or braces for sport activities with the intention of aligning the kneecap and preventing from hurting but research could NOT probe the benefit of this intervention.

Running gait retraining This study showed “weak evidence “ for Running retraining. Even though this weak evidence sometimes cuing for forefoot strike, increase in running cadence, or reduction in peak hip adduction may help to manage pain in the short term .

Patient education Patient education may include load management, body-weight management, adherence to active treatments, biomechanics contributing to overload, evidence for treatment options, and kinesiophobia. From all this options I found that Load management is a very important component when patients are returning to their sports by guiding them to slowly increase the frequency, intensity





Conclusion:


  • Patellofemoral pain is a complex condition.

  • Solving this condition requires a comprehensive approach to correct all deficits that can be causing the anterior knee pain .

  • Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to PFPS

  • Taping and Orthotics are secondary tools that can be using in the treatment of PFPS.



Also be sure you review our previous post on this topic



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 Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receiving information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”



#whitebayphysicaltherapy #kneepain #patellofemoralpain #PulledMuscle #Soccerinjuries #Soccercalfinjury #westonsoccer #westonkneepain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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