Achilles Tendonitis/Tendinopathy and Needling

Achilles pain. You can’t live with it and you can’t live with it. Can needling help? The obvious answer is yes, but there is more as well.

There appears to be sufficient data to support the use of needling for achilles tendon problems . Perhaps it is the “reorganization” of collagen that makes it effective or a blood flow/vascularization phenomenon. The mechanism probably has something to do with pain and the reticular formation sending information down the cord via the lateral cell column (intermediolateral cell nucleus) or pain (nociceptive) afferents sending a collateral in the spinal cord to the dysfunctional muscle, affecting the alpha receptors and causing vasodilation. 

Loss of ankle dorsiflexion is a common factor that seems to contribute to achilles tendinopathies . It would seem that improving ankle rocker would be most helpful. In at least one study, needling restored ankle function and in another it improved strength. 

And don’t forget to go north of the lower leg/foot/ankle complex. The gluteus medius can many times the culprit as well. During running, the gluteus medius usually fires before heel strike, most likely to stabilize the hip and the pelvis. In runners with Achilles Tendonitis, its firing is delayed which may affect the kinematics of knee and ankle resulting in rear foot inversion. Perhaps the delayed action of the gluteus medius allows an adductory moment of the pelvis, moving the center of gravity medially. This could conceivably place additional stress on the achilles tendon (via the lateral gastroc) to create more eversion of the foot from midstance onward.

Similarly, in runners with achilles tendoinopathy, the gluteus maximus does not fire as long and activation is delayed. The glute max should be the primary hip extensor and decreased hip extension might be compensated by an increased ankle plantarflexion which could potentially increase the load on the Achilles tendon. 

So, in short, yes, needling will probably help, for these reasons and probably many more. Make sure to needle all the dysfunctional muscles up the chain, beginning at the foot and moving rostrally.

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Tendon needling for treatment of tendinopathy: A systematic review.
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Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. Rabin A, Kozol Z, Finestone AS. J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.

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Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
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Forefoot strike running: Do you have enough calf muscle endurance to do it without a cost ?

Below you will find an article on footwear and running. Rice et al concluded that 

“ When running in a standard shoe, peak resultant and component instantaneous loadrates were similar between footstrike patterns. However, loadrates were lower when running in minimal shoes with a FFS (forefoot strike), compared with running in standard shoes with either foot strike. Therefore, it appears that footwear alters the loadrates during running, even with similar foot strike patterns.

They concluded that footwear alters the load rates during running. No brain surgery here. But that is not the point I want to discuss today. Foot strike matters. Shoes matter. And pairing the foot type and your strike patterns of mental choice, or out of natural choice, is critical. For example, you are not likely (hopefully) to choose a HOKA shoe if you are a forefoot striker. The problem is, novice runners are not likely to have a clue about this, especially if they are fashonistas about their reasoning behind shoe purchases. Most serious runners do not care about the look/color of the shoe. This is serious business to them and they know it is just a 2-3 months in the shoe, depending on their mileage. But, pairing the foot type, foot strike pattern and shoe anatomy is a bit of a science and an art. I will just mention our National Shoe Fit Certification program here if you want to get deeper into that science and art. (Beware, this is not a course for the feint of heart.)

However, I just wanted to approach a theoretical topic today, playing off of the “Forefoot strike” methodology mentioned in the article today.  I see this often in my practice, I know Ivo does as well. The issue can be one of insufficient endurance and top end strength (top end ankle plantar flexion) of the posterior mechanism, the gastrocsoleus-achilles complex. If your calf complex starts to fatigue and you are forefoot striker, the heel will begin to drop, and sometimes abruptly right after forefoot load. The posterior compartment is a great spring loading mechanism and can be used effectively in many runners, the question is, if you fatigue your’s beyond what is safe and effective are you going to pay a price ? This heel drop can put a sudden unexpected and possibly excessive load into the posterior compartment and achilles. This act will move you into more relative dorsiflexion, this will also likely start abrupt loading the calf-achilles eccentrically. IF you have not trained this compartment for eccentric loads, your achilles may begin to call you out angrily. Can you control the heel decent sufficiently to use the stored energy efficiently and effectively? Or will you be a casualty?  This drop if uncontrolled or excessive may also start to cause some heel counter slippage at the back of the shoe, friction is never a good thing between skin and shoe. This may cause some insertional tendonitis or achilles proper hypertrophy or adaptive thickening. This may cause some knee extension when the knee should not be extending. This may cause some pelvis drop, a lateral foot weight bear shift and supination tendencies, some patellofemoral compression, anterior meniscofemoral compression/impingement, altered arm swing etc.  You catch my drift. Simply put, an endurance challenged posterior compartment, one that may not express its problem until the latter miles, is something to be aware of. 

Imagine being a forefoot striker and 6 miles into a run your calf starts to fatigue. That forefoot strike now becomes a potential liability. We like, when possible, a mid foot strike. This avoids heel strike, avoids the problems above, and is still a highly effective running strike pattern. Think about this, if you are a forefoot striker and yet you still feel your heel touch down each step after the forefoot load, you may be experiencing some of the things I mentioned above on a low level. And, you momentarily moved backwards when you are trying to run forwards. Why not just make a subtle change towards mid foot strike, when that heel touches down after your forefoot strike, you are essentially there anyways. Think about it.

Shawn Allen, one of The Gait Guys

Footwear Matters: Influence of Footwear and Foot Strike on Loadrates During Running. Medicine & Science in Sports & Exercise:
Rice, Hannah M.; Jamison, Steve T.; Davis, Irene S.

http://journals.lww.com/acsm-msse/Abstract/publishahead/Footwear_Matters___Influence_of_Footwear_and_Foot.97456.aspx

This is apparently a growing thing, INTERVAL walking. Oy. We are not particular fans at this point, nothing exciting or earth shattering at this point (other than the concerns we hi light below) but we will look into it more.
What you need to see, and be aware of, is that this is what happens when you wear a shoe that has too soft a rear foot. At heel strike, instead of progressing forward into the mid and forefoot, the rear foot of the shoe deforms and forces you into more HEEL rocker, sustained heel rocker. If you stay in heel rocker too long, you won’t progress forward into ANKLE rocker (ankle dorsiflexion). This often causes knee hyperextension. If you have a good trained eye, you will see both of these things, prolonged heel rocker and never any ankle rocker/ankle dorsiflexion. IT is like the ankle in this video is frozen at 90 degrees the entire time, train your eye to see this absense of ankle rocker. This will cause premature heel rise and premature posterior compartment contraction which can cause premature forefoot loading. This is what happens when the heel of the shoe is too soft. A perfect example of “more cushion” is not always better. IT can be a liability as well. Remember the angry revolution over the MBT shoe and its mushy rear foot?. Same principle, same risks and concerns. Welcome to round two of the same old problems ????? Maybe. you decide. To be clear, this is a comment on the shoes being used, the technique is , well, perhaps interesting. That is all we are willing to comment on at this point until we look into it more. Look at the heel and ankle mechanics during the slow mo clips.
Sorry Ben Greenfield. We are not impressed, as of yet. We like your podcast Ben, you are doing us all a great service, but this one is promoting some potential problems that people need to know about.
Start with our “Shuffle Walk”. Google search it under the Gait Guys. That is a good start.

– Dr. Allen

Calf strength screen?  Um, maybe not. Specifics matter.
Thanks to barbellphysio.com for putting this up. We would like to take this deeper, because it is very important.
This screen in our strong opinion is mostly for testing sub optimal endurance, sure there is some strength assessment going on but if you are trying to determine strength, is it single rep strength ? Very likely what he truly meant is how does the calf strength hold up at a 20 rep endurance challenge.  This is more accurate and we are fussing about specifics here, but specifics matter.
*However, the potentially BIG HOLE here in the assessment, is that “perceived” top end calf/heel raise ROM is not necessarily top end FULL ROM. If one side is truly weak, and you cannot get to top end strength (say the heel is 10% lower than the other side) someone has to be there to assess and notice that top end strength failure (a top end ROM that could reduce as endurance challenge continues, but someone has to be there to observe. Going on just “feel” alone is a bad recipe there). One like is not going to feel that top end range loss even if it is large, you will perceive the effort which could feel the same as the good side but actually be a loss.  And is 20 reps enough? Sure, it is a start but is your test really telling you what you think it is telling you ? This is being shown as a gross screen in our opinion but it has holes even as a screen.  Top end strength, something we talk about here often, is critical to performance. Top end loss means  terminal plantarflexion ROM is insufficient, and this can lead to a whole host of injuries and biomechanical flaws including achilles tendonopathy to mention just one. Remember, the gastroc does  not play alone here (and gastrocs crosses the knee joint posteriorly, some of the other posterior compartment muscles do not). There is soleus, peronei, tib posterior, long flexors etc. So are you doing your test with bent knee or locked ? It makes a difference if you are trying to tease things out.  Are you ramming your toes into flexion to get more out of them to make up for a loss elsewhere ? Is the forefoot or rearfoot inverting or everting  on the up or down phase ? These things matter. Specifics matter.  For example, you can see in this video that the hip is a little lateral to the foot placement. This will mean that the heel rise will result in a lateral forefoot weight bearing load. Do you want to see if the peronei are doing their job during the heel rise ? Well then you should go into a hip hike to posture the hip over the foot so that you can get the weight bearing transition to occur terminally over to the big toe, the peronei and lateral gastroc help drive that last little shift and if they are weak and you are not driving that last piece of the movement the test may not show you the whole picture you are thinking it is. Clue, if you cannot feel the lateral compartment contract to finalize that medial foot weight bearing load shift, you may be weak there. You better assess then.

Can you do 20 reps at 80% of the full plantarflexion ROM or can you do 20 reps at 100% full plantarflexion ROM ? There is a performance difference, and to the client unobserved, the 80% on one side may feel and perform like the 100% on the other side. But make no mistake, there is a world of difference.  Someone has to  watch that you are comparing apple to apples, and not apples to figs, oranges, turnips or squash.
-Dr.Shawn Allen, the gait guys

https://www.youtube.com/watch?time_continue=55&v=QdWiXHsI8Q8

Achilles tendonitis: Lift the heel, right? It does not appear so.

There was a recent article in one of our favorite journals, Lower Extremity Review which reviewed and expanded upon another study from Medicine and Science in Sports and Exercise titled “Running shoes increase achilles tendon load in walking: an acoustic propagation study.” We discussed some perspectives of this topic in one of our recent podcasts.
The article discusses a new technique (1,2) for looking at tensile loads in the achilles and looks at 12 symptom free individuals on a treadmill barefoot and in a shoe with a 10 mm drop (heel is 10mm higher than the forefoot) and found:

“Footwear resulted in a significant increase in step length, stance duration, and peak vertical ground reaction force compared with barefoot walking. Peak acoustic velocity in the Achilles tendon (P1, P2) was significantly higher with running shoes.”(1)

According to LER: “The researchers also found changes in basic gait parameters associated with walking in running shoes versus barefoot, which the author Wearing said may help explain the increased tendon load with shoes. Shoes increased mean ankle plantar flexion by 4° during quiet stance as measured by electrogoniometry. When walking with shoes, participants adopted a lower step frequency but greater step length, period of double support, peak vertical ground reaction force, and loading rate than when walking barefoot. The researchers also noted that participants’ stance phase was relatively longer (4%) during shod walking than during barefoot walking.” (3)

Of course, our big question is why?

Why would an increase in step length result in increased tension?

Perhaps, as the force that the heel would hit the ground would be increased because of a longer acceleration time (F=ma), and it so happens this is what they found. The friction of the heel striking the ground would accelerate anterior translation of the talus, which plantar flexes, everts and abducts, accelerating pronation. The medial gastroc would be called into play to slow calcaneal eversion and this would indeed increase achilles tension.

Or perhaps it’s the fact that

the foot will strike in slight greater plantarflexion

(at least 4 degrees according to the study) and this results in an immediate greater load to the Achilles tendon.  Go ahead and try this while walking even if you’re barefoot. Walk across the floor and strike more on your forefoot. You will notice that you have an increased load in the tricep surae group.

Does this slight plantarflexion of the ankle contribute to greater eccentric load during stance phase?

This would certainly activate 1a afferent muscle spindles which would increase tensile stresses in the achilles tendon.

This seems to fly directly in the face of the findings of Sinclair (4) who investigated knee and ankle loading in barefoot and barefoot inspired footwear and found increased achilles loading in both compared to “conventional shoes”.

Of course this also begs the question of what type of shoes were they wearing? High top or low top shoes and were the shoes tied or not? High top shoes seem to reduce Achilles tension more so than low top shoes, especially if they are tied (5).

Whatever the reason, this questions the use of putting a lift or a higher heeled shoe underneath the foot of people that have Achilles tendinitis.  Once again what seemed to make biomechanical sense is trumped by science.

We think training people to have greater amounts of hip extension as well as ankle dorsiflexion,  as well as appropriate foot and lower extremity biomechanics with the requisite  skill, endurance and strength is a much better way to treat Achilles tendonitis regardless of whether they’re wearing footwear or not.

Dr. Ivo Waerlop, one of The Gait Guys

References:

1. Wearing SC, Reed LF, Hooper SL, et al. Running shoes increase Achilles tendon load in walking: An acoustic propagation study. Med Sci Sports Exerc 2014;46(8):1604-1609.  http://www.ncbi.nlm.nih.gov/pubmed/24500535
2. Reed LF, Urry SR, Wearing SC. Reliability of spatiotemporal and kinetic gait parameters determined by a new instrumented treadmill system. BMC Musculoskelet Disord 2013;14:249.
3. Black, Hank. Achilles oddity: Heeled shoes may boost load during gait. In the Moment:Rehabilitation   LER Sept 2014  http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait
4. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech (Bristol, Avon). 2014 Apr;29(4):395-9. doi: 10.1016/j.clinbiomech.2014.02.004. Epub 2014 Feb 23.
5. Rowson S1, McNally C, Duma SM. Can footwear affect achilles tendon loading? Clin J Sport Med. 2010 Sep;20(5):344-9. doi: 10.1097/JSM.0b013e3181ed7e50.

Journal of Foot and Ankle Research | Full text | Insertional Achilles tendinopathy is associated with arthritic changes of the posterior calcaneal cartilage: a retrospective study

Chronic achilles-problem clients, slow or non-responders ?
This study suggested that , “Degenerative arthritic changes of the posterior calcaneal wall cartilage characterize patients with IAT (insertional achilles tendonotpathy) and the severity of such changes is directly correlated to the degree of functional impairment.”
Read up… . .

Journal of Foot and Ankle Research | Full text | Insertional Achilles tendinopathy is associated with arthritic changes of the posterior calcaneal cartilage: a retrospective study

Achilles Tendonitis

The motion needs to occur somewhere…Make sure you look at the whole picture

Since the knee was bent, perhaps we should be looking at the soleus? And the talo crural articulation?

“A more limited ankle Dorsi Flexion Range Of Motion as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendonitis among military recruits taking part in intensive physical training.”

J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.
Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study.
Rabin A1, Kozol Z1, Finestone AS2.

The mighty Gluteus Medius, in all its glory!

Perhaps the delayed action of the gluteus medius allows an adductory moment of the pelvis, moving the center of gravity medially. This could conceivably place additional stress on the achilles tendon  (via the lateral gastroc) to create more eversion of the foot from midstance on

“The results of the study demonstrate altered neuromuscular control of the GMED and GMED in runners with Achilles Tendonitis. During running, GMED typically activates before heel strike so as to stabilize the hip and the pelvis. In runners with Achilles Tendonitis, GMED is activated with a delay, which consequently might affect the kinematics of knee and ankle resulting in rear foot inversion. Similarly, GMAX is activated with a delay and for a shorter duration in runners with Achilles Tendonitis. GMAX is the primary hip extensor and via a kinetic chain, a decreased hip extension moment might be compensated by an increased ankle plantarflexion moment which could potentially increase the load on the Achilles tendon.”

Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.

Medial or lateral ankle swelling. Not a unicorn, but perhaps close. 

Photo: note the enlargement of the soft tissue in the left medial achilles area.

Many times over the last 5 years we have written about the concept that you have to know something exists to even make it a clinical consideration when trying to troubleshoot a clients pain or problem. Without knowing something even exists, you will move onto another diagnostic assumption and perhaps be treating the wrong problem.  This is a big problem in medicine because there is no way any of us knows everything. But this is why we all read, we study, we ask questions and we learn from our mistakes and depend on lateral and higher pay-grade referrals.  

Look at the photos above. Do you or your client have a posterior mass or swelling along side the achilles, medially or laterally ? Are you a rare bipedal mammal or do you have a lipoma, hemagioma or even sarcoma ?  Perhaps it is a swollen achilles ? Are there nodular densities in the achilles tendon proper that might suggest micro tears ? Are the regional busae swollen ? Those are all logical first steps, but maybe it is just a rarity, a more common unicorn of lower limb anomalies (10% incidence), the “accessory soleus”.

When an accessory soleus muscle is present a soft-tissue mass appears bulging medially between the distal part of the tibia and the Achilles tendon. This apparent “swelling”, may be entirely symptom free because it is merely an anatomic variant.  However, variants can become a problem when they impair stability or mobility or when they become irritated because of the same issues elsewhere.  This muscle has its own individual tendon slip onto the calcaneus anteromedial to the Achilles insertion.  This entity is not always painful or symptomatic but it can be expressive during exercise in some clients.  When they present clinically symptomatic one must rule out pathomechanics of the foot, ankle or lower kinetic chain.  The appearance of the assessory soleus is easily diagnostic on CT and MRI imaging. Some sources recommend fasciotomy or excision of the accessory muscle, clearly radical initial measures, but most of the time they can be quieted by resolving the pathomechanics that have allowed this previously quite clinical entity to become symptomatic. If the problem is just recently symptomatic, it is likely not the problem, rather the environment (workout changes, shoe changes, tissue length-tension relationship changes, mobility or stability changes etc) has changed and put a demand on the area and created once quiet tissues to complain.

First one must rule out the nasties, as we eluded to earlier (lipoma, hemagioma, synovial sarcoma etc) and then rule out the complainers (busae, tendonopathies etc) and then look at mobility and stability deficits/challenges. Once all of the more likely suspects have been ruled out, it is time for considering unicorns.

Here are some thoughts. On heel rise does the soft tissue mass become firm as in a muscular contraction would become firm ? After all, it is a soleus component and can act as an ankle plantarflexor of the ankle. Or it is merely firm on forced dorsiflexion because the achilles is drawn firm and tight against the posterior tibia thus medially displacing the soft tissue into a smaller more compacted area? Is the area painful on running ? Jumping? Starts and stops ? Only painful during rest, going up stairs, down stairs, only biking, swimming ? One can see that an understanding the mechanics of an area and how to challenge that area to your diagnostic advantage can help you tease out many of the considerations above.  In this day and age, we always have imaging to fall back on, but remember, imaging is a static picture in a moment of time in an unloaded unfunctional posturing. You will treat your client and their problem, not the imaging. If they in fact do turn out to have an accessory soleus that is inflamed on imaging, you still have to figure out why it has suddenly become cranky and painful. The bottom line is that many people with a painful accessory soleus are coming to you because something they have done, or are doing, or are  compensating around is causing a change in mechanics that is bothering the tissue.  This is where your knowledge of the kinetic chain and foot types, shoe types (see our National Shoe Fit program review here) and gait biomechanics can be invaluable.  Figuring out these issues should be your first line of intervention, and then confirmation on imaging can truly be valuable. 

The accessory soleus, is a more common entity in primates. Is this further proof we used to have tails and swing from trees ? Maybe not, but it is still fun to think about though. 

Shawn and Ivo, the gait guys

The Bouncy Gait: Premature heel rise gait. Taking another look.

This is a great video example of a premature heel rise during gait. You should be able to clearly see it on the left foot (and this was toned down after we brought it to his awareness!).  The heel rise occurs early in the stance phase of gait, instead of the late stance phase.

We have talked about this bouncy type vertically oriented gait many times in blog posts and in our podcasts.  This is a pretty prevalent problem in the world, mostly because so many people have impaired ankle rocker/dorsiflexion from weak anterior compartments and short/tight posterior compartments.  None the less, for the majority, this is a pathologic gait pattern and it will impart undue stress into the posterior mechanism (calf-achilles complex). Just think about it, this person is going vertical at or prior to the tibia achieving 90degrees (perpendicular to the ground) instead of continuing to progress the tibia to 110+ degrees to enable normal timely pronation and foot biomechanical events.  This is not a normal gait. Period. This will change the function of the entire posterior chain upward. 

If you want to see another great example  from the frontal plane, check out this cute video representation of a vertial/premature heel rise bouncy gait. 

This gait style is caused by a premature heel rise from joint range limitation and/or from premature engagement of the gastrosoleus (and sometimes even the long toe flexors, you will see them hammering and curled in many folks). It can be a learned habitual pattern and nothing more, we have even seen it even in child-parental gait modeling in our offices. These people will never get to NORMAL full late-midstance of gait (without biomechanical compromise) and thus never achieve full hip extension nor adequate ankle dorsiflexion / ankle rocker. The gait cycle is an orchestrated symphony of timely events and when one or several timely events are omitted or impaired the mechanics are passed into other areas for compensation. This vertical gait style is very inefficient in that the gluteals cannot adequately power into hip extension into a forward progression drive, because the calf is prematurely generating vertical movement through ankle plantarflexion.  This strategy is sometimes deployed because the person actually is significantly ankle dorsiflexion (ankle rocker) deficient.  Meaning, they hit the limitations of dorisflexion and in order to progress forward they first have to go vertical.  This vertical motion, because they are moving into ankle plantarflexion, re-buys more ankle dorsiflexion range which then can be used if they so choose. Obviously, the remedy is to find the functional deficit, remove it and retrain the pattern.  There are a whole host of other problems that go with this compensation pattern but we wanted our mission to stay focused today.  Remember, this is usually a subconscious motor pattern compensation. Is it like the toe walking issue we talked about last week (post link here) ? It is similar in some ways and can have primitive and postural motor pattern implications. We will follow up the “Idiopathy Toe Walking Gait: Part 2” shortly but we wanted to strategically put this blog post ahead of it, because there are similar characteristics and implications. Trust us, there is a method to our madness 🙂

Shawn and Ivo

The Gait Guys