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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Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Zhang BM1, Zhong LW, Xu SW, Jiang HR, Shen J. Chin J Integr Med. 2013 Dec;19(12):900-4. doi: 10.1007/s11655-012-1218-4. Epub 2012 Dec 21.

The effect of dry needling and treadmill running on inducing pathological changes in rat Achilles tendon. Kim BS, Joo YC, Choi BH, Kim KH, Kang JS, Park SR. Connect Tissue Res. 2015 Nov;56(6):452-60. doi: 10.3109/03008207.2015.1052876. Epub 2015 Jul 29.

Tendon needling for treatment of tendinopathy: A systematic review.
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Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendonhealing.
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Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats.
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Changes in blood circulation of the contralateral Achilles tendon during and after acupunctureand heating.Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Int J Sports Med. 2011 Oct;32(10):807-13. doi: 10.1055/s-0031-1277213. Epub 2011 May 26.

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 Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion. Chimenti RL, Bucklin M, Kelly M, Ketz J, Flemister AS, Richards MS, Buckley MR.
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 In vivo quantification of the shear modulus of the human Achilles tendon during passive loading using shear wave dispersion analysis.
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Changes of gait parameters and lower limb dynamics in recreational runners with achillestendinopathy. Kim S, Yu J. J Sports Sci Med. 2015 May 8;14(2):284-9. eCollection 2015 Jun.

Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Foot Ankle Surg. 2015 Jun;21(2):77-85. doi: 10.1016/j.fas.2015.02.001. Epub 2015 Feb 26. Review.

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.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.

and what have we been saying about loss of ankle rocker and achilles tendon problems for years now?

Here is a FREE, FULL TEXT article talking all about it

“A more limited ankle Dorsi Flexion ROM as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendinopathy 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 Z, Finestone AS.

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243387/

What are we listening to this week? The Plantaris…

Thanks to Karly Foster of Twin Bridges Physiotherapy the: Physioedge podcast with David Pope

Imagine if you were able to dedicate a large portion of your life to the study of one individual muscle. That’s exactly what the main person interviewed here has done Dr. Kristof Spang from Sweden has done.  a lot of research on Achilles tendon tendinopathy.This podcast looks at the role of the plantaris muscle in mid tendon tendinopathy, with an emphasis on anatomy.

This muscle needs to be considered in recalcitrant cases of Achilles tendon apathy which of not respond to conservative means.

Dr Spang goes through some of the anatomical variations of attachment of the plantaris, with 10 to 20% attaching into the Achilles tendon. Since there seems to be at least nine different anatomical variations in attachment that can occur; this can often explain the variety of symptoms associated with plantaris issues.

The plantaris attaches from the lateral aspect of the femoral condyle downward to its insertion point within deli near its origin at the knee. The area of attachment distally can be between two and 5 mm and this “area attachment” may be part of the source of the pain. Phylogenetically the tendon attaches into the plantar fashia, similar to the palmaris. One theory is due to the small muscle size it may actually act as a proprioceptive sentinel for the knee and ankle. The peritendonous tissue may interfere with the gliding of the tendon in this is believed to be one of the ideologies of this recalcitrant problem.

Of the diagnostic imaging available, ultrasound seems to provide the most clues. In the absence of imaging, recalcitrant medial knee tendon Achilles tendon pain seems to also be a good indicator.

Our takeaway was that most often the problem seems to be had a conjoined area between the planters and Achilles tendon midcalf lead to most problems. Treatment concentrated in this area may have better results. If this is unsuccessful, surgery (removal of the plantaris, extreme, eh?)  may need to be considered.

Regarding specific tests for plantaris involvement, people who pronate seem to be more susceptible than those who supinate. This is not surprising since the tendon runs from lateral to medial it would be under more attention during predatory forces

It seems that plantaris tendonopathy  can exist separately from an conjoint tendinopathy and it may be that people of younger age may suffer from plantaris tendinopathy alone. This may indicate that the problem may begin with the plantaris and that the planters is actually stronger and stiffer than the Achilles!

It was emphasized that this condition only exists in a small percentage of mid Achilles tendon apathy patients. And that conservative means should always be exhausted first.

All in all, an interesting discussion for those who are interested in pathoanatomy. Check out part 2 in this series for more. 

link to PODcast: http://physioedge.com.au/physio-edge-041-plantaris-involvement-in-midportion-achilles-tendinopathy/

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.

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.

This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not.  A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.

Hmmm..

We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?

Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB.  Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.

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