Today I would love to discuss the role of strengthening of the achilles tendon in our practices. I think we all know the vital importance of the achilles tendon for normal human motion, and in handling the demands of our sometimes crazy activities. Yet, your daily practices will see patients that do not have good achilles health, and this fact holds true at any age and at any activity level. The precursors to poor achilles health are the subtle changes in strength loss and flexibility changes from what is considered normal and is needed to have these patients functioning at high levels. From the last two posts, technically a tight achilles or an over flexible achilles is considered abnormal and weaker than normal (see force length curve aka length tension curve). Weaker than normal means fatigue and strain can occur easier. When pain begins, it can be directly in the achilles tendon, which can be easy to recognize and normally easy to rectify. Yet, the problems related to achilles weakness, due to tightness, hypermobility, nerve damage or generalized weakness, on the rest of the body are many. Next week I will dive into the common indirect problems related to some version of achilles weakness that are fun to discuss. Today, I will discuss one patient in particular that presented with 3 years of achilles tendonitis to my office one day where simple strength testing and appropriate exercises turned his case around.
A 37 year old runner came into my office with 3 years of achilles pain which prevented him from running. I was his 8th doctor he was attempting to get help from, and he had 3 different physical therapists work on his problem over the last 3 years typically 12-20 visits each. No one had succeeded in getting him back to running. Most had used good achilles tendon rehab protocols, he had 3 different MRIs over the years, he had been fitted with great orthotic devices to center his everted heels. On the first visit, he was afraid of running in my halls, but I watched him walk with and without his orthotic devices to verify that they made him more stable. His daily routine had no strengthening, which he had done in PT and everyone agreed he was strong. He did stretch his gastrocnemius and soleus 3 times a day for the last 3 years. Everyone including Dr. Google had emphasized the importance of stretching, and he always felt tight when he did stretch.
The pain had begun while training for a half marathon, and got worse on subsequent runs. It started as pain only while running, but morphed by the 2nd month into pain walking. For the last few years he had given up on running, although this was still his goal, and his chief complaint to me was “achilles pain with the desire to walk without pain”. Everyone with a mechanical problem, and 3 MRIs had documented no structural damage, can typically be assessed with 3-4 most pertinent biomechanical examinations. For achilles I want to know RCSP and NCSP for orthotic positioning/ordering and strength and flexibility. He was great with the orthotic aspect, and his shoes were the right ones for stability. I noted that someday I needed to watch him run, but getting out of pain walking was my first goal. I did see the latest MRI at about the 3rd or 4th visit which agreed with the report of no damage. He had not been in PT for over a year, and since he was not walking much, his initial strength testing was below average. I want a patient to do 25 one sided heel raises with the knee straight, and 12-13 with the knee bent. He was at 10 knee-straight and straining, and only 3 with the knee-bent (however surprisingly he had never done bent knee heel raises aka calf lifts). No one had ever strengthened his soleus—important clue #1). When I told him he had very weak achilles tendons, he was quite shocked. With the weaker muscle being the soleus, many feel that those fibres strain first in runners. Soleus work in rehab is so vitally important. The two videos below show the basics of weight bearing achilles strengthening, although the second one emphasizes the slow progression when you are dealing with an injury that is slowly getting better.
Strengthening of the Achilles Tendon’s 2 Muscles
Achilles Strengthening for an Injured Achilles or Calf
Of course, you never know about the chicken or the egg syndrome. Did the weak achilles cause the injury, or did the weakness develop after the injury? We will never know but strengthening his gastroc and soleus was still vitally important in our attempt to rehabilitate. The next surprise came when I measured his achilles flexibility. Remember that in my method of measuring 8-12 degrees dorsiflexion of the ankle with the knee straight is normal and 15-18 degrees dorsiflexion of the ankle with the knee bent is normal. On the first visit, in a patient with achilles problems, this must be measured. The patient was 26 degrees with the knee straight, and 33 degrees with the knee bent. Yes, super flexible. I told him his achilles was like a wet noodle and could generate no force, so no wonder he had been hurting. I told him to stop all stretching for the next month, begin painfree evening weight bearing 2 positional calf raises, and I gave him 3/8th inch heel lifts. I also recommended no barefoot, clogs around the house, and as high a heel as he could comfortably find and wear. He had some dress cowboy boots that became his day to day shoe, and Dansko clogs around the house. I measured him each month and he became tighter and tighter. As he developed good tone in the calf again, first his walking pain disappeared, and then he wanted to start a Walk Run program. I put him on a 10 week every other day, three days per level,walk run program starting at 9 minutes walking with 1 minute running and repeating 3 times for 30 minutes. In 2 months basically he was running 30 minutes painfree every other day. When I saw him last, 6 months after he presented for the first time, he was running 4-5 miles 4 times a week, he was at 25 single leg straight knee and 15 single leg bent knee, and his flexibility measurements were 17 and 23 down from 26 and 33. Of course, I encouraged him to keep going with still no stretching (only strengthening) and see me in 3 months (which never happened). I assume he was fine. I always assumed that much of his pain was neurological, since he felt tight when he wasn’t. I will start the discussion next week with a final part to this patient when we talk about scenarios related to weak achilles tendons.
