David and Goliath: The calf and the glute.
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-by Dr. Shawn Allen
I recently saw yet another bulbous chronically inflamed achilles tendon, this one in an elite runner, a masters 1500 American record holder, so no slouch (this is not their photo, obviously) This thing had been baking for almost a year and they had achieved periods of zero pain and abilities to run and then flare ups would occur. There was a focal bulbous swelling (about 3/4 of inch in size) about one inch above the achilles insertion. The swelling was tendon intra-substance, not pre or post achilles soft tissue, this was clearly the tendon proper, you must be certain of this. There were no tiny nodular densities noted within the tendon proper (this is done slowly, with lotion, and fine palpation to look for nodules that might suggest enlarged microtears, not a full proof exam measure, but one I have made a habit of). The calfs were of equal size and shape.
The length of the posterior mechanism (gastrocsoleus-achilles complex) was good and ankle rocker was good. Calf strength, especially top end plantarflexion, was obviously and predictably weak. Lying prone it was clear to the naked eye that the same side glute was smaller. We know that a muscles maximal contractile force (strength) is the maximal contractile force produced per square centimeter of the cross sectional area of the muscle. Now, as a loose and low tech discussion here, moving through the sagittal universe we like to use our glutes and calf to push. If that glute is weaker, who is going to do all this work moving forward ? The calf is certainly in line to help out, (yes, there are others).
There was clearly gluteal weakness, same side quad tightness (this is obvious if you look at this from an anterior pelvis posturing perspective), lack of terminal hip extension range amongst other clues. But today, I wanted to just bring this principle forward to look all the way up the chain. Too many achilles tendonopathies get dozens of treatments of ultrasound, e-stim, acupuncture, cold, laser, orthotics, stretching, IASTM and the list goes on. There is nothing wrong with eccentric loading therapy for this posterior calf-achilles mechanism as long as it is not painful but one must find the reason behind this tissue failure. Local scraping is a silly choice over this tendon, do not be a fool, use your head. But, you must look at other failures along this chain. This client had obvious pain on heel rise in the office, but after 30 minutes of serious motor pattern restoration into hip extension and proper gluteal recruitment in all 3 cardinal planes of loading this client had pain free heel rising. Now, caveat, we tested this 3 times only, obviously this will not hold. But it gave us a clue, and proof, that restoring the proper posterior chain loading order and patterning, and restoring proper hip and pelvis stability loading patterns was a key parameter.
These are tough cases these achilles beasts. They will frustrate you to no end because they are frequently slow responders and frequently because there are several failed neuro, ortho and biomechanical components that must be addressed. But, these cases are more about being smart than volume treatments with passive modalities. And, it is near impossible to ask an elite runner not to run -- if you want to build a running practice, you will have to be smarter than all of the others in your community and not reflexively say "stop running". Tell them "lets just be a little smarter than we have been Mr. Jones", people want to be smarter and they want to be part of a team. Runners will find another doctor if you tell them to stop running (though, it is sometimes briefly necessary when they are just being knuckleheads about it), just get smarter, educate them, and spend some time with your client working through the bugs. I have not had ultrasound, e-stim, cold packs, hot packs, laser or any such toys in my office in my 19 years of practice for a reason, I spend 45 minutes with people and work through the bugs. Sure, go ahead and judge me, tell me I am missing out on tools to help, I am ok with you saying that. But I get results most of the time. Do I sometimes fail though ? Yes, we all do, I fail from time to time, but I tell my clients, "you will give up on this process before I do". I am just too curious for the deeper answers. I am in it to fix it, not to bandaid it. Anyhow, enough of my egoic rant, that was ridiculous, sorry, I just get really pissed off when I see someone who just fired their therapy place after 20 sessions of ultrasound, laser, e-stim, cook-booked rehab and stretching. We can and must do better than that dear brethren. But I guess that is why you are here with Ivo and myself, a team approach to getting wiser, here at The Gait Guys.
Oh, need research proof ? Here . . .
Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. Med Sci Sports Exerc. 2014 Mar;46(3):594-9. doi: 10.1249/MSS.0000000000000133.
CONCLUSIONS:
"This study provides preliminary evidence of altered neuromotor control of the GMED and GMAX muscles in male runners with Achilles tendinopathy. Although further prospective studies are required to discern the causal nature of this relationship, this study highlights the importance of considering neuromotor control of the gluteal muscles in the assessment and management of patients with Achilles tendinopathy."
Bam !
- Dr. Shawn Allen
