More on tendon stiffness

There has been much discussion about tendon stiffness in the last few years. Here is an interesting paper.

Here is a piece of the authors' hypothesis. " If tendons can be overloaded, their mechanical properties should change during exercise. "
The present study measured AT stiffness before and after a marathon.
Here is what they found in this study, "AT stiffness did not change significantly from the pre-race value of 197±62 N mm−1 (mean ± s.d.) to the post-race value of 206±59 N mm−1 (N=12, P=0.312). Oxygen consumption increased after the race by 7±10% (P<0.05) ". This was a small N study, but that leaves room for more large scale studies to see if it holds up.
What remains interesting and head scratching to us is that a tendon has its tension developed by the muscle contracting that is attached to it. So, one would think that a marathon would cause some fatigue in the calf which would change the tension in the achilles. But we are brought to the thought that perhaps stiffness and tension are not the same animals, not even close ?
However, the article mentions this, "A typical training effect, regardless of whether training is plyometric or isometric resistance training, is an increase in AT stiffness (Burgess et al., 2007), although the effect may be invariant to training background as runners and non-runners were found to have similar AT stiffness (Rosager et al., 2002). " Perhaps, what we are talking about however is a "baseline" level of stiffness, that is so fixed that even fatigue does not impact this low level ?
The big question is then, why the AT is so prone to injuries if stiffness remains the big question, and the goal post in rehab restoration?
Here is where these authors leave us, "Thus it may be that running itself does not predispose the AT to injuries. Rather, a combination of a rapid increase in stress, a quick crossover to new sporting activities without a training period, poor technique and/or improper footwear could play a role that has not yet been identified."
A reasonable thought, but leaving us all with more questions than answers it seems.

Additionally, 9 of the 12 subjects, the marathon induced a change in their foot strike technique but they postulated that this could be muscle fatigue related. After all, we cannot forget that there is a whole body attached to this achilles.

Achilles tendon stiffness is unchanged one hour after a marathon
Jussi Peltonen, Neil J. Cronin, Lauri Stenroth, Taija Finni, Janne Avela
Journal of Experimental Biology 2012 215: 3665-3671; doi: 10.1242/jeb.068874

Effects of high loading by eccentric triceps surae training on Achilles tendon properties in humans.

Maximum isometric force had increased by 49% and tendon CSA by 17% !
Tendons can change their cross sectional area, if you load them.

Here I show lateral forefoot loading in a heel raise, and a medial forefoot loading in heel raise. This has to be part of the discovery process outlined below.

Isometrics are useful, they have their place. In a recent podcast to load up here in the future, we discuss the place and time to use isometrics, isotonics, eccentrics and concentrics.
One of the goals in a tendinopathy is to restore the tendon stiffness. Isometrics are a safe way to load the muscle tendon complex without engaging a movement that might have to go through a painful arc of movement. With isometrics here is neurologic over-spill into the painful arc without having to actually go there.
The key seems to be load. More load seems to get most people further along. Remember, the tendon is often problematic because it is inflamed and cannot provide a stiffness across its expanse. Heavy isometric loading seems to be a huge key for most cases. But, we have to say it here, not everyone fits this mold. Some tendons, in some people, will respond better to eccentrics, and strangely enough, some cases like stretching (perhaps because this is a subset of an eccentric it seems or because there is a range of motion issue in the joint that is a subset of the problem). Now the literature suggests that stretching is foolish, but each case is unique all in its own way, and finding what works for a client is their medicine, regardless of what the literature and research says.
Finding the right load for a given tendon and a right frequency of loading and duration of loading is also case by case specific. Part of finding the right loading position is a discovery process as well, as noted in the photos above. Finding the fascicles you want to load, and the ones you do not want to load (painful) can be a challenging discovery process for you and your client. Finding the right slice of the pie to load, and the ones not to load takes experimentation. When it is the achilles complex, finding the safe However, if one is looking for a rough template to build from, brief, often, heavy pain free loads is a good template recipe to start with.

Here, in this Geremia et al article, "ultrasound was used to determine Achilles tendon cross-sectional area (CSA), length and elongation as a function of plantar flexion torque during voluntary plantar flexion."
They discovered that, "At the end of the training program, maximum isometric force had increased by 49% and tendon CSA by 17%, but tendon length, maximal tendon elongation and maximal strain were unchanged. Hence, tendon stiffness had increased by 82%, and so had Young’s modulus, by 86%.

Effects of high loading by eccentric triceps surae training on Achilles tendon properties in humans. Jeam Marcel Geremia, Bruno Manfredini Baroni, Maarten Frank Bobbert, Rodrigo Rico Bini, Fabio Juner Lanferdini, Marco Aurélio Vaz
European Journal of Applied Physiology
August 2018, Volume 118, Issue 8, pp 1725–1736

the current understanding of how tendons respond to loading, unloading, ageing and injury

A muscle contract, transfers load across the tendon into the attachment to another bone on the other side of a joint, sometimes across 2 joints. There can be a mechanical flaw/injury in the muscle or tendon, or the joint, if inflamed, can neurologically inhibit that muscle-tendon team. The journal abstract has a nice diagram looking at the potential cellular and molecular changes at the tendon interval.
"Here we review the current understanding of how tendons respond to loading, unloading, ageing and injury from cellular, molecular and mechanical points of view. "- S. Peter Magnusson, Michael Kjaer

https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP275450

Podcast 145: Tendons, Heel Drop and their impacts on the posterior chain,

Heel lifts, Sole lifts and their impact on the EMG of the posterior chain.

Keywords: gait, gait analysis, gait problems, running, ankle, tendinopathy, heel lifts, sole lifts, EMG, paraspinal activity, gluteal inhibition, posterior chain, anterior pelvic tilt, tight quads, diagnostic ultrasound

Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".

Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).

Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:

iTunes page:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

Google Play:
https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_149raw_-_31619.mp3

Permalink URL: http://thegaitguys.libsyn.com/podcast-tendons-heel-drop-and-their-impacts-on-the-posterior-chain

Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/9027890

Show notes:

Current trends in tendinopathy management
Tanusha B.Cardosoa, TaniaPizzarib, RitaKinsellab, DanielleHopec, Jill L.Cook
https://www.sciencedirect.com/science/article/pii/S1521694219300233

https://www.jospt.org/doi/full/10.2519/jospt.2015.5880

Insightful paper on how tendon adapts to loading and unloading. Discusses a lack of evidence supporting eccentric training as the treatment of choice for injury and notes that tendon response to loading is not normalized until ~6-12 months after injury
https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP275450
The impact of loading, unloading, ageing and injury on the human tendon
S. Peter Magnusson, Michael Kjaer

Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review
Chantel L.Rabusinac, Hylton B.MenzacJodie A.McClellandbcJade M.TanacGlen A.WhittakeracAngela M.EvansaShannon E.Munteanuac
https://www.sciencedirect.com/science/article/pii/S0966636218310075?dgcid=coauthor

The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip extensor complex during trunk forward flexion and return task
AnnaMikaa, Brian C.ClarkbcŁukaszOleksy
https://www.sciencedirect.com/science/article/abs/pii/S1356689X13000428

The effect of heel lifts on trunk muscle activation during gait: A study of young healthy females
Christian J.Bartonac, Julia A.CoyleaPaulTinley
https://www.sciencedirect.com/science/article/pii/S1050641108000424

A Systematic Review and Meta-Analysis of Crossover Studies Comparing Physiological, Perceptual and Performance Measures Between Treadmill and Overground Running
https://link.springer.com/article/10.1007/s40279-019-01087-9

Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus - ScienceDirect
https://www.sciencedirect.com/science/article/pii/S1466853X18305017

LLD's and Achilles Tendinopathy

Sometimes, it doesn't matter whether it is long or short.

 Achilles tendinopathy .. there are many factors that can contribute. Have you considered leg length inequality? Generally speaking, People have a tendency to overpronate on the longer leg side and under prone only shorter leg side with strain on the medial and lateral aspects of the Achilles tendon respectively. It would make sense that this could be a contributing factor.

 "The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. "

Age and pathology can play a role with younger, healthy tender and having greater compliance.

Proprioception is impaired on the affected side of folks with Achilles tendinopathy. This is a "chicken and the egg" scenario. Did impaired proprioception cause the tendinopathy or is the tendinopathy causing the impaired proprioception? Probably, a little bit of both.

Dr Ivo, one of The Gait Guys

Leppilahti J, Korpelainen R, Karpakka J, Kvist M, Orava S. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Foot Ankle Int. 1998 Oct;19(10):683-7.

Scholes M, Stadler S, Connell D, Barton C, Clarke RA, Bryant AL, Malliaras P. Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side. J Sci Med Sport. 2018 May;21(5):479-482. doi: 10.1016/j.jsams.2017.09.594. Epub 2017 Oct 6.

Intziegianni K, Cassel M, Rauf S, White S, Rector M, Kaplick H, Wahmkow G, Kratzenstein S, Mayer F. Influence of Age and Pathology on Achilles Tendon Properties During a Single-leg Jump. Int J Sports Med. 2016 Nov;37(12):973-978. Epub 2016 Aug 8.

#achilles,#tendon, #achillestendon, #tendinopathy, #proprioception

Sometimes, it doesn't matter whether it is long or short.

Achilles tendinopathy (AT) .. there are many factors that can contribute.

Have you considered leg length inequality? Generally speaking, People have a tendency to overpronate on the longer leg side and under prone only shorter leg side with strain on the medial and lateral aspects of the Achilles tendon respectively. It would make sense that this could be a contributing factor.

 "The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. " (1)

Age and pathology can play a role with younger, healthy tendons having greater compliance, with compliance being considered a risk factor for AT.(2)

Proprioception is impaired on the affected side of folks with Achilles tendinopathy (3). This is a "chicken and the egg" scenario. Did impaired proprioception cause the tendinopathy or is the tendinopathy causing the impaired proprioception? Probably, a little bit of both.

All this and more to be discussed in one of the 3 cases we will discuss tomorrow evening, Wednesday, August 15th on onlinece.com: Biomechanics 320   5PST, 6 MST, 7 CST, 8 EST

Hope to see you there!

1. Leppilahti J, Korpelainen R, Karpakka J, Kvist M, Orava S. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Foot Ankle Int. 1998 Oct;19(10):683-7.

2. Intziegianni K, Cassel M, Rauf S, White S, Rector M, Kaplick H, Wahmkow G, Kratzenstein S, Mayer F. Influence of Age and Pathology on Achilles Tendon Properties During a Single-leg Jump. Int J Sports Med. 2016 Nov;37(12):973-978. Epub 2016 Aug 8.

3. Scholes M, Stadler S, Connell D, Barton C, Clarke RA, Bryant AL, Malliaras P. Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side. J Sci Med Sport. 2018 May;21(5):479-482. doi: 10.1016/j.jsams.2017.09.594. Epub 2017 Oct 6.

Tendinopathy video

Tremendous narrative explaining the Cook and Purdham Continuum Model of Tendon Pathology
*Do not miss this video !

https://www.youtube.com/watch?v=gGicPXm3n30

Podcast 128: Usain Bolt, Plantaris Tears, Arm Swing

Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_128final.mp3

http://thegaitguys.libsyn.com/podcast-128-usain-bolt-plantaris-tears-arm-swing

https://www.thegaitguys.com/podcasts/

Key Tagwords:

usain bolt, plantaris tear, plantaris, sole lifts, heel lift, leg length, short leg, heel drop, shoeque, symmetry, asymmetry, sprinters, scoliosis, tendinopathy, achilles, runners, marathons, running injuries, arm swing

Our Websites:
www.thegaitguys.com
summitchiroandrehab.com   doctorallen.co     shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Superficial plantar cutaneous sensation does not trigger barefoot running adaptations.

https://www.ncbi.nlm.nih.gov/pubmed/28728130

Arm swing
http://www.medicalnewstoday.com/articles/173680.php

Usain bolt
https://mobile.nytimes.com/2017/07/20/sports/olympics/usain-bolt-stride-speed.html?referer=

Plantaris tears
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978447/

Podcast 127: Tendinopathies, Tendon Pain & more.

Key Tagwords:

neuroscience, hip pain, tendonopathy, DNA, running, injuries, achilles, tendonitis, gait, shoecue

Show Links:

http://traffic.libsyn.com/thegaitguys/pod_127f.mp3

http://thegaitguys.libsyn.com/podcast-127-tendinopathies-tendon-pain-more

Our Websites:

www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

New neuron science
http://trendintech.com/2017/04/05/groundbreaking-study-reveals-neurons-communicate-in-a-way-we-never-imagined/

Exercise strengthens you DNA
http://www.mensfitness.com/training/build-muscle/exercise-strengthens-your-dna

Development of overuse tendinopathy: A new descriptive model for the initiation of tendon damage during cyclic loading
Tyler W. Herod, Samuel P. Veres
https://twitter.com/stijnbog/status/875270547562692608

The neuromechanical adaptations to Achilles tendinosis.
J Physiol. 2015 Aug 1;593(15):3373-87. doi: 10.1113/JP270220. Epub 2015 Jun 30.
Chang YJ1, Kulig K1.

Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achillestendinopathy: A cross-sectional study.
Phys Ther Sport. 2017 May;25:55-61. doi: 10.1016/j.ptsp.2016.09.008. Epub 2016 Sep 13.
Habets B1, Smits HW2, Backx FJG3, van Cingel REH4, Huisstede BMA5.

Changes of gait parameters and lower limb dynamics in recreational runners with achilles tendinopathy. Kim S1, Yu J2.
J Sports Sci Med. 2015 May 8;14(2):284-9. eCollection 2015 Jun.

Vibrations and strides
http://www.popsci.com/measuring-vibrations-runners-strides-could-prevent-muscle-injuries

ShoeCue product:
https://www.shoecue.com/?gclid=CKL1mI_e8tQCFZi4wAodgXMPJA

RULES of tendonopathies:
https://pbs.twimg.com/media/C3BbmWlXgAAg-ZA.png:large

Roger Enoka
http://www.humankinetics.com/products/all-products/neuromechanics-of-human-movement-5th-edition

http://onlinelibrary.wiley.com/doi/10.1002/jor.23629/abstract?campaign=wolacceptedarticle

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.

Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. Cox J, Varatharajan S, Côté P, Optima Collaboration. J Orthop Sports Phys Ther. 2016 Jun;46(6):409-29. doi: 10.2519/jospt.2016.6270. Epub 2016 Apr 26

Acupuncture’s role in tendinopathy: new possibilities. Speed C. Acupunct Med. 2015 Feb;33(1):7-8. doi: 10.1136/acupmed-2014-010746. Epub 2015 Jan 9.

The effect of electroacupuncture on tendon repair in a rat Achilles tendon rupture model.  Inoue M, Nakajima M, Oi Y, Hojo T, Itoi M, Kitakoji H. Acupunct Med. 2015 Feb;33(1):58-64. doi: 10.1136/acupmed-2014-010611. Epub 2014 Oct 21.

KIishmishian B, Selfe J, Richards J A Historical Review of Acupuncture to the Achilles Tendon and the development of a standardized protocol for its use Journal of the Acupuncture Association of Chartered Physiotherpists Spring 2012,  69-78

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.
Krey D, Borchers J, McCamey K. Phys Sportsmed. 2015 Feb;43(1):80-6. doi: 10.1080/00913847.2015.1004296. Epub 2015 Jan 22. Review.

Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendonhealing.
de Almeida Mdos S, de Freitas KM, Oliveira LP, Vieira CP, Guerra Fda R, Dolder MA, Pimentel ER. Acupunct Med. 2015 Feb;33(1):51-7. doi: 10.1136/acupmed-2014-010548. Epub 2014 Aug 19.

Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats.
de Almeida Mdos S, de Aro AA, Guerra Fda R, Vieira CP, de Campos Vidal B, Rosa Pimentel E. Connect Tissue Res. 2012;53(6):542-7. doi: 10.3109/03008207.2012.710671. Epub 2012 Aug 14.

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.

Microcirculatory effects of acupuncture and hyperthermia on Achilles tendon microcirculation. Kraemer R, Vogt PM, Knobloch K.
Eur J Appl Physiol. 2010 Jul;109(5):1007-8. doi: 10.1007/s00421-010-1442-6. Epub 2010 Mar 28.

Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Eur J Appl Physiol. 2010 Jun;109(3):545-50. doi: 10.1007/s00421-010-1368-z. Epub 2010 Feb 6.

 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.
J Orthop Res. 2016 Jun 16. doi: 10.1002/jor.23338. [Epub ahead of print]

Forefoot and rearfoot contributions to the lunge position in individuals with and without insertionalAchilles tendinopathy. Chimenti RL, Forenza A, Previte E, Tome J, Nawoczenski DA.Clin Biomech (Bristol, Avon). 2016 Jul;36:40-5. doi: 10.1016/j.clinbiomech.2016.05.007. Epub 2016 May 11.

Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for AchillesTendinopathy. Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Foot Ankle Int. 2016 Mar 17. pii: 1071100716638128. [Epub ahead of print]

 In vivo quantification of the shear modulus of the human Achilles tendon during passive loading using shear wave dispersion analysis.
Helfenstein-Didier C, Andrade RJ, Brum J, Hug F, Tanter M, Nordez A, Gennisson JL. Phys Med Biol. 2016 Mar 21;61(6):2485-96. doi: 10.1088/0031-9155/61/6/2485. Epub 2016 Mar 7.

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.

Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack 1992.

Chan YY, Mok KM, Yung PSh, Chan KM. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1:14. doi: 10.1186/1758-2555-1-14.

Bilateral effects of 6 weeks’ unilateral acupuncture and electroacupuncture on ankle dorsiflexors muscle strength: a pilot study. Zhou S, Huang LP, Liu J, Yu JH, Tian Q, Cao LJ. Arch Phys Med Rehabil. 2012 Jan;93(1):50-5. doi: 10.1016/j.apmr.2011.08.010. Epub 2011 Nov 8.

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/

We had a great PODcast in the studio last Friday, talking about tendon vascularity and compression vs tension therapies for tendinopathies.

Here is a great FULL TEXT article on tendon vascularity that can serve as a catalyst for designing your treatment programs

“Conclusions
Neovascularization is critical to tissue repair and wound healing. Therefore, strategies to enhance vascularization to promote regeneration are considered promising treatment modalities, i.e., the use of platelet rich plasma (PRP) to restore functional bone (Zhang et al., 2013) or skin (Kakudo et al., 2011). However, in acute or chronic tendon injuries hypervascularity often does not pave the way to functional recovery of the tissue. Therefore, to overcome the limited intrinsic regeneration capacity of tendon and to achieve scarless healing will most likely require a balanced manipulation of the angiogenic response in tendon tissue. For a variety of treatment methods, such as the use of PRP, the availability of clinical data is limited, due to heterogeneity in application (Khan and Bedi, 2015). In order to develop rational strategies to achieve a well-balanced angiogenic response following tendon injury, we need a thorough understanding of the molecular and cellular networks driving tendon vascularization and regeneration—a challenge for years to come.”

image from: http://www.slideshare.net/ShoulderPain/rotator-cuff-repair-23326992

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650849/

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/