Avoiding and Treating Heel Pain

Avoiding and Treating Tendon Dysfunction

Dr.Bruce Buckman PT, DPT, ART

 Background

 It has been reported that approximately 1 in 10 individuals will develop chronic heel pain with nearly 2 million Americans affected annually. Furthermore, tendinopathies of the Achilles tendon affect 2% of the general adult population. The typical report of pain presentation of plantar heel pain includes excruciating pain with the first few steps after waking up in the morning, prolonged sitting and with prolonged weight bearing activity. These symptoms often reduce throughout the day as compared to first thing in the morning, but lead to significant functional limitations and even prolonged disability.

Identifying the Problem

A tendon is an anatomical structure that connects muscle to bone, examples include the Patella tendon and Achilles tendon. A tendon is an inherently strong tissue; however, just as with muscular injuries, tendons are subject to overuse. Overuse injuries to tendons often occur with constant and repetitive loading in biomechanically flawed positions. Characteristic changes occur in the tendon structure, resulting in a tendon that is less capable of sustaining repeated tensile load (Cook JL, Khan KM, Kiss ZS, et al). Tendon injuries can occur in the mid-tendon, which is often the case in Achilles tendonitis/osis; however, most tendon pathology arises from the insertion of the tendon to the bone such as with patellar tendonitis/osis.

Tendonitis, Tendonosis, and Tendinopathyathy

The suffix “itis” implies acute (of recent onset/new) injury with inflammation. Different from acute injury with inflammation, tendon”osis” implies chronic (long term) pathology or degeneration without inflammation. Finally Tendon”opathy” simply refers to a disease of a tendon.

Can Exercise Improve Tendon Function?

Research suggests that eccentric exercise affects both the tendon structure as well as pain by increasing collagen production in abnormal tendons with both short and long term. Furthermore, recent research has added that exercise with a combination of manual therapy (hands on approach to treatment) provides greater clinical benefits in terms of function than just exercising and using modalities such as heat, ice, ultrasound, electric stimulation etc.

Eccentric, Concentric and Isometric Contractions

When you consider a muscular contraction, you may think of a simple motion such as a heel raise. During the initial part of the heel raise your triceps surae (calf muscles) are concentrically contracting (or shortening); however, what about the second portion of the exercise? During the descending portion of the heel raise, the triceps surae must control the decent of the weight being held or else your heel would simply drop towards the ground. Here, these muscles are contracting eccentrically, meaning contracting while simultaneously lengthening. On an unrelated note, isometric contractions involve a static muscle activation without associated movement. Consider the same heel raise exercise; however, after raising heels from a neutral position, your heel maintains in the same position for approximately 45 seconds, here your triceps surae muscles are active as to maintain the heel off position, but are not causing physical movement of a structure.

Physical Therapy Protocols for Achilles Tendinopathyathy

The exercises listed below are helpful in preventing and improving tendon pathologies; however, they should not be performed without proper evaluation by a physical therapist in order to determine proper dosage and prescription. To find out more contact us now!

Plantar Fascia Rolling        

Why focus on the bottom of the foot for pain in the back of my ankle you ask? Understanding anatomy is key! The plantar fascia inserts to the dorsal aspect of the calcaneus, which happens to also be bone in which the Achilles tendon attaches to (more posteriorly and superiorly). If your plantar fascia is tight, it certainly will affect the kinetic chain by increasing passive tension on the Achilles tendon. Rolling this structure is not “fun”, plain and simple, it hurts for most, but has a drastic impact on foot and ankle health!

Intrinsic Muscle Activation

The intrinsic foot muscles help to stabilize the arch of your foot and improve the biomechanical forces dispersed through the foot with simple activities such as walking to more complex activities such as running, cutting and jumping. Strengthening and activating these muscles will help to improve pain by improving functional movement patterns, thus reducing risk for re-injury.

Self Plantar Fascia Massage

Taking rolling to the next level, massaging the bottom of the plantar fascia will be imperative for the improvements of kinetic chain mobility. While doing so, observe the distal (far) attachment of the plantar fascia to the digits, this means that flexing and extending your toes passively with your non massage hand will sensitize the massage in order to create the best response to treatment.

Triceps Surae Foam Rolling

As always, rolling is imperative prior to stretching, rolling relaxes tissue prior to stretching the tissue out. This is important because stretching a tonic or tight muscle can actually cause more pain in an irritated irritable musculotendonus structure.

Gastrocnemius and Soleus Muscle Eccentric Activation (Heel Raises)

Properly performing this exercise depends on the location of pain, for mid belly Achilles tendon pathology, perform on a step. Start by raising your heels up in the air to the top of motion and slowly lower yourself back down below parallel. This exercise will help to strengthen the posterior lower leg muscles and reduce recurrent pathology.

 

 

Gastrocnemius and Soleus Stretching

The gastrocnemius is the large posterior lower leg muscle that crosses both the knee and the ankle joints, as seen below. What this means is that in order to effectively stretch this muscle both the knee and the ankle need to be taken into consideration (extended). To stretch the soleus muscle, the knee is slightly flexed secondary to this muscle not crossing the knee joint. Flexing the knee will eliminate some of gastrocnemius’ tension allowing for a deeper and more effective stretch.

References

O’Brien M. e anatomy of the Achilles tendon. Foot Ankle Clin 2005; 10(2): 225–38.

Cook JL, Khan KM, Kiss ZS, et al. Asymptomatic hypoechoic regions on patellar tendon ultrasound: a 4-year clinical and ultrasound follow-up of 46 tendons. Scand J Med Sci Sports 2001; 11: 321–7.

O’Neill, S, Watson PJ, Simon, B. Why are eccentric exercises effective for Achilles tendinopathy. The International Journal of Sports Physical Therapy 2015; 10: 552-63.

Cleland JA, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: A multicenter randomized clinical trial. Journal of Orthopedic and Sports Physical Therapy 2009; 39: 473-86.

Cook, JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–416.