High Performance Physical Therapy & Sports Medicine

Dr. Lara Johnson, PT, DPT, MS – Rehabilitation, Injury Prevention, and Sports Training. Located in Boulder, Colorado

Achilles Tendinitis Q & A

I was recently requested by Active.com to provide insight into the common problem of Achilles tendinitis. Here is the article: How to Treat and Prevent Running Injuries: Achilles Tendinitis.  Here are my answers to their questions:
Q. -Do you work with a lot of runners who encounter Achilles tendinitis issues? Why is this such a frustrating issue?
Yes, it seems to be quite common among runners and I do see this quite often in the clinic. I think it’s frustrating because it can be one of those lingering issues that just doesn’t seem to go away.  Tendon tissue, compared with bone or muscle, is less straight-forward in terms of healing times and progressions, leaving many runners with lingering pain that they are not sure what to do about. Many runners will continue to run through it without getting proper help for resolving it.
Q. -What are the symptoms that would indicate you have Achilles tendinitis?
Early symptoms typically include a mild ache in the achilles region, which is the back of the lower leg above the heel (between the heel and the calf muscle). Severity may increase with increased stress to the tissue, such as prolonged running, hills, or increased intensity. You may also experience accompanying calf tightness, and sometimes heel or foot pain due to altered force distribution in the foot and ankle.

Q. -What is the difference between Achilles tendinitis and tendonosis?
The biggest difference between any “-itis” (which means “inflammation of”) and “-osis” (“condition of”) of a tendon is acuity, or how long it has been a problem. An “-itis” generally refers to an acute inflammation of a tendon, something that has just come on and has been painful for a just a day or a few days. An “osis” refers to a condition that is more chronic, that has been going on for several weeks to several months (or even longer). Therefore, a condition of tendinitis that is acutely painful and problematic can turn into a tendonosis if it is allowed to continue to become a problem over a long course of time. Another term I like to use is “tendonopathy”, which is a more general term referring to a condition of the tendon. Often times there is not a clear idea as to which category the condition falls under (for example, there can be periods of increased acuity and inflammation within a chronic, ongoing problem). We can therefore use this term to describe a dysfunctional condition of the tendon we can therefore call it tendonopathy.
Q. -What generally causes Achilles tendinitis?
There are many potential causes and contributors, but the main pathophysiology of achilles tendinitis is excess stress or strain on the tendonous tissue that connects the calf muscle to the heel bone in the back of the leg (the achilles tendon). This means that there is increased friction or tension on the tendon causing decreased fluidity of motion (ie. restricted motion). Musculoskeletal contributors to this tendon tissue restriction may include calf tightness at either or both calf muscles (the gastrocnemius and/or the soleus muscle) and/or foot/ankle joint dysfunction, and/or alignment dysfunction higher up the chain (eg. back or hip tightness or instability) that can alter the way your foot strikes the ground. We then must consider external factors that may lead to the tissue restriction, or further contribute to restricted motion at the musculoskeletal level.  External factors may include: footwear (eg. old, worn-out shoes), running surfaces (concrete vs asphalt vs trail vs grass), terrain (hilly vs flat), and training choices (eg. sudden changes in training volume and/or intensity). As a PT, I like to look at a person’s whole body to be sure every aspect is addressed, including global motion, trunk/pelvic symmetry and motion, lower leg tissue mobility, and training choices/changes. So often with runners, with all of these potential factors there is likely not just one thing to address. It is often a combination of multiple factors and we must address not only the symptoms but the source of the problem, such as training and/or tissue integrity.
Q. -How might a runner work to prevent Achilles issues from developing in the first place?
  1. Make smart choices with training, such as increasing volume and intensity gradually. We have to make sure to allow all tissues time to adapt to each stress we place on it so it can become stronger. But this takes time. Any time we rush training and don’t listen to our bodies we are risking injury. So my second piece of advice is:
  2. Listen to your body. As a fellow runner, I know how hard it is to back off of training, miss group runs or workouts, or skip a race, but the old adage is true: it’s better safe than sorry. You’re better off sacrificing a day to save a week, a week to save a month, etc.
  3. Warm up well at the start of each run (as in, take it really easy and keep your eyes off the Garmin), and avoid excess strain such as hills if you have any symptoms. 
  4. Employ great self-care with self-massage, foam rolling, using a lacrosse ball, gentle stretching. Make sure to keep those calves and feet supple and pliable. If you’re getting symptoms, ice your lower leg for 5-10min (ice bucket works well for this) after exercise.
  5. Choose good shoes for you. Get good help choosing the best running shoes for your feet. You may also need additional support or orthotics. And don’t run in them until the bottom is worn shiny and the upper is turning into shreds. Get new shoes every 300-500 miles or sooner if you start feeling flat.
  6. Strengthen your lower legs, and not just your calves but all 4 sides: front (anterior tibialis), inside (posterior tibialis), outside (peroneus), and back (gastrocnemius and soleus). We need to maintain and progress our muscle strength and keep all sides balanced.
  7. Stay strong and balanced, especially in your pillar (core, gluts, hamstrings). Runners are notorious for having weak gluteus maximus and medius, among other things. We have a lot of stabilizers that need to be working just right.
Q. -If a runner has Achilles tendinitis, what are the best treatments? How should you modify your training?
  1. Get on that ball/roller/massage tool and keep those tissues loose. Or have someone do it for you.
  2. Back off of training. Don’t progress forward until pain and symptoms subside. Be smart and listen to your body. Inflamed tissue won’t be as responsive and most likely will become more irritated with persistent pounding. If you do run and symptoms are manageable, avoid hilly terrain and anything that will add excess strain to the area.
  3. Warm up the tissues well before any exercise.
  4. Cross train. If you begin to feel symptoms, you may buy some time to get it sorted out without making things worse by spending some sessions in the bike or in the pool (swimming or pool running).
  5. Ice. I suggest the ice bucket (or ice pack) for 5min increments with at least 20min off between, and periodically throughout the day.
  6. Don’t wait to get help! If you’ve tried to relieve the symptoms on your own but they are still persisting, see a licensed Physical Therapist. I see so many patients who wait until they are unable to run to come in for treatment. And many runners may not realize that I, along with many PTs, are heavily interested in preventive care. Meaning, we want to keep our athletes moving and running, and if we can address the issues early, we can help save you from significant time off letting the tissues heal. We can also look at the bigger picture, such as other areas that may be contributing to the problem. We can work together to find the source of the problem, while also treating the symptoms, in order to prevent it happening again down the road. Keep in mind also that continued strain on damaged tissue, as well as risk factors, such as age, can lead to an achilles rupture, which requires surgical repair. So please be cautious to prevent this occurrence.

Graston Technique Certified

Post coming soon…

Calf Stretch Quick Tip

I have found myself helping several people with their calf stretch technique over the past couple of weeks.  Stretching the calf area is important for preventing continued muscle shortening, and during rehab for conditions such as plantar fasciitis and other foot or ankle problems. When we perform a calf stretch we are affecting the gastrocnemius muscle, soleus muscle (especially if the knee is bent), as well as the achilles tendon or heel cord, and connective tissue.  When most of us think of stretching a muscle we think of needing to feel that stretch.  I noticed for example, while stretching with the aid of a slant board, many individuals tend to stand over the the board with a mega-slant angle to try to use their body weight to force a bigger stretch in those posterior lower leg muscles.

Here is a variation, and a  potentially safer way to stretch the gastroc-soleus complex: Scoot the slantboard back from the wall so that you have room for your other, non-stretching leg to step forward while the back leg is still on the board (feel free to lower the angle of the slant for this). This allows your muscle to relax a little more, and puts you in a more function-friendly position (think stepping or walking).  Try it out and you can be the judge of whether you like it better.  If you don’t have  or use a slantboard, then try taking a small hand weight (2 to 5 pounds is sufficient) on which to rest your forefoot. You can use anything that is a similar height, such as a book, half-step or half-curb, a rock outside, or whatever you may find.  Allow that muscle to relax rather.  And it is okay to not feel the stretch- this means you are elongating the muscle into it’s natural range of motion rather than the muscle acting to resist. Good luck- keep those lower legs loose and healthy!

    

Step forward with forefoot raised and rested.

Hold for 20-30seconds each side.

New Blogger

Hopefully I gave some insight into my background in my first post, but now I want to share my reason for going at this blog thing. My aim is to provide education and promote health. I am passionate about health, wellness, and the science of exercise, and I’m fascinated by the way the human body works (or sometimes doesn’t). In posting, I hope to help inform and inspire, or at least motivate you to learn about and understand your own health, and then do all you can do to optimize it. I am always learning, through my own fitness and injury problems as well as through my patients and article research. I wish to discuss anatomy and injury, health and nutrition, exercise tips, and new treatment techniques, among other topics. And I want to know what questions you may have. If I don’t know the answer to something, I will research like crazy until we find a solution. My background is competitive running, so much of my passion stems from this, however I also love swimming and cycling, strength training, yoga, climbing, eating a clean diet (chocolate counts, right?), cross training (I could be a professional pool runner), and anything that is inspiring, motivating, and keeps us all living life, surpassing our goals, and doing the awesome activities we love. I truly hope you find this a useful and enjoyable resource.

Return to Colorful Colorado

I have had the good fortune to return to my home state of Colorado after many years of moving farther and farther away. And what better place to land than in Boulder, home of the outdoor enthusiasts, the activity addicted, the friendly foodies. I all but vibrate with excitement over the fancy bicycles that speed by and the multitude of runners, of all types, and on all types of runs from road to trail to path to track. And don’t leave out the year-round outdoor pools, for those of us who wish to keep our workouts outside regardless of the temperatures or precipitation.  Couple these fun and active individuals with entrepreneurial businesses (food, health, gear) and a collective love of the outdoors and sunshine, and this is one wonderful and amazing place to live.

I have lived in many wonderful places in between my start and return to the mountain state. Although Nebraska does not sound to most people like the most exciting place to be, my collegiate experiences more than made up for the lack of overall hills and trees. In fact, our home Cross Country race course was the hilliest and hardest I’ve ever run, set in Brickyard Park in Hastings, NE, the course wound up, down, through, and around a bowl-shaped grass- and woodchip-laden park. And your efforts are rewarded by brick-colored tainting to your shoe soles after the race or workout. Long runs and workouts with to-be-lifetime friends underscore these college memories. That and lots and lots of corn fields.

A long drive while watching the changing countryside brought me to North Carolina for graduate school. Consistent beauty on the Wake Forest campus must be credited to the University’s landscaping team. While Spring rolls around early in March with green grass and blooming flowers, summer is prone to high humidity, though winter is comparatively mild with sporadic ice storms. Groomed campus trail loops, and fast track workouts with the team were highlights of this running chapter. A bonus collegiate season was just what I needed to feel at home at the school and on the track. Even though I was teaching the undergraduates in the classroom, I was enjoying running with them in workouts and races. This, combined with my coursework in Health and Exercise Science, made for an exceptional graduate experience.

My next experiences came in the form of professional employment, and took me north to Boston. A city full of history. And successful pro sports teams. And runners. And colleges. And hospitals. A great place for employment in academics and health care. And for athletic pursuit. Boston fever took hold on this this middle distance runner as I felt the need to go for the marathon (among other distances). And, thanks to consistency along the way, and to great coaches and teammates in the Boston Athletic Association (BAA) running club, I found continued personal bests in every distance. Boston stretched me to the capacity of my creative means of commute, as I went from riding the train to bike commuting to running all of my commutes from home and back. I will miss the sun rising and gleaming off the Charles River, the dark workouts at the Harvard track, quieter trails along the Emerald Necklace, but most especially the wonderful friends I had the opportunity to chat with over hours and hours of running.

As I sadly say farewell to Boston, I excitedly welcome new friends and experiences in Boulder. As I return to my sunny home, I am already enjoying exploring the trails, swimming outside in the winter, and taking the bike out for a spin. I am proud to move forward while having been shaped by many wonderful people along the way: educators, friends, running partners, clients, classmates, patients, students, study participants, colleagues, and mentors. So on this return to home, I remain the same person who traveled away, though altered and still growing, and I enthusiastically await a new wave of such wonderful people to come along and help shape my life as I hope to do the same for them.

Dr. Lara Johnson, PT, DPT, MS

Physical Therapy and Rehabilitation. Injury Prevention, Sports Training, and Athletic Performance Located in Boulder, Colorado

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