Print- Share
Email- A A A
PrintHeal your Achilles Heel
Most cases of achilles pain that we see at our clinics have reached the tendinosis stage. In simple terms this stage is where the cells are degenerated and not repairing properly. This is different to Achilles tendinitis where inflammation is the primary process.
There are many factors to consider for effective healing of an Achilles tendinosis. The purpose of this article is to provide you with some useful pointers to promote recovery.
1. Tight muscles
The calf muscles are generally tight in people with Achilles conditions. Stretching exercises are often very useful, but at the same time, they can aggravate the condition if overstretched. Most commonly the inside of the calf is often tighter and therefore usually leads to pain on the inner side of the achilles tendon or on the insertion attachment on the inside of the heel.
To stretch this muscle effectively, you can turn the foot away from the body slightly to increase the stretch to the medial gastrocnemius. Bending the knee slightly will increase the stretch further down, nearer to the achilles tendon.
2. Weak muscles
Muscles not only function to move a body part, but also absorb energy like a spring. The achilles tendon is an important shock absorber with almost any weight bearing activity we do, like walking, running, jumping etc. When your calf muscles are weak, they will not be able to function efficiently to absorb the shock or move your body in tandem with the demand of your activity. Hence the impact will be instead taken up by the tendon itself leading to dysfunction.
To train the shock absorption function of your calf muscles, stand on the edge of a step (heel off the step) and perform heel raises (go on to your tiptoes) and then the slowly drop the heel down (heel dip) (about 3 seconds) just before you feel the stretch in your calf muscles, push the heel up again. You will feel the obvious weakness of your affected leg especially if you do it only on one leg. You will notice that the heel can’t go up as high and you need significantly more effort compared to your other leg.
3. Foot Arches
A high arched foot has a smaller surface area in contact with the ground. It is also stiffer into pronation which is what your foot should normally do as it bears weight. The combination of poor shock absorption from impaired pronation and a smaller area will increases the amount of force that goes through the high arch foot. A higher arch tends to have the heel rolled outwards and a lower arch tends to have the heel rolled inwards. This means that the achilles tendon will not be lifting the heel up normally. Instead it will be lifting up the heel plus tilting the heel sideways, either inwards or outwards.
4. Foot biomechanics
When your foot and ankle joint are too stiff or too lax, they either have poor shock absorption or your muscles have to exert more force to stabilise. The biomechanics has a lot to do with the foot arches too (see above).
Customising foot orthotics or inserting of heel wedges may help to correct such dysfunction in biomechanics. The physiotherapist may also perform mobilisation techniques to help facilitate movement in the foot and ankle joints.
5. Training intensity
As mentioned above, tendinosis is a degenerative stage where breakdown of cells is faster than your body’s ability to repair, i.e. overuse. Be mindful of how much you are exerting yourself. Some variables that you can take note of are, speed, distance, terrain etc. For example increasing running speed, walking further or running up a slope can aggravate the injury.
Try increasing the intensity by 10% each week, and always listen to your body.
No pain no gain is definitely not the mantra for healing an Achilles tendinosis.
Pilates and Physiotherapy
What is Pilates?
Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.
Background
Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.
Clinical Pilates vs Pilates
Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.
In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.
Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery.
The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.
Peripheral injuries
When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries.
Spinal Injuries
Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.
In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.
Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.
In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.
If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt.
The benefits of Pilates
• General fitness and body awareness greater strength and muscle tone
• Improved flexibility
• A flatter stomach
• Improved efficiency of the respiratory, lymphatic and circulatory systems
• Better posture and awareness
• Less incidence of back pain
• Increased joint mobility
• Lower stress level
Which clients would benefit from Pilates?
• Males and females
• Pregnant: Pre and post natal
• Athletes and dancers
• Amputee and stroke rehabilitation clients
• Elderly
• Children 12 years-old +
Clinical pilates therefore targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.
If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!
Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome
Do you have heel pain? And think it is Plantar Fasciitis?
Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.
What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?
As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).
While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.
Plantar Fasciitis
Plantar fasciitis is an overuse condition of the plantar fascia.
Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.
Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.
Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.
Heel Fat Pad Syndrome
Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.
Contributing factors: Increased age and weight decreases the elasticity of the fat pad.
Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.
Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.
References:
- Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3rd edition, Tata McGraw Hill, Australia .
Ankle Overpronation and Injuries video
Have you wondered why overpronation (rolling inward) of your ankles can cause injuries? Click on the video to find out more.
How to prevent ankle sprains from happening … again
Have you ever wondered that maybe there is a way to change this?
Did you know that 85-90% of untreated ankle sprains will be recurrent, but with correct management after the first occurrence those number of cases can be brought down to only 35%?
What happens in an ankle sprain? Which structures are involved?
As a result of continued rolling, turning or instability of the ankle, the ability to make rapid adjustments in the position of the foot on uneven surfaces (proprioception) becomes limited. If this happens, the likelihood of a more severe ankle sprain occurring increases.
A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to completely torn ligaments where the ankle can be quite loose.
The common diagnosis for pain on the outer side of the ankle is an inversion sprain. This usually occurs when the foot lands in an awkward manner and rolls inwards, creating stress on the outside ligaments. When this stress is severe enough, an ankle sprain occurs.
There are three major ligaments attached to the outside of the ankle: the anterior and the posterior talofibular ligaments (ATFL and PTFL), and the calcaneofibular ligament (CFL). The ATFL is the most common ligament to sprain due to the mechanics and the limited support at the front of the ankle.
The other type of ankle sprain is an eversion sprain for pain on the inner side of the ankle. This happens when the foot is twisted outwards. The inner ligament, called the deltoid ligament, is over-stretched.
What can I do after spraining my ankle?
If you are unable to put weight or walk on it, you may have a small fracture. It is advisable for you to get it X-rayed. However, if you feel like you simply rolled over the ankle and putting weight on it hurts a little, apply RICE (Rest, Ice, Compression and Elevation) immediately. Head home and avoid walking on it as much as possible. Fill a wet thin towel with crushed ice or with a bag of frozen peas, and apply to the painful area for 10-15 minutes. Do not apply ice directly to your skin for more than five (5) minutes as it can cause cold-burns. Keep this up every 2-3 hours for the first 48 hours. This will help to minimize pain and control swelling in the area, limiting the extent of damage to the ankle.
For the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Make sure it is tight enough to stop the swelling from going down into your ankle but not enough to make your toes turn blue. However, remember to take it off at night but put it back on even before you leave your bed. Keep your foot elevated at night by placing pillows underneath the affected foot to give you just enough elevation to sleep pain-free. Foot pumping exercises (continuously bending and pointing your foot out) are also especially useful when the foot is elevated to help push the fluid away from you and back to your heart. Strictly adhere to the RICE regiment for another 2-3 days or until the swelling is about 75% gone.
How do I prevent a recurrence?
If this is not the first time you have sprained the ankle, the bad news is that once a ligament has been overstretched and not taken care of, it loosens and will never go back to its original length. Not only do ligaments hold bones together, but they also part of your balance-control system by sending messages to your muscles (via the brain), telling them how to react to maintain your balance and prevent excessive movement
The basic philosophy of any rehabilitation programme is to retrained your ligaments to sense and send the required balance signals and strengthen the muscles. This restores and improves the balance around your ankle to help prevent recurring sprains and protect it from the stresses of everyday life.
A physiotherapy rehabilitation treatment programme may include:
1. Therapeutic ultrasound would be administered to promote healing and decrease in pain.
2. Soft tissue massage to aid lymphatic drainage and remove any residual swelling.
3. Individualised exercise programme which may include:
a. Calf stretch alphabet exercises – moving the ankle in multiple directions by drawing alphabets in lowercase and uppercase motions.
b. Isometric strengthening exercises, such as pushing against an immovable object (e.g. wall or floor) or with the unaffected foot, can begin.
c. Balancing exercises such as standing on your affected leg and try to hold your balance. You will probably notice at first that your injured foot is much more wobbly, which will get better with practice.
Finally, your physiotherapist would also work closely with you to plan a proper activity based training programme to get you back to sport or normal daily activities. You can follow this whole recipe for old recurrent sprains.
Heel Ergonomics – Part II
This interview continues from Handbag Ergonomics – Part I
MCR: Can high-heeled shoes change the way a person walks?
Flickr
MCR: Most shoes stores these days sell a lot of high-heeled shoes and wedges, what are the potential health dangers if they are worn for too long and too often?
Cheryl: Ankle and foot injuries while wearing high heels/ stiletto shoes are commonly reported. Commonly high-heel related injuries are calf sprains, twisted ankles and injuries from falls. Wearing high heels long term can seriously harm the feet by damaging the tendons in the heel and causing blisters, bunions, corns and calluses which some of them may even require surgery. Other conditions such as hammertoes, ingrown toenails and ankle and knee joint pains. Heel pains such as inflammation of the plantar fascia (bottom connective tissue of the foot) or plantar fasciitis are very common too.
MCR: What is the most serious scenario that can happen?
Cheryl: Fractures of the ankle or foot on falling and complete tear of ankle ligaments which requires a cast or ankle reconstruction operation to heal. Other more serious injuries that can be sustained on falling can be trauma to the head and shoulder fractures and strain. On a long term basis, research shows that wearing high heeled shoes regularly causes long-term health problems such as a distortion of the lower spine and arthritis in the knees which can lead to postural spinal stenosis and rapid degeneration of the lower spine (also known as lumbar spondylosis) leading to chronic low back pain and/or numbness or any other sensation changes in the legs.
MCR: What advice on choosing shoes?
Cheryl: There are no hard and fast rules about it, but it is recommended that high heel wearers take sensible precautions when going out in high heels or new and unfamiliar shoes in order to reduce injury. These include wearing shoes with ankle straps to help hold ankle and feet in place, making sure your shoes are properly fitted (size-wise), switching to flats during the day to give your calf muscles a break, and placing appropriate measures in shoes (i.e. heel pads, corn pads) to minimise the chance of blisters and painful friction.
MCR: How can physiotherapy help a person with heel pain?
Cheryl: Heel pain can be a result of bad walking posture/gait pattern, excessive walking and running (overtraining), wearing high heels frequently and/or muscle imbalance of the leg (hip, knee and ankle). Depending on the nature of the injury, be it a sprain or an accumulative stress related injury, physiotherapy help by applying various strategies in the reducing the stiffness, pain and discomfort in joints or muscles affected. Strategies include manual techniques, such as joint mobilization and manipulation, deep friction massage, stabilization exercises and electrotherapy i.e. ultrasound therapy. Should wearing heels be required on the job, the physiotherapist may make recommendations on the footwear, and advise on posture correction and specific muscle strengthening for injury prevention. Nevertheless, treatment is always more effective if the problem is detected and treated early as chronic problems (more than 3 months) have poorer treatment results. Therefore, if the pain does not resolve within 3-7 days and seems to get worse, it is time to make an appointment with your physiotherapist.
MCR: Besides heavy bags and high heels, what are the other potential fashion health hazards?
Cheryl:
Badly Fitting Bras
Studies have shown that as many as 90% of women are wearing the wrong bra size, many still hanging on to the same bra size they were fitted for years ago – irrespective of growing, losing weight or having children. Wearing the wrong bra could lead to shoulder tension, chest/ breathing restriction, headaches and chest and upper back pain. If the bra is too loose, it is not supportive enough and if too tight and restrictive, it can lead to restrictions in breathing normally, upper back pain and reduction of spinal movement.
Tight Pants/jeans
The trend for skinny jeans, hipsters/ low riding jeans tend to restrict movement and can also cause bad posture, changing the alignment of the spine. The tight, low riding jeans/ trousers can squeeze a sensory nerve under the hip bone, known as the femoral nerve, and cause a tingling sensation in the thighs (pins and needles) also called paresthesia.
Tendon Disorders: Inflammation and Degeneration
One common form of musculoskeletal injury is tendon-related disorders like tennis elbow and Achilles tendonitis. Your tendon is the connector that transfers power from your muscle generators to your skeletal structure to create movement. Under normal circumstances, healthy tendons glide easily and smoothly as the muscles contract. When tendons are injured, they cause pain, especially during movement. (more…)
Orthotics for Achy Feet
"Dear Sir, I am a lecturer and an avid, regular sports player. My feet aches every week and I go for regular foot massages. I did an analysis on my feet during one of the orthotic analysis booths at some shopping centre which reported I have high arch and pronation. I wonder what can be done to correct that and reduce my achiness? " - Mr Ho
How to tell the difference between an ankle sprain and a fracture
This is a brief video on how to tell the difference between an ankle sprain and an ankle fracture. If you are thinking of taking an X-ray to confirm if it is a fracture, the Ottawa Ankle Rules has a guideline to check if you need an x-ray.
Simple Exercises For Plantar Fasciitis Sufferers
In an earlier post, we discussed on what plantar fasciitis is about, including the causes, symptoms and treatment options available. If you think you might be sufferring from plantar fasciitis, read on and find out more about the exercises that you can do to help ease the pain in your foot!
