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Achilles tendon trouble in a runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Jan 13, 2010.

  1. David Smith

    David Smith Well-Known Member

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    Dear All

    I have a customer who likes to run, he's 45yrs old but only started running seriously / a lot for the last few years. He finds that when running he strains his Achilles tendons especially the right. He tore the right calf muscle (no more specific info than that) last November.

    Initially, this sounds like it might be a simple case of ankle mobs, stretching exercises, heel lifts and orthoses to allow the foot to function correctly.

    However my videos and pressure scans comparing running to walking and barefoot to running shoes show some things that need advice from you guys.

    Regarding video analysis: In barefoot walking gait the knees are always flexed and at heel strike the foot in not dorsiflexed very much relative to the ground. In running shoes the right knee especially in more extended at heel strike but most notabley the knee is fully, even hyperextended at late midstance early heel lift. This leads to a visually noticeable increase in tightness / tension in the Achilles tendon.

    Running barefoot the knees are very flexed and never achieve full extension. Running in shoes, especially the right again, the knee fully extends at heel strike and the foot is much more dorsiflexed with respect to the ground than running barefoot. There is also more knee extension again at late stance but the differential is not so great as in walking.

    The Running shoes are a moderate anti pronation type with a medium stiffness sole. The shoe heel lifts by about 20mm-25mm relative to the forefoot.

    The open chain STJ axis position is moderately medial. Ankle dorsiflexion is good but hamstrings are short re SLR test. Leg lengths appear equal by comparison and measurement..

    Regarding Pressure analysis: In walking, both feet, the CoP has a lateral path going medial to the 1st MPJ / hallux at propulsion. Much pressure is shown on the 5th styloid process through most of the stance phase. Heel lift is early but mid foot contact is prolonged indicating flexion of the midfoot. This is noticeable in saggital video view also. In walking the right is more propulsive, in terms of vertical peak force, than the left. However in running the left is more propulsive (by the same terms) by about 10%. (85kg body weight = GRF peaks of 2000N Vs 1800N).

    The right fore foot is varus/supinatus and there is late pronation as the heel lifts.
    My evaluation is that since the GRF remains lateral the medial tissues resist pronation moments. The midfoot cannot supinate and so remains flexible to GRF and dorsiflexes about the cuboid. As CoP moves forward and the moment arm to pronation moments about the STJ increases then the foot pronates more and becomes more weight bearing medially and so CoP moves medially.

    The left hip has no internal rotation past the knee straight ahead position i.e. there is an external femoral torsion compensated by an internal malleolar torsion.
    Therefore the torsion in the left leg due to contralateral swing through causes the left foot to supinate and the CoP to move laterally, as the CoP moves forward pronation moments increase about the STJ and midfoot and it to is able to flex about the cuboid.

    In running this is not the case, the CoP remains more medial in both feet through out the stance phase. Even so the mid foot still flexes and the 5th styloid pushes on the ground for a significant period of time after heel on lift both feet.

    My problem is: The running shoes seem to be increasing posterior muscle group extension, which might be good if they didn't also increase in tension to the point of injury.
    So, do I add heel lifts and orthoses and give stretching program for Ach ten and Hammies and risk that he won't damage his posterior muscle groups in the interim while running. - Or would it be better to use a running shoe with no heel and simulate barefoot running and allow the propulsion to come from flexed knee extension while at the same time avoiding excessive Ach ten tension. This might result in a less efficient running action, but he's not training to be a champion and I know several guys who run for fitness and quite happily use knee extension for propulsion.:confused:

    I guess I could try no heeled running shoes and see how he goes and review him from there.

    Over to you

    Cheers Dave
  2. Hi Dave I´m sure people will be along with more info, but this seems to be a patient that you might have to consider 2 different tx plans.

    1. consider the walking pt. Design your treatment plan around that.

    2 Consider the running pt and have a completly different treatment plan.

    He might need to completly different orthotic with heel lifts for walking and no heel for running with a forefoot type of device.

    Just a thought as it sounds like it would be a square peg in a round whole if you try to get one tx program for both walking and running.

    I follow along see what happens. Good luck
  3. David Smith

    David Smith Well-Known Member

    Mr Weber

    Good Thought! Although he has no problem walking only running, as far as he's concerned he only need an intervention for running activities. However reducing the tendency to pathology while walking might reduce the actual trauma when running especially when combined with running orthoses.

    Nice one

  4. Dave:

    Have the patient stretch their gastrocnemius and soleus before running, after running and at least once more during the day. Put him into a shoe with a higher heel height differential (most Nikes, for example) and then give him two 3 mm neoprene (Spenco) heel lifts for each running shoe that he will place under his running shoe insole/orthosis. Start him with the 6 mm heel lifts and, as long as he doesn't develop knee pain with running, the 6 mm lift may stay in the shoe, or be replaced by only a 3 mm heel lift. The Achilles tendon should be iced for 20 minutes after running and then one more time a day. Also, make sure he is wearing heeled shoes for walking, instead of barefoot. As the injury improves, the heel lifts in shoes can be removed, depending on his response.

    Hope this helps.
  5. Admin2

    Admin2 Administrator Staff Member

  6. musmed

    musmed Active Member

    Dear Dave

    I like the thought of having customers.
    I hope they don't trundle off to consumer affairs like customers do here.

    The square is very large in this man.
    You state he has no internal rotation in the left hip.
    Surely this needs investigation.
    Does he have a capsular or non capsular range of motion?
    If he has a capsular pattern is running days are over due to OA present. Running will accelerate his need for a hip.He is so young

    A non capsular pattern needs hands on therapy such as massage and tretching first while he keeps his cardio fitness up in a heated pool.

    What is a capsular pattern I hear..
    Cyriax described the petterns for the hip and shoulder.

    In the hip:
    the greatest restriction is in Internal rotation
    followed by abduction of the hip and
    least in external rotation.
    Normal ranges are:
    E/R 45
    I/R 60
    Abd 70
    so if he has
    I/R =0
    Abd 50
    E/R 40
    it fits a capsular pattern.
    If the variance is not in this sequence he has a non capsular pattern ad you can do something with his problem.
    I cannot see how heel lifts etc. will not do anything without a diagnosis of the whole kinetic chain.

    If interested come to Brighton on the weekend of 6-7 where I will be running a Biomechaincs workshop. All welcome.
    Paul Conneely
  7. HansMassage

    HansMassage Active Member

    "A non capsular pattern needs hands on therapy such as massage and tretching first while he keeps his cardio fitness up in a heated pool."
    Hey that is why I joined this forum. There is a good possibility that he has week and uneven psoas minor and therefore maintains his pelvic balance with his hamstrings. Look for stress at T11/12 where the psoas minor attaches.
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
  8. musmed

    musmed Active Member

    Dear Hans
    Hi and thank you for your response.

    There are some very intersting things associate with the psoas major muscle.
    Each muscle fibril is of the same length irrespective of where it originates or inserts.
    L1,2 are flexed by contraction of the psoas
    L4,5 are extended by the contraction of the psoas
    Only about 30% of us have a psoas minor muscle and it may not be bilateral.
    to see how to stress this muscle, go to my web site
    Paul Conneely
    hey, anyone coming to Brighton?
  9. David Smith

    David Smith Well-Known Member

    Dear Paul

    Thanks for your input

  10. musmed

    musmed Active Member

    Dear Dave

    From what I am reading you are describing external rotation of the leg not specifically the hip.
    I use the good old Kendall technique
    That is
    Patient supine
    face their right leg
    right hand elevates the knee to 90 (if possible)
    left hand then stabilises the knee
    right hand then elevates the lower leg to 90 degrees
    a rotation of the lower limb towards you (internal rotation) is performed and degrees noted
    again the reverse is performed.
    This technique is far more accurate than having a leg rotated.

    The main difference is that you are only moving the hip.
    In the extended leg
    you are allowin for the hip (ould be in any plane)
    femoral torsion
    knee laxity
    tibial torsion
    ankle laxity

    If this technique is applied you can get good reliable resuts and thus my 45 and 60 degree ranges make sense and are the results from this technique can be translated into capsular and non capsular patterns as I described before.

    Hope this makes it clearer to all.
    Paul C
    They tell me Brighton is almost sunny for 3 mins a day now
  11. David Smith

    David Smith Well-Known Member


    We are straying a bit but I like to discuss and explore hip assessment

    I usually use a knee extended / hip extended then knee flexed / hip flexed both 90dgs and internally externally rotate in both positions, then max hip flex SLR and max hip flex with knee flexed to assess hip RoM. I see these techniques described in many manual testing books and so they have a universal reference.

    I then look at knee to foot positional relationship in terms of facing straight ahead and quantify them as tibial/malleolar torsion. The hip rotation with knee extended has its reference in the femoral condyle and so is not affected by knee joint rotation in the longitudinal axis /transverse plane or relative foot knee positions or joint laxity.

    I'm not quite understanding the description but what is the advantage of your technique you described earlier? Does lifting the knee to 90dgs = 45dgs hip flexion or 90dgs hip flexion in the supine position? What is lifting/elevating the lower leg to 90dgs? Should this read elevate thru 90dgs so the knee is now extended and the hip is flexed at 45dgs? I'm not sure what the origin or position of reference is here. Most people, by my experience, cannot attain 90dgs hip flexion with knee full extended (SLR test) in the supine position.

    Regards Dave
  12. Dave hows the patient and what treatment plan did you implement?
  13. David Smith

    David Smith Well-Known Member

    Mr Weber

    I fitted Amfit Custom EVA orthoses. 5mm heel lifts, 1st ray lowered 4mm right 2mm left, medial rearfoot post biased to STJ axis position, 3dgs right 5dgs left, 2dg varus forefoot post on both, extended to met toe sulcus, 1dg varus post 2-5 left. met raise 2mm both extended to cuboid - right 1mm teardrop cuboid lift. Arch height profile lowered 3mm both.

    Mobilise ankle joints plus Stretching exercises hamstrings and achilles tendons. Due for review end of March. Has not rung to report any problems so assuming things are ok.

    At fitting I did have to significantly grind out the medial arch height on the right foot due to severe arch discomfort at the 1st cuneiform, which is very unusual and probably the first time I have done this. I am assuming that during walking and running the midfoot is still bending and lowering the arch profile more that the static scan even tho I did lower the arch profile further at design. I may remake the right orthosis with a low arched, pronated foot position if this is still a problem at review or this may be one for a complete design review and go to a MASS type shell design with a high flexible arch.

    Cheers Dave
  14. Just thought Id check as he had very different gait paterns walking-running see what you came up with and the outcomes for the patient . I guess you will have more of an idea in late March.

    Thanks for the update Dave

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