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Advice for the treatment of runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Davey, Jul 29, 2009.

  1. Davey

    Davey Member

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    Hi I am going to see a runner who is training for a marathon, He can only get to approx 7 miles before he experiences calf spams and achilles pain.

    He has been seen by a physio recentley who feels he is pronating quite quickly from heel strike creating increased stress on the achilles and calf muscles. The patients rom has been assessed and ankle rom is reduced due to tightness of calf muscles.

    I will be assessing this patient today and on history was thinking of stretching programme for calf muscles along with strengthening programme for TIB POST to reduce any accelated pronation, I will also be checking for any footwear issues and maybe issuing some type of orthoses.

    I know I will have to wait until I assess the patient but any advice anyone could offer would be appreciated.

  2. Ella Hurrell

    Ella Hurrell Active Member

    Re: treatment of runner

    Hi Davey

    First and foremost is your thorough assessment. As I'm sure we would all agree, definitions/descriptions of "pronation" can vary from professional to professional. In my experience, some people blame everything on "over-pronation" when in actual fact, the patient has anything but! :bang: I tend to be very sceptical about referrals like that until I can prove things to myself.

    Any advice re treatment before assessment is purely speculation - I would be assessing foot type/structure etc ie. ruling out any forefoot equinus (which has been discussed on a recent thread but I can't find it at the moment - hopefully admin will help me out?). Check his running shoes for the model and the control it provides. How long has he had this problem? Could he run further prior to the pain beginning? If so, what has changed? Discuss his running route - is the 7 mile point when there is suddenly a steep hill?? Is it only unilateral?

    Obviously I have asked more questions than I have answered ;) Sorry about that! Will be interested in what you find on assessment!
  3. Re: treatment of runner

    Read: Runner-patient history. What to ask and why by Prof. Kevin Kirby


    Perform a thorough examination including running gait analysis- sounds daft, but you would not believe the number of runners that I see who have been seen previously by a variety of "health-care professionals" that haven't even looked at them running.

    P.S. if it really is a problem of rate of pronation consider Brooks Adrenaline GTS, they have a tri-density midsole which is supposed to decelerate pronation more gradually. However, I have issues with the concept of rate of pronation, but that's another story...
  4. Re: treatment of runner


    Like Simon said, I would first suggest that you read the paper above (which I wrote at the tender age of 25). By the time that I wrote that paper, I had been competing as a long distance runner for 13 years, had been reading Runner's World from cover to cover for 9 years, and had read every runner's injury book that I could purchase or get my hands on.

    My point is that, in order for the clinician to treat runners effectively, they must first understand the specific mechanics of running compared to walking, must understand the mechanics of running shoes and the principles of proper shoe fit and, and must understand the psychology of the runner. There are many good books on these subjects that I suggest would greatly aid you in treating all your runner-patients, if you desire to become an expert in treating runners within your community. If not, it would probably be best to refer them to someone who does have an interest in this fascinating facet of podiatric practice.
  5. Griff

    Griff Moderator

    Hey Davey,

    How did it go/what are your thoughts now you have assessed him?

  6. Davey

    Davey Member

    Hi thanks for the replies:

    I have assessed the patient but could not assess him running at this time as I do not have the facilities in the clinic which I work out of, although I know it would be invaluable to do so.

    The patient has been training for approx 4 months and he is experiencing pain in the calf and achilles tendon approx 1 mile into his run. The patient states that his running all takes place on level hard surface and that he has been increasing his training gradually.

    There is a lot of tightness in all posterior muscle groups where I could not get the patients foot dorsiflexed to a 90 degree angle.

    The patient has a semi rigid pes cavus foot which on weight bearing does excessively pronate although it is not a great deal.

    The patient does compensate his gait with an abductory twist and early heel raise.

    I put some low dye taping on the patient and initiated an intense stretching programme for posterior muscle groups along with some tib post strengthening.

    ELLA there is a forefoot equinus present so if you can find the link to the paper you were talking about it would be greatly appreciated.

    SIMON and KEVIN I have now got the paper you both mentioned along with the rest of the papers posted with it and will be reading them all as only being 1 year out of uni I have a lot to learn!

    All feedback is welcome.
  7. Griff

    Griff Moderator

    Davey - not everything is about pronation (how much is 'excessive but not a great deal'?), and you may find that reading up on the tissue stress theory will help you view things a bit differently rather than trying to always just consider foot kinematics or positional observations.

    Once you start thinking about the actual structure which is injured, and then try to identify the pathological load/stress that is being placed on it you may find it is far easier to formulate management plans and design orthoses which will have favourable outcomes.

    You may also want to read up on Howards theory regarding sagittal plane biomechanics - it sounds like it may be useful in this particular case.

    The Forefoot Equinus thread is here

  8. Griff

    Griff Moderator

    Hey Davey - send me a private message with your email address and I will send you the Tissue Stress and Sagittal Plane Biomechanics papers

  9. Hi davey,
    Theres not a lot out there on FF equinus which you will soon understand whats you read the thread which Ian provided some great pictures for me.

    I would suggest that you defintly look at the patient running in this case which and with out heel lifts. Most likley this patient will be forefoot striker which will mean that you will have to think a little different when considering what happens during the gait cycle.ie No lateral heel strike thru to midstance so some video of the patient running towards the camera and away will be great tool for you and the patient.
    Also if you are not a runner remember to explain everything to the patient you will get 1000s of questions. Their body is the machine that allows them to do what they love and they want to know why its broken.

    Also did you check on the stj axis if it was medially deviated before you began the tib post strenthening program, if the axis medially deviates you maybe helping to make the foot pronate and at a faster rate ( which i beleive plays a big part in tissue stress, )check out some threads on stj axis.

    good luck
    Michael Weber
  10. Davey:

    The first step is to give the patient a 1/4" (6 mm) heel lift to wear while running. A softer heel lift made of neoprene (Spenco) works quite well for runners. This may be all of what the patients needs.

    In addition, I agree that troubleshooting runners using tissue stress theory is the way to go. However, since functional hallux limitus does not occur during running, then I don't agree that sagittal plane theory will do you much good when treating runners.

    Here are the notes from my lecture on running vs walking biomechanics I have given in the China, UK, Australia and the USA:

  11. Griff

    Griff Moderator


    Agreed functional hallux limitus is not such a problem when running, and I'm sure its also true that less range is needed at the ankle when comparing running to walking... But, would you not consider increased dorsiflexion stiffness at the ankle a 'sagittal plane blockade'?

  12. Ian:

    I don't even consider an increase in ankle joint dorsiflexion stiffness as a "sagittal plane blockade" for walking, so why would I consider an increase in ankle joint dorsiflexion stiffness a "sagittal plane blockade" during the spring-like motions of running? The idea of "sagittal plane blockade" is Dr. Dananberg's idea, not mine.
  13. drsarbes

    drsarbes Well-Known Member

    "A runner" - well, what does that mean?

    If he gets pain one mile into a run I would not define him as a "runner"

    Obviously he's a way away from getting to a 26 mile mark.

    Is he in shape?
    What other activities does he do?
    What is his age?

    When you say "runner" I'm sure we are all picturing a young athletic in shape man who is trying to increase his running a bit to run a marathon.

    I think we are all assuming a lot.

    It would help to know his age, previous running experience, current level of fitness, any other orthopedic concerns, etc..........

  14. Davey

    Davey Member

    Hi drsarbes,

    Just to clarify some points for you:

    The patient is 49 yrs old but is in good physical shape and has completed marathons before although this was in his late 20's.

    He does begin to get pain 1 mile into his run but can continue running for approx 7miles and it is the pain which stops him at this point and not his fitness.

    Other than trying to increase his distance running he does no other activities as he is concentrating on the running aspect and fitness.

    Other than the pains mentioned he has no other pain or orthopeadic concerns.

  15. Griff

    Griff Moderator

    Hi Kevin,

    Whilst I'm fully aware you do not subscribe to Howard's ideas surely none of us (irrespective of our own particular lens) should discourage a new graduate from reading about it and deciding for themselves?

    In light of the above quote, what are your thoughts regarding the mechanism of the CoM moving from a position behind the foot to infront of it during walking? (I suppose what Howard refers to as an 'upside down pendulum' motion). Do you not feel this is dependant on sagittal range?


  16. david3679

    david3679 Active Member

    Hi Davey

    One of the other elements I look at when he is running is
    body posture. Where is his centre of gravity. If we have a forefoot equinas and he has his torso further forward than his centre of pressure then he has put a naturally tight posterior compartment into antagonist irritation.
    maybe he needs to bring his centre of gravity back and use legs as a driver, instead of the reaction. do you think that the stretching would be overly beneficial if the patient is a forefoot equinas?

  17. Davey

    Davey Member

    Hi some feedback from the patient:

    He has been running since I saw him a few days ago and feels that the low dye taping was beneficial to the point that his pain was not as severe but there was still pain present.

    He is continuing with the stretching programme given which as David3679 states may not be overly beneficial, I am hoping will reduce the stress on the calf muscles when running.

    I am going to see the patient next week again and will be using some poron or eva heel raises as suggested by Kevin to see if that helps, I also hope to see him running at this time even for a short period and hope to get some on video.

    As before all advice welcome.
  18. Hal Goolman

    Hal Goolman Welcome New Poster

    I am an experienced runner, having raced for nearly 30 years. I've run many marathons including Boston, NYC and Chicago. Keep it simple. Your pt. should avoid hills and speed work as he increases his training mileage, ice after running, insert bilateral 3/8" heel lifts under the sockliners in his running shoes, stretch and consider orthotic casting for his overpronation. Mileage increases on a daily and weekly basis should be gradual taking lower mileage weeks as "rest" rather than constantly increasing.
  19. Ian, please show me where I told the "new graduate" to not read any of Dr. Dananberg's fine contributions to the podiatric medical literature. I think they should be required reading for all podiatry school students.

    The inverted pendulum model of walking mechanics is not something that Dr. Dananberg invented (try typing inverted pendulum, walking into Google and see all the references). It has been proposed as a model of walking kinematics/kinetics for many years within the international biomechanics community. I think you would find that if you did create an inverted pendulum model of the foot and center of mass above it moving anterior to posterior over the planted foot, and then put a couple of screws across the 1st metatarsophalangeal joint (MPJ) of the model, that once the center of mass of the model was anterior to the center of pressure from the model's foot, that there would be no "sagittal plane blockade", as you call it, to preventing the center of mass from progressing anteriorly. If this were the case, then why do the patients that I fuse their 1st MPJ on still walk and run (even marathon distances) with absolutely no problem at all???
  20. Griff

    Griff Moderator

    Kevin, I did not state you 'told' Davey (the new graduate by his own admission) not to read Howards work, but your previous statement:

    could easily discourage a new graduate (in my opinion) from believing the sagittal plane model is of any value when treating runners - and I believe it is.

    I apologise - I did not mean to insinuate it was Howard's idea originally - just merely mentioned it to clarify/illustrate the point I was trying to make regarding sagittal range and CoM progression when walking.

    Whilst I am not the researcher (or model maker) that you are, and I do not perform surgery/arthrodeses as you do, I still find it hard to completely rule out the importance of sagittal plane range with respect to forward progression. I am not trying to be confrontational, just merely trying to understand your thoughts on this.


  21. Ella Hurrell

    Ella Hurrell Active Member

    Davey - I was referring the thread that Ian has linked further up, rather than a specific paper. I hope it helped to read that - I suspect the heel raises you are going to try will work wonders. Good luck - keep us informed.
  22. Ian:

    No need to apologize. I'm just trying to be as clear as possible so that my response to your many questions is not misunderstood.

    I do not think that the sagittal plane facilitation (SPF) model that Dr. Dananberg proposed is helpful in treating runners since running biomechanics is very different from walking biomechanics and the SPF model is based upon the inverted pendulum model which is a popular way to describe walking biomechanics within the international biomechanics community. In the thousands of runners I have successfully treated over the last quarter century, I have never used any part of the SPF model to treat these runners.

    That is not to say that I don't consider the sagittal plane kinematics and kinetics of the hip, knee, ankle and metatarsophalangeal joints in all my runner-patients, since I always have considered any limitations of motions at these joints to possibly be a contributing factor to their abnormal running biomechanics or to their running injuries. However, just because I do consider the sagittal plane kinematics and kinetics of the foot and lower extremity of the runner does not necessarily mean I am using the SPF model to do so. There are many other models of running mechanics that are far older and far more important for treating runners than Dr. Dananberg's SPF model.

    Any clinician or biomechanist that has taken the time to read outside the podiatric literature will realize that the ideas of podiatrists over the past 25 years are just a small speck of the accumulated knowledge that has been written on the subject of running biomechanics over the past few centuries. In fact, running biomechanics has been studied since the time of Aristotle (384-322 BC) with Leonardo DaVinci (1452-1519) even commenting on "sagittal plane biomechanics" of runners by making the following observation “He who runs down a slope has his axis on his heels; and he who runs uphill has it on the toes of his feet; and a man running on level ground has it first on his heels an then on the toes of his feet.”

    Therefore, for Davey, our newly graduated podiatrist, I would not, as I stated in my earlier post, recommend necessarily using any of the principles of the SPF model in trying to learn how best to treat runners. Rather, the first paper that Davey should read is the one I am attaching by Dr. Tom Novachek which I believe is the best paper I have ever read on running biomechanics. He should also read my lecture notes on the Biomechanics of Running in one of my earlier posts here, and then see if he can read some of the classic books on running and running biomechanics such as:

    1. Nigg BM, Karr BA (eds.): Biomechanical Aspects of Sport Shoes and Playing Surfaces. The University of Calgary, Calgary,1983.

    2. Nigg, B.M. (ed.). Biomechanics of Running Shoes, Human Kinetics Publishers, Inc., Champaign, Illinois, 1986.

    3. Cavanagh, Peter R. (ed): Biomechanics of Distance Running. Human Kinetics Books, Champaign, Illinois, 1990.

    4. Alexander, R. McNeill: Principles of Animal Locomotion, Princeton University Press, Princeton, New Jersey, 2003.

    5. Noakes, Tim: Lore of Running. Leisure Books. 1991.

    Now, Ian, since I have answered many of your questions, let me ask you a question. What part of the sagittal plane model would you propose either explains running biomechanics or is helpful in treating runners? It seems to me that you must certainly think the SPF model is important in your treatment of runners in order to be recommending it as a model that a young podiatry school graduate should also be using when they start treating runners?

    Attached Files:

  23. Griff

    Griff Moderator

    Kevin, thank you for this response - that clears things up for me. I misunderstood your earlier post and thought you did not consider the sagittal plane at all.

    On reflection you have actually got me thinking about whether I actually do apply the SPF model to my runner-patients or whether, like you, I am instead just considering sagittal plane kinematics and kinetics of the hip, knee, ankle and metatarsophalangeal joints. I suspect I am not the only one who is guilty of doing this and referring to it as the SPF model?

    I agree that the Novacheck paper is excellent, and attended your running biomechanics lecture first hand in Oxford, UK a few years back so also agree Davey should give that a thorough read through also. However I do still stand by my decision to recommend Howards papers to young graduates/students I have for one main reason -> I believe Howards writing style is very 'new graduate friendly', (lets not forget how intimidating journal articles can sometimes be to students) and whilst perhaps it is not the only literature students should read when trying to grasp the concepts of sagittal plane biomechanics I think once they have read it they will have the confidence to read deeper into the subject as you recommend.

  24. Ian:

    Since I consider you one of the more intelligent posters here on Podiatry Arena, then my initial impression in reading your response was that you misunderstood what I originally wrote. No worries.

    However, in regards to the treatment of running injuries, this is, unfortunately not done well by most podiatrists. Running biomechanics and the treatment of running injuries is a subject that podiatry students get little education in and, if they do, these subjects are probably being taught by individuals who are not experts in running biomechanics or the treatment of running injuries. All in all, the young podiatrist, if they desire to become a sports podiatrist specializing in treating running and other sports injuries, must do some serious studying on their own to learn what they weren't taught in podiatry school so that they can more effectively help their patients with sports injuries.

    Just yesterday in my office, I had a 17 year old track athlete that had flown 2,000 miles with her father from the Chicago area to see me since they had contacted me about via e-mail about her medial tibial stress syndrome and the problems she had been having with her previous pairs of orthoses that had been made for her. Even though I am flattered by people going to such great trouble and expense to see me here in Sacramento, it would have been ideal if she could have found a solution locally.

    With the abundance of excellent information available here on Podiatry Arena, it has become an excellent vehicle by which to transfer the valuable information that many of us have to offer to other podiatrists....and to many of our patients.
    Last edited: Aug 1, 2009
  25. drsarbes

    drsarbes Well-Known Member

    I have come to know you from this arena and I'm quite sure you did not mean to insult all the podiatric physicians in the Midwest, but I feel obligated to reply --------------

    There are some very very good podiatrists in the Chicago area and just because your patient did not "find" one doesn't mean there aren't any. I'm sure Weil's group could have helped her, not to mention many other very well trained experienced and competent doctors.

    Although I agree that some are more sports mined than others, like any subspecialty, I think it may be a bit judgmental to blame anyone's ongoing foot problems on incompetency.

    My main point here - There are patients that have pain when they "over do it" or reach their overuse point. Much like a patient that can work an 8 hour shift at the "mill" with no pain but can't do a 12 hour stretch. Some athlete's, runners especially, expect too much.

    There are limits. We can extend it at times, but there are always limits.

    Not every 50 year old who hasn't run more than 7 miles in 20 years is going to be able to run a "painless" marathon, I don't care what kind of orthotic you put under his feet. We sometimes assume we can cure everyone and somehow make them into a bionic man, we can't. There are age, physical and biomechanic limitations placed on us.

    This patient in question may very well have some pathomechanical problem that an orthotic may help with (somewhat), he may also have claudication or some type of mucinous degeneration of the achilles, a posterior compartment syndrome or an old peripheral nerve pathology manifesting with overuse or maybe just a gastroc-soleus complex unable to get him more than seven miles at a certain pace on a planet with gravity.

  26. Steve:

    Thanks for your reply and, after rereading my last post, I entirely agree with your analysis above. I have changed my posting to be more considerate of my Midwest podiatric colleagues. Sorry for being so insensitive. I apologize. I truly did not mean it that way.:drinks
    Last edited: Aug 1, 2009
  27. Davey

    Davey Member

    HI thanks again for all the reference points to read up on.

    I have just finished reading the tissue stress theory and it seems to make sense even though I have been constantly using the Root et al teaching I received at uni.

    Just to check if I am getting this theory right, by assessment of my patient would I be right in saying that as he has always pronated and had his forefoot equinus, it has been the increased exercise which has caused the increased tissue stress on the achilles and gastroc/soleal complex.

    If this is right then the treatment offered by Kevin using the 6mm heel raise makes perfect sense as this would decrease the load on the posterior aspect of the leg.

    After this would it be applicable to introduce strenghening of the anterior muscles of the leg and some manipulation of the posterior muscles to prevent reoccurance and hopefully remove the heel raises in time, or will the patient have to use the heel raises at all times.

    If I have got this wrong please feel free to point out my miscomings.

    Ian and Kevin thanks for all the references even though I have not read them all yet:drinks
  28. Davey

    Davey Member

    Sorry Simon thanks to you also, my head is spinning from all this new information I can't thimk straight:wacko:
  29. drsarbes

    drsarbes Well-Known Member

    Please let us know if your treatment enables this patient to run 26 miles with no achilles pain.
    There are so many threads here that ask for help but relatively few report back in these kinds of cases to let us know if the advice given has resulted in the success that the patient was looking for.

    Kevin: apology accepted ......but not really necessary.
    I've gotten to know you over the years through this arena and would never expect anything but the most professional, intelligent and forthright responses from you.

    Last edited: Aug 5, 2009
  30. Davey:

    Too bad your podiatry instructors did not train you in a more practical way of treating injuries.

    Tissue stress theory is actually such a simple concept, I often wonder why more podiatry schools don't teach it as the primary method of treating all types of musculoskeletal injuries in the foot and lower extremity and why they still insist on teaching subtalar joint neutral theory as the primary method of treating injuries. Go figure.:confused:

    In the tissue stress approach, there are three basic things you must do for each injured patient that presents in your office:

    1. Determine the exact anatomical structure that is injured.

    2. Determine the types of abnormal stress (i.e. tension, compression, shearing) that has caused the anatomical structure to become injured.

    3. Design a treatment plan that will: A) heal the injured anatomical structure, B) optimize gait function, and C) prevent further injuries from occurring.

    Now, in a runner with Achilles tendinitis, here is how I would proceed:

    1. Ask the runner where the injury is, how it started, what type of training they were doing when it started, etc.

    2. Examine the runner and make sure that the Achilles tendon is the only structure injured.

    3. Watch them walk, run (if not too sore), examine their shoes and check for basic foot alignment and flexibility in non-weightbearing and weightbearing exam.

    4. Design a treatment plan for them that will reduce the stress on the injured Achilles tendon, reduce the inflammation in the tendon and allow it to heal, without losing significant cardiovascular fitness:

    A. Give them 1/4" heel lifts bilaterally.
    B. Have them ice 20 minutes two times a day.
    C. Have them always walk in a shoe with a heel (i.e. no barefoot walking or walking in sandals or flip-flops).
    D. If they can't run without significant pain with heel lift, then do alternative exercises (e.g. bike riding, elliptical trainer, swimming, rowing machine, etc)
    E. Stretch gastrocnemius-soleus complex 3 times a day.
    F. See them back in the office every 2-3 weeks to follow up on them while they are recovering from their injury, gradually reducing their heel lift height as they start to show clinical improvement..

    This is not rocket science. Rather, the tissue stress approach is good medicine without all the nonsense that is currently taught in many podiatry schools as to how one should evaluate and treat patients with musculoskeletal injuries.
    Last edited: Aug 5, 2009
  31. Steve:

    I appreciate those individuals that point out my comments when they are inappropriate or insulting. I don't want to offend the good guys like you, Steve. I only want to offend and make uncomfortable a small number of select individuals who deserve such treatment.;):drinks
  32. Hi Davey all sound a good start to treatment, as to if you can take out the heel lifts time will tell, You maybe be able to reduce the height as the length of the posterior muscle increase but the patient body will tell you how far you can go, so tissue theory will guide you. If you dont know massage techniques a good sports masseur should be used for this type of patient as well.

    Michael Weber
  33. Kent

    Kent Active Member

    The only problem I see with this is that we haven't come up with a specific diagnosis. Not all Achilles pain is the same and not all Achilles pain can be treated with the tissue stress model. In fact, most of the research on Achilles tendinosis done over the last 10-12 years probably is the complete opposite of what the tissue stress model proposes. Alfredson and others have shown the beneficial effects of eccentric loading exercises which I find clinically to be far superior than adding heel raises for Achilles tendinosis. Of course, we don't know if Davey's patient has Achilles tendinosis or some other tendinopathy. So I think as well as identifying the anatomical structure involved, we need to attach a specific diagnosis.
  34. Davey

    Davey Member

    Hi Kent,

    I checked that paper mentioned and this seems like a sound treatment plan along with the heel raises in the acute phase, as this is what the paper recommends. I will issue this treatment plan soon and then review the patient in approx 4 weeks and post any results I find.

  35. Davey Can I suggest that you stop and think a little before you add some eccentric exercise to this patients treatment plan.

    You have stated that a FF equinus is present and that the pain occurs after 7 miles of running, this indicates overuse. Think about what a FF equinus is and how is changes the way the foot works.

    Most likely he is a forefoot striker, the heel will then plantarflex causing a pull on the triceps surea muscle group which overtime, say 7 miles will lead to the muscle overuse symptoms you discribed.

    So by loading up the muscle more the symptoms may increase.

    I also use eccentric training for achilles patients but think about the presentation of symptoms and why they occur first.

    Michael Weber
  36. Davey

    Davey Member

    Hi Michael I understand what you are saying although I am using the eccentric training from neutral and only getting the patient to lower slowly then return to neutral. I had the patient try this with bodyweight and he coped well. The patient is also going to be using ice during and after his training along with having sports massage.

    I have seen this patient running and he strikes on the medial aspect of his heel and it does seem to be an over use injury but with the eccentric training I am hoping to acheive a stretching and strengthening of the calf muscles, although time will tell if this was the besty option.

  37. I have seen this patient running and he strikes on the medial aspect of his heel and it does seem to be an over use injury but with the eccentric training I am hoping to acheive a stretching and strengthening of the calf muscles, although time will tell if this was the besty option.


    Really? On heel strike, in running gait, he hits the medial aspect of the heel?
  38. Atlas

    Atlas Well-Known Member

    Kent is right, in that the diagnostic stuff seems like an nth-order issue in this thread. A tendinopathy has a warm-up phenomenon associated with it; so I doubt it is this. For mine, I would think about a compartment pressure test if plans a & b didn't ease symptoms and increase mileage.

    It all comes down to assessment. I hope that you have cleared posterior impingement (including os trigonum) pathology.

    I think the eccentric stuff is grossly overrated though IMO.

    Kevin is right in that tissue stress should be placed the central teaching philosophy in podiatric training. And finally, it should be simple.

    Physiotherapist (Masters) & Podiatrist
  39. Kent

    Kent Active Member

    Just to clarify, I wasn't saying that this patient has a tendinopathy. My point was that Kevin's approach:

    does not include a specific diagnosis of the anatomical structure. That was the point I was trying to make. For example a paratendonitis will managed differently to a tendinosis which will be managed differently to a tear etc...

    Ron, care to elaborate on this?
  40. Atlas

    Atlas Well-Known Member

    I didn't think you suspected a tendinopathy from the start.

    As for eccentric stuff, the outcomes haven't matched the promised rhetoric in my clinical experience. Whether we go back to "Stanish & Curwin's program for achilles "tendinitis"'; eccentric work for lateral epycondylits/epicondylalgia aka tennis elbow; or even Jill Cook's patella tendon work....

    Similar experience to core stabilising IMO. We have swollowed it hook, line, sinker, rod and arm. Interesting retrospective study on all the core stabilising research 2-3 years ago. Big discrepancy between statistical and clinical significance.
    We have been salivating too much about the former IMO.

    Physiotherapist (Masters) & Podiatrist

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