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Calcaneal Apophysitis - Eccentric Achilles Loading

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Bridge the Gap, Mar 5, 2019.

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    Hi all,

    I understand there is no research but I have been sampling clients with Calc Apophysitis and prescribing Eccentric loading exercises, 1x30 reps, and findings that this is resulting in approximately 80% resolve in symptoms. The last 20% is normal only related to their specific loading patterns which is easily managed.

    My though process was that if they were an fully developed adult would they and they had the exposed soft tissue loading would they possibly be presenting to me with an Achilles Tendinopathy??
    I have assumed the apophysis been a fibro/non fused joint is the weak point that then the tendon in this case?

    I am not aware of any research but am very curious to what peoples thoughts are?

    The be clear I have used this for about 12 months and had no sinister or complications but rather all my present clients have had significant pain reduction and have continued their normal level of sport?

  2. Craig Payne

    Craig Payne Moderator

    As you said, no evidence.
    The only problem with the approach is distilling out if doing it is better than the natural history. Calcaneal Apophysitis tends to improve and come right over time, so does the intervention do better than that.
  3. Craig,

    That is a very valid point. I must say I feel it has has improved acute symptoms in these clients.

    I guess it is something we need to do more testing on.

    Keen to see if anyone is willing to give it a run and see what outcomes they got.

    I must note I do use manual therapies like dry needling, IASTM and taping techniques in conjunction at the initial consult but normally give them 2 weeks to settle into a routine with the exercises. I feel confident it is helping as the other therapies would but all indications only have a short term benefit.

    I rarely use heel raises since I began seeing success with the conditioning exercise.
  4. Bug

    Bug Well-Known Member

    I'm wondering if we have evidence supporting something working, and it's cheap and easy, why continue to reinvent the wheel with new protocols that are potentially more labour intensive for the patient and involves more monitoring and visits?

    As a clinician (with an added disclosure of being a researcher who has contributed to the evidence in the field and changed my practice because my prefered treatment was shown to be as effective but more expensive than heel lifts), this is a condition we know effects kids quality of life. I've not seen a typically developing kid yet who had strength deficits unless it was particularly related to excelling in a sport. Parents are busy, kids hate exercises, why bother.
  5. mmmmm.....

    I have actually found a very good compliance and the parents have noted in most cases they are not having to chase the kids.

    In regards to the strength deficits, I completely agree that its not a matter poor strength but I rather think of the dysfunction that can result from injury and the pain cycle and the possibly of improving collagen and the ability of the Tendon to manage load using isometric and eccentric loading. So many questions.

    As mentioned, just clinical experience and my way of thinking. I appreciate the feedback. I will go and do some digging I think.
  6. Craig Payne

    Craig Payne Moderator

    I not disagreeing that its an intervention that is worth pursuing; its just that due to the natural history of this, it is so hard to tease out treatment effects vs natural history.

    Just this morning I seen a case of calcaneal apophysitis that I first seen last week - she came in with her mother limping last week - the mother was here for the appt and the daughter came in as she could not go to school from the pain in her heel. I was to busy to do anything with the daughter at her mothers appt other than a quick chat and come in and see me next week ... well they came in this AM and there was a 70-80% improvement in symptoms since last week and I did nothing - it was all natural history. If I had used any intervention last week (even if it was crap), that intervention would have been given the credit for fixing her ..... therein is the problem.

    I have gotten hate mail from parents for comments I have made about Oscon for calcaneal apophysitis - there is no mechanism by which is could work and despite it being widely touted for so long, there is no clinical trial that shows it works any better than a placebo or natural history .... yet look at the extraordinary number of testimonials for it.... 1000's of them

    Despite teaching about calcaneal apophysitis for so many yrs, I never learnt as much about it until both my daughters had it. I did every thing right; nothing seemed to help ... the problem was I could not control nor stop them running around chasing and playing with friends during the school lunch break, despite my pleading with them to not do it and rest (I know they did it as they are twins and relish telling tales on the other) ... I just gave up in the end and they both eventually came right of their own .... natural history.

    None of that means they should not be treated as it hurts; we just need to treat them with interventions that have been shown to do better than a placebo to account for that natural history and natural variation in pain levels.

    Having said that, a load program as you describe is intriguing and probably worth looking at. Intriguing if loading can "strengthen" the "apophysis"
    Last edited by a moderator: Mar 7, 2019
  7. That is really interesting about both your daughters Craig. Thanks for sharing.
    Please do not get me wrong I have taken all the feedback as constructive.

    I do think it would be interesting to see a few sizable case studies on this but I guess the nature of the "pathology" will create variables.

    I am confident that it has improved quality of outcomes fro the clients.

    As for strengthening the apophysis I am not sure, but improving Achilles conditioning I feel it must be having some affect.
  8. NewsBot

    NewsBot The Admin that posts the news.

    Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol
    Shawn L Hanlon et al
    BMJ Open Sport Exerc Med. 2022 Sep 7;8(3)

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