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Interesting forefoot runner with Achilles problems

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Foot Traffic, Sep 11, 2008.

  1. Foot Traffic

    Foot Traffic Member


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    Hi there,

    I just had an interesting client and wanted to get some ideas on best ways to manage her.

    Brief Hx - early 20yo female training for a 1/2 marathon. At 10yo she was put into a plaster cast on her left leg which plantar flexed her foot to treat an apparant Achilles Tendon problem (I suspect Sever's diease). Since being removed from the cast after 6 weeks she had continued to experience Tendoachilles and calf pain and tightness due to the contracture of the muscle whilst in cast. She is currently wearing a 'casual' Puma and not surprisingly having recurrent achilles problems during training for the race.

    Static WB analysis - Genu Recurvatum L > R She can't flex her knees due to the bilateral ankle equinus. calcanei inverted and her right leg is slightly behind her left as a compensation for the left leg deformity.

    NWBG analysis - passive ankle dorsiflexion nowhere close to 90 degrees bilaterally, however with active dorsiflexion her right is slightly better, other pedal joint ROM's unremarkable.

    gait - (If I knew how to insert the Silicon Coach footage I would, but a description is about the best you get) obviously she has a marked forefoot running gait inwhich there is absolutely no heel contact. The tension on the Achilles Tendons is clearly visible - and it looks very sore for her to run!! because there is basically no useful ankle dorsiflexion there is excessive flexion and adduction of the knees at midstance

    Treatment today - No more wearing the Casual Pumas for running, I have asked to to purchase the Nike Voomero which is a nicely cushioned shoe with a slightly higher heel pitch. Referred her to a local Sports Massage Therapist for her calves. Suggested she adds core/PGM strengthening to her gym programme and avoids concentric calf raises

    My thoughts for the future - I have told her to consider putting the half marathon on hold until we see how the Achilles responds to the new shoes. She will be back next week and I may even pop a 4mm heel raise into the left shoe to see if it settles her symptoms down. Personally I think this will settle relatively well as I race/train with a lot of forefoot runners with no problems, I just think she needed the guidance on the appropriate footwear, soft tissue work and stretching.

    I do welcome people's ideas on other ways they treat these types of athletes. It did get me wondering at what point is surgical intervention a potential modality - if at all? How would this affect her season coming up if she was to have surgery on releasing her calf slightly.

    Thanks in advance

    Rob Dallimore.

     
  2. Adrian Misseri

    Adrian Misseri Active Member

    G'Day Rob,

    I'd be suggesting a very aggressive massage and stretching program for the achillies/gastrocsoleal complex to try to get some more length out of it, however it sounds like it's been arround for such a long ime that the contracture may be more than can be stretched out. A pericutaneous lengthening procedure woudl have her back to training sooner, but you'd expect that any surgery (especially more invasive surgery such as a Z-lengthen) would have her off training for a considerable period. I'd also be looking at her tibialis posterior and peroneus longus and getting some stretches for them as well as strengthening the tibialis anterior.
    Good luck!
     
  3. Foot Traffic

    Foot Traffic Member

    Thanks Adrian,
    I agree that the stretching/massage avenue is the best option at this stage.
    I would have loved to have seen her prior to going into the cast to see how bad it actually was.

    Cheers,
    Rob.
     
  4. Griff

    Griff Moderator

    Hi Rob,

    Does she have a leg length discrepancy?

    Ian
     
  5. Rob:

    I agree that having this 20 y/o runner stop training temporarily for the half-marathon is reasonable since it is likely to get worse as the training intensifies. However, don't put in just one heel lift, use bilateral heel lifts to prevent gait asymmetry.

    On the first visit for a patient such as this I would recommend starting her wearing a 6 mm heel lift bilaterally, put her on three times a day gastrocnemius and soleus stretching exercises, have her avoid barefoot walking or walking in a shoe without some form of heel lift, and to take a week or two off of running and substitute bicycle riding, swimming or elliptical trainer for cardiovascular fitness.

    It would be a big mistake, in my mind, to do any Achilles tendon/gastroc/soleus surgery on this young of a patient. Many runners have tight Achilles tendons and train over 50-80 miles a week. Keep her away from surgery. It won't be necessary.

    Finally, in the 25 years I have been treating runners and in the 36 years I have been treating my own running injuries, there is a saying that I have developed that seems to resonate well with runners that are training for an upcoming marathon or 1/2 marathon: It is much to compete in your event uninjured but slightly out of shape, than to try and compete in your event injured and in great shape!
     
  6. Admin2

    Admin2 Administrator Staff Member

  7. Foot Traffic

    Foot Traffic Member

    When I viewed her in static stance and running I thought she may have but once lying prone there was no apparent LLD.

    Craig Payne may appreciate the fact that I assessed her gait prior to any other assessment. He mentioned it in one of his lecture series and I think it is a great way to take any subjectivity and preconceived ideas about what is happening.

    Cheers,
    Rob.
     
  8. Foot Traffic

    Foot Traffic Member

    Thanks Kevin,

    Thats a great line. I always tell my clients and the athletes I coach this and it is so true - I just wish I would heed my own advice.

    It still astounds me that someone training for a half marathon wouldn't actually think that the shoes she wears casually on the weekend wont necessarily be ok for a half marathon. It's like me lining up in the Monaco Grand Prix in my Holden Vectra!!
     
  9. Sorry, the quote should have read as follows:

    It is much better to compete in your event uninjured but slightly out of shape, than to try and compete in your event injured and in great shape!
     
  10. Beth Gill

    Beth Gill Member

    Quote:

    On the first visit for a patient such as this I would recommend starting her wearing a 6 mm heel lift bilaterally, put her on three times a day gastrocnemius and soleus stretching exercises, have her avoid barefoot walking or walking in a shoe without some form of heel lift, and to take a week or two off of running and substitute bicycle riding, swimming or elliptical trainer for cardiovascular fitness.
    Unquote.

    Hi Kevin,
    I'm just wondering if these exercises that involve a lot of plantarflexion against resistance (bicycle riding, swiming or elliptical trainer) would create any increase in calf tightness? Athletes who I see that do these sports tend to have really tight gastroc/soleus. But we still want to keep up cardiovascular fitness, so I know we need to continue some training. I'm cool with the rest of it, but when I tell people to swim and ride their bike, I wonder if I'll be making the calves even tighter. Non weight bearing is obviously preferable to weightbearing exercise here. Just a query, really.
    With great respect,
    Beth.
     
  11. Foot Traffic

    Foot Traffic Member

    FYI folks,

    New cushioned shoes with a higher heel:forefoot profile have helped a great deal - Don't try running a half marathon in a skate shoe.

    I fitted her today with bilateral heel lifts and she is onto the stretching regime.

    I will see her in a couple of weeks time and I expect a good result.

    Thanks for your help.

    Cheers,
    Rob.
     


  12. Beth:

    Good questions. First of all, it is thought that most tendon injuries are caused not by concentric contractions of the muscle (i.e. the muscle-tendon unit shortens when the muscle undergoes contractile activity), but rather tendon injuries are caused by eccentric muscular contractions (i.e. the muscle-tendon unit lengthens when the muscle undergoes contractile activity). In running, the Achilles tendon undergoes strong eccentric activity during the first half of the support phase whereas it undergoes concentric contraction during the latter half of support phase. Achilles tendon injury probably, therefore, occurs during early support phase in running, not during propulsion.

    In bicycling, the gastrocnemius-soleus-Achilles tendon (GSAT) complex has a strong concentric activity during the power phase whereas has weak eccentric activity during the recovery phase. In swimming, there is little load on the plantar foot so that very low loads would be experienced on the GSAT complex, except during starts and turns. In the elliptical trainer, there is slow loading of the GSAT with relatively limited ankle dorsiflexion that would tend to also produce low GSAT complex loads compared to running.

    Calf "tightness", which I would probably describe more as muscle tone, will occur in any activity where the muscle is actively contracting over long perods. Periodic stretching of muscles that are used frequently helps maintain proper muscle-tendon length that should help prevent injury. So it is good to see muscles that are strong and have good tone, but not good to have muscle-tendon units that are too short to allow the full range of motion that is necessary to allow optimum kinematics for that specific athletic/sports activity. Regular exercise will help keep the muscles strong and stretching combined along with exercise will prevent the shortening of the muscles that may occur without routine stretching.

    I have no problems having injured runners cross-train in swimming, cycling or elliptical trainer. Have them continue to stretch daily while doing these cross-training activities and no increase in muscle shortness will occur. These are time-tested methods that have produced very favorable results for thousands upon thousands of runners. I wouldn' worry about these alternative exercise suggestions to your patients for their rehabilitation from running injuries.

    Hope this helps.
     
  13. Rob:

    Thanks for the followup. Glad to see that you expect good results. I'm sure you are on your way to making another runner very happy. This is the way you will build up a very good sports injury practice. Please let us know how your patient progresses.

    Those were the days.................23 years old and legs with spring still left in them........
     
  14. sjc

    sjc Welcome New Poster

    I get great results from acupuncture with achillies trouble.
    Also for the long distance running - silicon heel lifts seem to be well appreciated.
     
  15. Foot Traffic

    Foot Traffic Member

    Nice pic Kevin. What are the tyres you are running on there? Looks like the Brooks Kona Coast or similar generation racing flat.

    I always wanted a pair of those but all I could afford were a pair of Lazer Lydiard Kiwi Flyers! My how things have changed - I am now running in the new Midfoot Strike New Balance 800 and wouldnt look back!!
     

    Attached Files:


  16. Honestly, that was 28 years ago and I don't remember which shoes I'm wearing or even which race I'm running. However, that was just after the time I was racing in Nike Elite's, which were my favorite cross-country/racing flat at the time.
     
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