Why do people get Achilles tendonitis and plantar fasciitis???
There are many factors that can contribute to Achilles tendonitis and plantar fasciitis. The number one factor is usually an overuse of the gastroc-soleus complex. The two muscles in your calf join together at the Achilles tendon in the back of the heel. When this structure gets overused, it can pull the heel bone (calcaneus) in a way that irritates the plantar fasciitis in addition to it just getting irritated right at the Achilles tendon.
The real question we ask as physical therapists is “Why Are You Using Your Calf So Much!?” Ironically, your calf being tight may be the immediate source of your pain but more often than not your pain is probably coming from a lack of strength or range of motion somewhere else entirely. I have found throughout my experience in physical therapy and taking two intensive courses on running injuries that there are two main places that can cause an overuse of your calf muscle: 1. Hip Extension Range Of Motion and 2. Great Toe Extension Range Of Motion
In the gait and running cycle, we have phases called “terminal stance” and “pre-swing,” which is when our toe just barely comes off the ground to take that next step forward. This particular position requires a certain range of motion at the hip and big toe. The hip should be able to achieve at least 10 degrees of extension and the big toe should be able to achieve at least 60 degrees (if walking) and up to 90 degrees (if running) of great toe extension.
If you take a look at this picture, you can see that the femur (thigh bone) is angled slightly behind a totally vertical line (imagine a straight line from the pelvis down to the ground) and that the big toe is starting to extend or bend as the foot/ankle rolls through. This position allows optimal contraction of our gluteus maximus muscle - the huge power generating muscle of the entire lower kinetic chain. When the range of motion is limited in the big toe, we cut the terminal stance and pre-swing phase of gait short. This means we get off of the foot more quickly and we don’t access the range of motion that allows the glute to work. Thus, we use something else - the CALF. The same principle applies with limited hip range of motion. If we can’t get our femurs to extend beyond neutral and into that 10 degrees of extension, the glute cannot properly fire so we again ask the calf to help with power more than we normally would. As luck would have it, when I have a patient come in with plantar fasciitis or Achilles tendonitis, they are usually lacking BOTH hip range of motion and toe range of motion - double whammy.
Can it be fixed?! YES! My approach to treating plantar fasciitis and Achilles tendonitis is to treat locally first. This means treating calf tightness to help with symptom management right away - massage, dry needling, stretching, etc. As the calf responds to treatment, we are able to shift gears to the actual origin of the injury. This usually includes manual therapy to the big toe or the hip to improve any limitations noted. Whilst improving the range of motion is a big component to improving the motor efficiency in your gait cycle, there needs to be accompanying functional exercises to promote muscle activation in the appropriate positions. This is where physical therapy can get really fun and creative using balance equipment, speed adjustments, plyometrics, and sport-specific exercises.
There is this concept we discuss in physical therapy where we describe being strong throughout the available range of motion. What this means is that even if we improve your flexibility and range of motion, you’re still at risk for injury if you don’t know how to CONTROL that new range of motion. But once you learn to do this, your risk of re-injury is significantly less - assuming you keep up with your homework!
This blog was meant to discuss the most common reasons plantar fasciitis and Achilles tendonitis may occur, but is certainly not all-inclusive. Overall, I want to remind all patients that the longer plantar fasciitis or Achilles tendonitis are bothering you, the longer it takes to heal. Don’t wait too long to get it checked out! Key identifying factors are sharp pain felt in the center of the heel, pain felt along the inside of the heel, pain in the arch of the foot, pain in your Achilles tendon, and pain with your first steps out of bed in the morning. If you feel like you have any of these nagging pains, let us know and we can get you started on your road to recovery!
Lisa Corken, PT, DPT
The importance of unilateral training for overall body strength
A question we often get as physical therapists is: “What’s the best way to protect my body when lifting weights?” Of course, there are several different ways to answer this question. This blog is going to emphasize my professional and personal approach on how to reduce risk of injury when you are lifting weights.
There are so many amazing different lifting techniques that are great for strength building. A few of the popular ones are deadlifts, snatch and cleans, front squats, back squats, pull-ups and bench press. These are more of your power moves that are great for strengthening, but often are performed incorrectly. Now, you may have every intention of performing the exercise perfectly, but your body just won’t cooperate. This is where I incorporate my approach to protecting your body.
We commonly see patients in the clinic who have a dominant side. This is totally normal! However, this can also lead to imbalances in your squat, deadlift, pull-up, etc. I use slow motion video technology to see if you are using one side more than the other and then address it with a more appropriate warm-up for these power moves. This usually involves a more unilateral approach to strengthening. Thus, I prescribe SINGLE LEG squats, SINGLE LEG deadlifts, and other challenges that will engage each side of your body prior to bigger lifts.
The reason that this ends up protecting the entire body is that it increases overall core activation. The big squat and deadlift are very bilateral motions where the majority of the force is going through the center of our body - the spine. While the spine is a very strong structure with complex ligamentous support, muscular stability, and discs - it still has its limits. Now, if we take your standard front squat with dumbbells as shown in the picture on the left you can see that the force is through the midline of your body. Most of my patients believe this to be ideal as they feel centered, but in fact it places more strain through the spine if not performed perfectly. If we compare it to the picture on the right where you are holding a dumbbell on just one side, this will create a sidebending force thus increasing more oblique and core activation to stop you from leaning or falling that way. This more rotational torque helps move the force from straight down your spine to now requiring that core control.
The same principle can be applied to upper body lifting as well. See below the difference between bilateral overhead military press compared to unilateral military press. If the man on the right didn’t engage his RIGHT obliques, that weight in his left hand would cause him to tip over!
Overall, these are just a few tips I like to educate my patients about when returning to bigger powerlifting or weight lifting. They are great ways to continue strengthening while promoting a healthier and stronger core. The purpose of this blog was meant to shed light on how unilateral vs bilateral forces on the spine can be manipulated to improve muscle activation in addition to adding a balance component for full body involvement. Ultimately, the best approach to a routine like this is to schedule an appointment with your physical therapist to have them evaluate your squat, bench press, deadlift, etc after which they can create an individualized program for your specific workout needs!
Lisa Corken, PT, DPT
Acromioclavicular Joint Separation
If you live on the Front Range of Colorado you probably know at least a few mountain bikers, if you are not one yourself. And if you talk to mountain bikers about their injuries you will start to see a trend: lots of collarbone injuries. Falling over the handlebars -- a right of passage among mountain bikers -- is a common culprit for collarbone injuries. The most common collarbone injury amongst mountain bikers is an AC joint separation.
AC joint separation occurs most commonly when a downward force is placed on the shoulder or upper arm, tractioning the arm from the body (including the clavicle). This occurs in biking with a crash onto the shoulder, or in football when a player takes a strong hit to the top of the shoulder. The joint at the end of the clavicle -- the acromioclavicular joint -- takes the most stress in this injury and the ligaments that hold the joint in place can tear.
Degree of Injury
AC joint separations are graded from I to VI depending on the type and severity of separation. In a Grade I sprain, the ligaments are minimally torn and normal activity can usually resume painfree within a few weeks. Grade II includes more ligament tearing and can result in a small bump deformity on the top of the shoulder, but usually heals within two months without functional deficit. Grade III sprains involve a complete tear of the ligaments and visible “step deformity” over the top of the shoulder. The “piano key sign” occurs with this grade of separation where you can push down on the raised collarbone and it will pop back up like a piano key. Grade III injuries can be treated surgically, especially if someone is concerned with their physical appearance, however, functional outcomes are roughly equal between those who undergo surgery or not. Grade IV-VI AC joint separations are rare, but more serious, and require surgery.
So what can you do if you separate your AC joint? In the short term you want to let it heal without injuring it again. Icing it is likely beneficial for at least the first week and taping over the joint with kinesiotape or a more rigid tape can help give a feeling of stability for a few months. Avoiding high contact sports until it’s completely healed will help prevent a worsening of the joint separation. As it starts to feel pain free, the strengthening phase begins. Because of the separation of the joint and tearing or stretching of ligaments, the shoulder joint will be inherently less stable; using muscular strength to support the AC joint becomes more important. Strengthening exercises include rotator cuff, shoulder blade, upper trap (top of shoulder), and chest strengthening to provide support all around the joint. A physical therapist can guide this strengthening phase over the course of a few weeks to a few months, depending on the severity of injury
As a rule of thumb, if there is a visible bump on the shoulder more than a quarter inch and/or pain lasting more than 2 weeks it is advised to get the injury evaluated by a physician or physical therapist to help grade the injury and guide recovery. If pain is severe or the separation is more than a half an inch then immediate medical attention is advised as surgical treatment for this injury, if needed, can be time sensitive.
What is a tendon
A tendon is a strong rope like structure that attaches a muscle to a bone. A common example of a tendon is the Achilles, which attaches your gastrocnemius and soleus muscles to your calcaneus or heel bone. Tendons are an essential part in allowing our bodies to move. They help transfer forces from our muscles (when contracted/tighten) to the bones they attach to, which leads to movement of that bone/body part. Often, they will attach from a large muscle such as your bicep to a small single point on a bone. Therefore, they must be made of strong material as they often undergo strong force transfers
(tendons are known to have one of the highest tensile strengths of any soft tissue in the body).
Anatomy of a Tendon
Tendons are made of dense fibrous connective tissue that is made up of mostly collagen fibers (structural proteins). These fibers are found in very tightly wound bundles throughout the tendon. This collagen and bundling make them very strong and resistant to tears. Another important aspect of tendon anatomy is that they do not receive as much blood as the muscles and bones that they attach to. This is because they have a lower density of blood vessels (reason for their white color). This is an important factor when it comes to tendon injuries. While tendons are strong and resistant to injury they do occur and can be classified into 4 categories: tendinitis, tendinosis, tendon tear and tendon rupture.
The medical definition of the suffix “itis” is inflammation, so the term tendinitis translates to
“inflammation of a tendon.” This is often more of an acute injury (short-term) and is associated with
swelling around the tendon and pain when that tendon is used (contracted by muscle). This
inflammation and pain is caused by micro-tears in the tendon that occur when there is a force applied
that is too heavy and or to sudden applied on that tendon. The treatment goal for tendinitis is to reduce
inflammation. This can be done in a number of ways, starting with RICE (rest, ice, compression, and
elevation), anti-inflammatory medications, and physical therapy techniques including soft tissue
mobilization. Recovery time varies between days-6 weeks.
This term refers to degeneration of a tendons collagen fibers often caused by chronic overuse (longer
periods of time). This degeneration of collagen fibers can lead to loss of fiber continuity, causing
decreased overall tendon strength. These are often seen when a tendon is injured and not given the
appropriate time to rest and recover. Because tendinosis is a chronic issue, there is no tendon
inflammation/swelling present, so the treatment goals are different. Primary treatment goals are to
inhibit the cycle of injury (or tendon overuse) and to optimize normal collagen production and
maturation so that the tendon regains normal tensile strength. To do this we must determine what is
causing the repetitive injury by looking at ergonomics, biomechanics, etc. Once this is determined we
can use support (braces, tape, etc.) to help reduce forces on the tendon and allow for appropriate
healing. Light stretching while minimizing pain is crucial to limit shortening of muscles and maintain
flexibility. Eccentric strengthening and loading the tissue without pain is essential to help with collagen
production and improve collagen alignment. Treatment time can vary from 6-10 weeks (if caught early)
all the way up to 3-6 months.
If you are having any tendon pain (most commonly in heel, elbow, shoulder, knee) please give us a call.
We can help evaluate this pain and determine the underlying cause then come up with a plan to get you
back on track!
A common question that I get from patients is, “Should I use ice or heat?” My immediate response is always, “It depends.” The debate of whether to use ice or heat depends on numerous factors, including the type of injury/ailment and the chronicity of the injury (i.e. time since injury onset). I will take this time to discuss the indications and contraindications for ice and heat, based on both the current research and my clinical expertise.