The View from Sports Center

Lower Leg (Peroneal) Tendonosis: Part II

In my last post, I covered the Five Keys to Solving Lower Leg (Peroneal) Tendonosis and I mentioned at the end of that article that I would describe a few drills.

Just as a reminder, the drill selection is driven by at least three things: the nature of the injury (tissue or tissues involved), the severity and irritability or what we refer to as the "stage", and the mechanics of the involved structures. In Chuck's case, the tissue is the peroneus longus and brevis, the stage is unknown, and the mechanics are deceleration of the lower leg over the foot in a weight bearing position.

For someone who has symptoms either at rest or very quickly with activity, one of the drills we might choose would be a bilateral squat with a less than body weight load. We prefer to use a Total Gym to reduce the bodyweight force.

After testing to find out the appropriate level, the client would perform 3-5 minutes of squats with a focus on pressing the ball of the foot into the footplate. This puts the dosage close to 100 reps per set. The peroneus longus plantarflexes and everts the foot which you can create by simply applying force into the base of the first metatarsal (ball of the foot). Although the foot doesn't move, you'll increase the tension in those muscles from just trying. Near the end of the set, you should feel a mild degree of fatigue and pain or discomfort.

A progression would be to move to a sidelying position and place the foot on a foam pad to create an inverted position (or supinated). Now, as Mike squats, he tries to pronate the foot by pressing the ball of the foot into the foam pad. This increases the load on the peroneus longus and brevis.

For less irritable or severe cases, we might choose a split squat with a lateral vector. The vector or line of force  pulls the leg away from the midline of the body (which is why we call it a lateral vector). In the picture, you can see that at rest, Mike's leg has been pulled out and even rotated out a bit. His job during the drill was to press the great toe into the floor and keep the lower leg straight which he did. And, his comment was that he could feel the muscles on the outside of his leg working fairly hard.

The dosage for this drill is lower than the bilateral squat since the load is higher. It's still fairly high, from muscle training standards, at 20 to 30 repetitions per set. And, we want both a moderate degree of fatigue and pain at the end of the set(s).

The difficult part of this process is finding the right mix of load and reps and pain. We often have to coach clients that all pain is not bad. Some pain is actually good for you as in the case of tendonosis.

But, since all pain is emotional, you have to be careful in applying this concept to your self or someone else. It's just a lot easier to have a coach - not necessarily right there with you all the time -  but someone who can help you interpret what you're doing and feeling.

DK

Thanks to our physical therapy student intern, Mike Coller, from the University of Wisconsin, for helping me with this post by generously serving as a subject and asking some great questions.

Five Keys to Solving Lower Leg (Peroneal) Tendonosis

Hi Doug...

I was introduced to your practice and subsequently your blog(s) by a local (Austin) Neurologist whom you treated successfully. You receive our praise in absentia at our annual Fall Rocky Mountain hunting trips which involve hiking over rough terrain (as opposed to TX style hunting blinds). I use your advice remotely from Montana to treat various arthritic joints and keep my 62 year old decrepit body active. I have studied your therapy recommendations for tendonosis of of various tendons but have been unable to infer from those a treatment for my disabling peroneal tendonosis (it makes me want to scream while sidehilling or walking on rocks....bad for hunting). I know that it is a somewhat rare diagnosis but I would appreciate a blog dedicated to this diagnosis and its treatment.

Thanks,

Chuck

P.S. I haven't tried downhill skiing yet...it will be interesting to see if the rigid boots stabilize the ankle enough to minimize the pain.

---

Thanks for your note Chuck and your question. Here are my thoughts on your situation.

1. The more irritable the condition, the lower the load and the higher the volume you'll need. If your leg hurts quickly and takes a while to subside, days for example, you'll need low loads and high volume of reps to alter the tension capacity of the tendon. You have to sneak up on it and nudge it into a healthier state. The rep range is around 100 reps / set with low levels of fatigue and very mild discomfort. If you can hike for a hour or two and the symptoms subside within a few hours, then you can use a higher load and lower volume - around 30 reps per set with moderate fatigue and discomfort.
2. Move your body over a stable, fixed foot. The peroneus longus muscle likes to restrain motion of the leg and provide stability to the arch of the foot rather than produce motion even though the classical definition of the muscle action is to produce eversion (moving the foot sideways) and plantarflexion (pointing the foot). This is because anatomists define muscle action as creating motion from the insertion of the muscle toward the origin. The peroneus longus inserts on the bottom the foot near the first metatarsal. So, if you  flip the action around so the motion is from the origin to the insertion, the tibia moves back and down. When your foot is on the ground, the muscle is pulling back on the tibia to keep it from moving to quickly over your foot. This is, as you noted, the time when you're apt to feel the symptoms - when your foot is on the ground and you're decelerating your center of gravity as in walking down hill sideways or over uneven surfaces like rocks. Once your leg tolerates a stable surface, you can then advance to unstable surface training.
3. Train to pain. You have to train hard enough that you produce some symptoms and this is where it's often tough to do alone. What's too much? What's not enough? Well, the intensity is too much when you compromise your motion and it's too little if you don't hurt at all. You want the symptoms to show up near the end of each set. And, ideally you want motions that produce the symptoms in real life. You use the very thing that bothers you to heal you but you control the load.
4. Train the hip. Your hip external rotators counter the pull of gravity and the collapse of the leg toward the ground when doing things like walking, climbing and hiking . The stronger your hips are the more they will help the peroneal muscles do their job. 
5. Poke and Prod. Sometimes, I'll use a manual technique to induce an inflammatory reaction. The technique itself is probably less important than the intensity and duration of it. Tendonosis is a condition of tissue weakness. If you can create a mild inflammatory reaction (and this is what some of the drills do as well), you will jump start the production of collagen which is what the tissue needs. Rolfing, Deep Tissue Massage, certain forms of Myofascial Release, and Graston Technique all can create an inflammatory reaction (This is also the framework for Prolotherapy, an invasive technique used to promote soft tissue healing.) You'll need a professional to help you with this though.

As for snow skiing, the boots will help but your foot still works inside the boot as you carve in the snow to turn one way or the other. So depending on how irritable your tissues are, you may still hurt a fair amount.

Last thing specifically for you Chuck. If you have arthritic joints, such as a knee or hip, you'll want to recondition those joints so you get as much help as possible for your foot / ankle. Sometimes one area of the body ends up working too hard because the arthritic joints dial down the muscle power of the muscles around the effected joint (s). This is called arthrogenic inhibition. So, in the knee for example, you can lose some strength in the quadriceps, hamstrings, and even the gastrocnemius. The gasctrocnemius is a direct synergist for the peroneus longus meaning it helps it do its job.

Next time, I'll go over some drills for this condition.

Do You Have Any Suggestions for My Plantarfasciitis?

Below is an email I received from a reader about plantarfasciitis. My answer follows her email.

Hello Doug,

I came across you site and you have the best information I have seen ever!  I have chronic plantar faciitis  and am trying to find a physical therapist or Dr. that uses a newton speed trainer as I read in your previous articles.  I am currently in the process of searching for affordable crutches, the TED sock (found it at Walmart), and ordering the night splint.  I can only stay on my feet without pain in the morning for a few hours then its downward from there.  I went to the site you had suggested on your site to search for a physical therapist but do not know what or whom I am looking for.  Do you have any suggestions for someone in my area?  I have no insurance but have saved money to pay for this.  Your answer will be greatly appreciated.

Thank you for your time,

Kate (not her actual name) -

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Thank you for your note and question Kate.

Unfortunately, I don't know of anyone with a Newton in your area but you should search for a therapist who is board certified in orthopedic physical therapy.

The Newton is only one of the components to overcoming something like plantarfasciitis.
Sometimes you can use a pool and walk in chest deep water to reduce the force on the tissue and then use that as one of the drills to increase the loading capacity of the foot.

Most musculoskeletal problems, like plantarfasciitis, break down into three main components: tissue injury (or disease), biomechanical faults, and mental/emotional attitude and reactions.

For the tissue injury in plantarfasciitis, we've had success by reducing the force on the foot in everyday activity while at the same time using specific exercises to increase the tissue's force capacity. To reduce the force during the day, I've referred a number of people for a pair of Z-Coils. Almost everyone has immediate relief. But, this is not intended as a long term solution. You'll still want to recondition the tissue in your foot and gradually get out of the shoes.

Some people also have restrictions or tightness in the fascial network that connects to the plantar ligament specifically the gastrocnemius (calf) and hamstring. Fascia is plastic but not elastic. So, you can alter the relative length but it's not easy to do and of course it's not supposed to be easy otherwise your muscle system would have inadequate support. There are a number of techniques practitioners use to facilitate change in the fascia such as Rolfing, Myofascial Release, and other forms of manual therapy. I would get someone to assess your flexibility and help sort out if you have biomechanical faults in the lower leg or hip that might be contributing to the overload in the foot.

And, finally, the choices you make each day have a large role to play in what happens with your body. I've had clients with, for example, a tibial stress fracture who simply refuse to stop running even though the leg is very painful and, as a result, interferes with other parts of their life. You have to listen to your body and respect it. After all, your body is you.

Plantar Fasciitis: When a Pain in the Foot is a Pain in the Butt

Heel pain and pain on the bottom of the foot, often referred to as Plantar Fasciitis, is a common ailment (I've written about this before - click here for more info). And, it sometimes can be very difficult to get rid of. One of our readers sums up the problem quite well: 

"I've been experiencing heel pain for at least 10 years on and off. I've had physical therapy, with electro wave treatment, cortisone shots which helped for about two months and then the pain returns. I have been diagnosed with plantar fasciitis being the problem but I'm grasping for straws with this pain. I use custom made orthotics and several store bought orthotics and I find that it helps a little bit. However, the pain still continues and in the morning its obvious the worst. Please, help/direct what I can do next. I desperately want my full mobility back. I think my lower back is now compensating. Please advise."

Signed,
Audrey

Audrey's story is a common one: chronic heel and foot pain seemingly unresponsive to a bombardment of treatments. Early in my career, when I chased symptoms as fast and as furiously as my clients did, I tried almost as many things to alleviate the symptoms of plantar fasciitis as there are letters in the alphabet : massage, ultrasound, iontophoresis, heel cord stretching, toe stretching, orthotics, taping, positional release, active release, myofascial release, strain-counter strain, strengthening exercises, heel cushions, heel wedges, soft shoes, hard shoes. Some of these things seemed to help some people some of the time for a while. But, what I wanted was the same thing my clients wanted: an answer, not a temporary fix.

The problem with plantar fasciitis, at its most fundamental level, is that the body, specifically the foot, is unable to withstand the forces of everyday life. Walking creates too much physical force on the foot and the result is pain. Healthy plantar fascia has substantial tensile strength. In fact, walking uses less than 50% of the plantar fascia strength so, you have plenty of reserve. But, once the tissue has been injured, the strength drops and so does the reserve. So, the questions are, "How do I change my body's ability to withstand force? How do I improve it? How do I get the strength back in my foot?"

The answer is something referred to as tissue remodeling. The tissues of the body (e.g. bone, ligament, or tendon) respond to the stress applied to them. Too much stress, too fast, for too long, and tissues get weaker. Too little stress, too slowly, for too long, and tissues get weaker.  Tissues need just the right amount of stress for the right amount of time. When this happens, the tissue adapts and becomes stronger.

To find the right amount of force that your foot can tolerate, you somehow must reduce the effect of gravity. You could try walking in a pool; in chest deep water. The buoyancy of the water reduces your body weight and the force on your foot. In most cases, people with plantar fasciitis feel much better when walking in water.

But, your body needs a little more stress from week to week to get stronger. At some point, your foot will be ready to take a little more force but the buoyancy of the water doesn't change. No transformation without perturbation.

To simulate the buoyancy of water on land, but give us more precise control of the force, we use a special machine, the Newton. The Newton reduces the effect of gravity (makes you weigh less) while you walk or run on a treadmill. What we want to know is, "How much force can you place on your foot and walk without hurting?" Once we know the force your foot can tolerate, you can exercise on the Newton safely, stimulate a strengthening response in your injured tissues, and have a very good chance of recovery. From one week to the next, you'll know how much improvement has occurred. Your force level will change.

Here's how it works. Let's assume you weigh 150 lbs. and your foot hurts when you walk. But, in the Newton, we discover that if you weigh 100 lbs., you can walk completely pain free. The first few sessions, you walk on a treadmill while weighing 100 lbs. Outside the training sessions, you  control the force on your foot during the day (this is where insoles, inserts, heel lifts, heel cups, a cane or a crutch have a role to play. These tools help reduce the force that is transferred into your foot. The decision about which thing to use depends on how much force your foot can tolerate. Some may need a crutch while others need only an insole). Then, we increase the weight to 110lbs. No problems. You exercise at 110 lbs. Then, 120 lbs. Then, 130 lbs.  Get the idea? A gradual step-wise progression back to full body weight.

You can certainly try other things to help you manage the discomfort of plantar fasciitis but, bottom line, your foot has to somehow get stronger. The only way tissues become stronger is from the appropriate amount of exercise. Use it or lose it.

A pain in the foot does not have to be a pain in the butt.

Doug Kelsey

 

If You Have Plantar Fasciitis, READ THIS!

"How can I help you?"

"You can fix my foot."

"What's wrong with your foot?"

"I think I have Plantar Fasciitis. It hurts near the heel and when I get up in the morning, my foot hurts a lot when it hits the floor. When I run, it hurts some too but after I finish, I have a lot of foot pain."

"How do you know you have Plantar Fasciitis?"

"Well, that's what I've been told and I kind of came to that conclusion too. From the research I did, it seems like it to me."

"So, tell me what you think it is. Plantar Fasciitis. What is it?"

"I think its when your heel gets inflamed or the tissue or stuff on the bottom of your foot is inflamed. Right?

"How long have you had this?"

"Well, let's see. I guess about two years or so."

"What have you done for your foot pain thus far?"

"I stretch it and do another stretch for my heel cord. I use ice when it's bad and take Advil. Seems to help some. Have had some massage. Tried some acupuncture too."

"Are you getting any better?"

"A little I guess. But, I still hurt a lot when I run."

"Have you tried not running?"

"Yeah. I did. But, really, I didn't notice much difference so I figured I might as well run."

"Beyond the massage and acupuncture, have you seen anyone else? Received any other type of treatment?"

"Nah. What for? Everybody says basically the same thing. Stop running, stretch, ice, try a heel lift, take these pills. I don't know. I feel like I'm just wasting my money really. No one seems to have a solution that makes sense. I've wasted a lot of time and money."

I have had that type of conversation with people, many, many times. Plantar Fasciitis is one of the most difficult foot injuries to beat. And, I believe I know why.

Have you ever been to a movie with someone and walked out saying, "Wow, what a great story!" Great movies always have great stories. The best stories are ones that keep us guessing but at the end, bring everything to a conclusion leaving you feeling good. Satisfied.

When you hear "sprained ankle", what comes to mind? Perhaps turning your foot over, landing funny on your foot, occurs with basketball frequently, swelling, ice, crutches, some type of brace? Something will be tumbling around in your head. That's because we use the phrase "sprained ankle" to define a story. An ankle sprain has a predictable story. In over 85% of ankle sprains, you injure the ligament on the outside (lateral) of your ankle. If you know the story, you will be less anxious about the injury because you know what you injured, how you injured it, what makes the injury worse, what makes it better and anything else that may be associated with it.

But, people with plantar fasciitis rarely know the story and most of what they do know is wrong. The reason Plantar Fasciitis is hard to beat is because they don't know the true story. The story they know goes something like this:

"Well, Jim, you have Plantar Fasciitis. That's inflammation of the tissue on your foot and heel and you hurt because it's inflamed. So, you'll need to stretch your foot and ankle to keep the tissue from tightening up, put ice on your foot to keep the swelling down. I'm going to write you a prescription for some medicine to bring down the inflammation. We'll get you some inserts, too. That usually helps. Now, you'll probably hurt for a while but be patient. Of course, you should stop running. Eventually, you'll get better. "

That's it.

Jim may decide to get more information on his own perhaps using the Internet but the story is the same: tissue is inflamed, stretch, ice, heel lift, inserts, etc. In fact, read what Emedicine.com has to say about Plantar Fasciitis:

"Considered a chronic inflammatory syndrome rather than a post-traumatic disorder, plantar fasciitis is common in runners and dancers who use repetitive, maximal plantarflexion of the ankle and dorsiflexion of the metatarsophalangeal joints. It is common in those who experience sudden weight gain and in overweight individuals who increase their activity level."

The biggest problem is the name "Plantar Fasciitis". What if I told you, that instead of Plantar Fasciitis, you have a torn ligament in your foot? Yikes. Torn? Are you serious? I have a torn ligament in my foot? Yep. You do because that is what happens in the misnamed and poorly told story of Plantar Fasciitis. You have torn the plantar ligament in your foot. Suddenly, it seems a bit worse somehow. Doesn't it?

The correct term or name for the story, to be consistent with other body areas (have you ever heard of a Lateral Ankle Fasciitis for an ankle sprain or a Medial Collateral Fasciitis for a Medial Collateral Ligament Sprain?), is a Plantar Ligament Sprain. A sprain is a tear in a ligament. And, as with all sprains, it is either a Grade I, II, or III. Grade I is mild, Grade II moderate and Grade III severe.

Now that we know it is a sprain, what should you do? Well, what do you do with an ankle sprain? Do you stretch an ankle sprain? Never. Do you use crutches? Yes, if you cannot walk without a limp. Do you wrap the ankle creating a graduated compression from toes to calf? Yes. Do you consult a professional for advice and rehab to prevent further injury? Yes. Do you run on a sprained ankle? Not if you're smart. Do you gradually put more weight on your foot and ankle respecting what you feel and how your foot and ankle responds? Yes.

A sprained Plantar Ligament story is not much different from an Ankle Sprain story. But, for many reasons, the Plantar Ligament Sprain has managed to become one of the worst stories in health care. Practitioners are taught the story in school or on a clinical rotation (as I was). They're told about the characteristics of Plantar Fasciitis (heel pain, hurts first thing in the morning when the foot hits the floor, starts usually from overuse), and the treatment which is largely symptom based (ice, stretch, NSAIDs, heel lifts, inserts, massage). So, practitioners learn the story, recognize it in their patients and follow the suggestions to bring the story to a conclusion. Unfortunately, just like a bad movie, this story leaves you feeling dissatisfied.

A better, more satisfying Plantar Ligament Sprain story would go something like this:

"Well, Jim, you have a Plantar Ligament Sprain. This is a tough tissue on the bottom of your foot. A sprain is a tear of this tissue and from your history and examination, I suspect it is a Grade II, which is a moderate type of tear. Right now, your ligament is inflamed which means that the tissue is very sensitive to load and motion. Inflammation is a normal healing response and there are some things you can do to help.  Ligament sprains heal the best when you keep the tissue at its ideal length, keep the area compressed with a graduated compression garment, and gradually increase the load placed on your foot. When you sleep at night, you may need a special sock or brace to keep your ligament from healing in a shortened position since your foot will tend to fall into a relaxed position allowing the ligament to shorten. You may need some additional padding in your shoes to help absorb the load. And, you will need to use crutches, probably for the next 2-3 weeks or until you feel like you can walk normally and have very little discomfort.

What will make this sprain worse and potentially turn into a chronic problem is if you place too much load on your foot too fast. This can cause your tissue to stay inflamed and become gradually weaker and weaker. So, for now, use the crutches, the special sock at night, wear the compression garment. As your tissue heals, you will have less pain and stiffness. We have other exercises for you later, but for now, we need to help your body work its way through the inflammation. Control the load, move your foot a little, and use the crutches."

This story makes sense and, it is consistent with other "Sprain" stories. If you have an ankle sprain, the first phase of recovery will sound very similar to the above. Can you see how something simple, like a Plantar Ligament Sprain, becomes a complicated and complex problem later? Because it is not viewed as a tear, the tissue is easily and rapidly overloaded leading to a chronic, low grade inflammatory state resulting in weaker and more easily damaged tissue. All because of a bad story.

Success with "Plantar Fasciitis" starts with first understanding the nature of the problem and having the correct story. From this, you will make good choices, help your body heal and go back into an active and fun life.

Get your story straight first.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

P.S. If you are a clinician who works with injured athletes and would like to learn how we work with disc and joint disease in the spine, join us for our first professional seminar in 2005 entitled "The Spine: Diagnosis and Treatment of Lumbar Degenerative Disc and Joint Disease". Come to our training facility in Austin on April 28th-29th, 2005 for this cutting edge seminar for physical therapists and athletic trainers who want simple, powerful solutions for their active clients. Learn proven examination techniques and specific drills for back pain that you can execute with confidence on Monday morning. Seating is very limited and already filling. Call Angie Francis at 512-206-0433 to sign up today.

Weighing in on Terrell Owens' Injury

ESPN radio called the other day to talk about Terrell Owens' ankle injury. They wanted to know if he would make it back in time for the Super Bowl. The 6'3", 225 lb, All Pro, wide receiver for the Philadelphia Eagles suffered a nasty injury on December 19, 2004 in which he sustained a severe sprain of his ankle's deltoid ligament and a fracture of his fibula. Team physicians and trainers determined that surgery was necessary, so he went under the knife on December 22, 2004. Terrell had two metal screws (and a plate), called syndesmosis screws, drilled into the end of his fibula and tibia to stabilize the joint (see the image below for an example of syndesmosis screws).

The question is not whether will he play, but rather should he play?

His surgeon, one of the foremost experts in foot and ankle surgery, Mark Meyerson, MD, will not clear Terrell to play. I agree. The Super Bowl is February 6, 2005, just over six weeks from surgery. Bone needs at least six weeks to heal. And, the price of rushing his rehab is steep. No one thus far has discussed this: delayed union of the bone, chronic instability, early arthritis, or re-fracture to name a few. Any one of these will end his career.

If Terrell is on the field for the Super Bowl, he is not playing football. He is playing Russian roulette with his career.

Doug Kelsey
Author. Teacher. Therapist.

When Can I Run Again

Harry opened his front door and felt the cool morning air on his face. The sun was just coming up creating a soft glow in the distance. He was anxious to get started. Harry loved to run and it had been a very long time since he injured his heel cord. He stopped running altogether for several months. It seemed as if the pain and stiffness would be a permanent fixture in his life but finally he felt ready. He waited not only until the pain had gone away but an extra two months just to be sure. Today he would run. Run for his health, to lose weight and run for fun.

He did not know he was smiling as he walked down the street and began a slow jog. He was surprised. His muscles felt tight. He moved as if he needed oil in his joints. He could hear the air rush in and out of his lungs. But he was running. Then he noticed a faint but familiar sensation. The heel cord was talking again. He ignored it. "Nah, I'm just not warmed up. It'll go away," he thought.

But it did not go away. The message grew in intensity as if the heel cord was shouting "Hey, are you listening to me? I do not like this at all! And if you keep it up, I am going to just shut down the whole system!"

Harry was listening though. He slowed his jog to a walk and turned around to go home. What had started out as such a gloriously bright day turned gloomy and hazy. "When will I ever be able to run?" thought Harry.

Tendinosis lurked silently in Harry's heel cord only to come out to wreak havoc when he tried to run. Tendinosis is the body's attempt at repairing weakened and damaged collagen. The result for Harry is a weak, flimsy tendon incapable of withstanding the physical demand of running. It operates in stealth mode only revealing its true nature with physical exertion.

What can be done about tendinosis? From recent scientific studies, it appears the repair is influenced by mechanical load.

A group from the University of North Carolina has demonstrated a relationship between tendon healing and eccentric exercise. The mechanical load produced by eccentric exercise appears to promote DNA and collagen production (Banes AJ, Hu P, Xiao H, et al. Tendon cells of the epitenon and internal tendon compartment communicate mechanical signals through gap junctions and respond differentially to mechanical load and growth factors. In: Gordon SL, Blair SJ, Fine LJ, ed. Repetitive motion disorders of the upper extremity. Rosemount: American Academy of Orthopedic Surgeons, 1995: 231-245.). Harry thought by resting his ailing heel cord he was healing it. Instead, the prolonged inactivity left him pain free but weak.

What should Harry have done? At SportsCenter, the first step in our rebuilding program for Achilles Tendinosis is to find Harry's pain free threshold to rise up onto his toes. This motion will load the Achilles Tendon. We use a Variable Incline Plane (VIP) such as a Total Gym for the test. Each angle of the VIP is a specific percentage of body weight. By raising or lowering the VIP, we increase or decrease the physical force applied to the tendon. Harry rises onto his toes then lowers the heel slowly down. We adjust the load until we find the amount of force which produces pain. We then lower the force a few pounds to locate his pain free threshold. We now know exactly how much physical load Harry can withstand.

Harry's training requires both eccentric loads to stimulate collagen production and high volume repetitions to stimulate the sluggish tendon metabolism. For eccentric loads, we generally use 20-30 repetitions, 2-3 sets per drill. Higher volume training includes lower physical loads with 100-200 repetitions per set, 2-3 sets per drill. By the end of the session, Harry should have a low level of pain. The pain indicates the training has stressed the tendon (no transformation without perturbation). The pain will subside within 24-36 hours. He trains 2-3 sessions per week.

Every two weeks, we test Harry's pain free threshold and adjust his training accordingly. After 2-3 months, Harry should be close to a full body weight force but in some cases the time frame can be as long as a year (dependent upon severity, chronicity and initial pain free threshold). But, to run he needs above body weight force capability. The forces created while running are 4-6 times body weight. To help Harry shorten the rebuilding time, maintain and improve his cardiovascular fitness and give him a glimpse of what is possible, we use a Newton Speed Trainer.

Healing tendon requires physical loading. While stretching, massage, ice and other measures relieve the discomfort, only one thing changes the physical capacity of tendon: controlled loading. Now that you know how to heal the chronic Achilles Tendinosis, can you think of how to apply the same idea to perhaps a rotator cuff tendinosis? Or how about patellar tendinosis? Just remember, tendon is tendon regardless of where it is in the body. Once you know the fundamentals of the healing stimulus, you will be well prepared.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

The Snake

Frank loves to run. He’s been running for many years and sometime last year discovered an area of discomfort near the bottom of his leg, right at the Achilles tendon. Frank did what most normal males do. He ignored it. But one day he rolled out of bed, placed his foot on the floor and stood up. The tendon felt like it was made of concrete and the pain was hot, searing and extreme. He sat down immediately and took a breath. “Maybe I’m dreaming,” he thought. Then he stood and realized he was very much awake.

Frank hobbled around for a few weeks and to his surprise the pain went away. So he started running again. First slowly with short periods of running then gradually increasing his time. He thought he was over the problem until he noticed some tightness and a little pain. This continued until his wife couldn’t tolerate the moaning and frequent complaining any longer. Upon the verbal pummeling and persistent urging of his wife (some of us might call it nagging), he came to see me.

It seems Frank has no clue why his symptoms returned. He believes his return to running was slow, reasonable and well planned. He did not suddenly increase the intensity or the volume of running. He is quite perplexed.

At 55 years of age Frank is in excellent health and has remarkable flexibility, strength and balance. About the only unusual configuration is a slightly pronated left foot he has had for many years. Now I am nearly as perplexed as Frank.

“Frank, the only thing so far I have found that could be related to your problem is your pronated left foot. But considering you have been pronated for many years and have run for many years and from what you describe, have resumed running in a very reasonable way, I am wondering how have you managed this pronation in the past?” I asked.

“I know. I wear shoes to correct it – Asics. They have really good pronation control and I’ve never had any trouble,” replied Frank.

“I see.” I was wondering if perhaps Frank had changed his shoes to some other brand recently although surely he would have mentioned it. My wife Ellen has a great expression she uses when you are looking for something that is right in front of you. She yells “SNAKE!” as if you are about to get a nasty bite. I happened to glance around the room and tucked back way under the chair were two additional pairs of running shoes sitting innocently begging me to ask them a question. I thought “SNAKE!” to myself. So I decided to ask the question this way. “Frank, when was the last time you changed running shoe brands?”

Frank replied quickly, “Well, I changed to Reebok a while ago. They were a lot cheaper but I don’t think it’s related to my problem.”

“Why is that?” I asked.

The tone of Frank’s voice sharpened and the volume went up a few notches like I had hit a nerve. “Well…..shoes are shoes aren’t they? What difference do they make?” said Frank.

“Right. You seem a little bit angry here. Am I sensing that correctly? Are you upset?” I asked.

Frank sighed deeply. Then he said, “When I bought those shoes I wondered if it was a smart thing to do. But they were so much less money and my leg felt fine. I guess I’m a little mad at myself for being so stupid.”

“You know Frank, I think stupid is when you do something twice when you know you shouldn’t. Doing it the first time is just a bad choice – not stupid. Now, those shoes on the floor – are those yours?” I asked

“Yeah, they are. I thought you might want to see them. I don’t know why I didn’t bring it up sooner,” said Frank.

“Let’s look at them,” I said as I picked up the left shoe of each brand and set them on the table. Frank suddenly exclaimed, “Whoa – I can’t believe how different these shoes are. Look at how far in the heel leans on the Reebok. They can’t be good.”

Frank was right. The Reebok shoe leaned inward at the heel 26 degrees while the Asics was a steady 0 degrees.

“Frank – I think we found one of the sources of your problem. Go back to the Asics and follow my running program and you should be fine. You body should adapt once your rearfoot is under control. The Reebok shoe permitted too much pronation. The excessive pronation increases the strain on the tendon. I think once you correct the position, the strain levels will match the tissue capacity and the symptoms will go away,” I explained.

This story has several learning points for me. First, it’s a good example of the subtle interplay between physical loads, biologic tissue health and biomechanics. When the physical loads exceed tissue capacity, symptoms often follow. Interventions can be focused on tissue health, reduction of physical force, altering biomechanics or all three. Second, is the concept of the pivot. The pivot in this story occurs when I ask Frank when he had last changed shoe brands and then followed with an observation of what I perceived to be anger. By reflecting back to him what I sensed I gave him room to vent his own frustration and get the real issue out for discussion. Together we were able to converge the facts into a resolving storyline and diffuse Frank’s festering self-directed anger.

Sometimes the solution and pivot are right in front of you. Look for the SNAKE.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

The Heart of the Issue

Sara's mother stood tensely concerned as her daughter came off the tennis court. "Honey, are you hurt? You're limping?" "I'm fine, Mom. Really. I ran too hard is all."

The ten year old was determined to play at Tennis Nationals in six weeks. "It will go away. I'll be fine," she told herself as she subconsciously rubbed her left heel cord. She vividly remembered the moment it happened. Two days ago rushing from one side of the court to the other, Sara tripped and felt her left foot stick suddenly on the court causing her body to lunge forward. After rapidly stretching her heel cord beyond capacity, she had a nagging feeling something was wrong and it was getting worse.

Even after another week she couldn't run, walking hurt, and her left heel cord was very sore, swollen and even warm to the touch. Sara and her mother both wondered what was wrong and what to do. The tournament was just over a month away.

After another week of unresolved symptoms, Sara ended up in my office. She seemed older than her ten years. She explained to me what happened and then asked:

1. What's wrong with my leg?
2. Why does it hurt?
3. What do I do?
4. Will I be able to play in the tournament?

The simplicity of her questions was penetrating. She went to the heart of the issue in a matter of seconds. Unlike adults who might feel the need to be careful with their questions or hesitate, children just say it. And, they know when you don't know. I discovered from Sara that answering her four questions is what every client wants. Simple but not easy.

Sara had achilles tendinitis which is caused by too much physical load. Exposure to too much force too quickly or for too long causes damage to the tendon sheath. The ensuing pain, swelling, warmth and dysfunction are all hallmarks of inflammation. The warmth comes from an increase in blood as small blood vessels dilate. The exudation of plasma and leukocytes from the leaky microvessels into the small space between the cells causes the swelling. The pain is from excitation of sensory nerve endings caused by mechanical compression from swelling and by chemical irritants released from the cells such as prostaglandin and bradykinin.

Many people think of tendon strength in physical terms as if an injured tendon is "torn" much the same way you tear a piece of paper. While this makes the injury easy to visualize, it is not exactly correct. A tendon is held together by a chemical bond referred to as a "cross link". The number and strength of these bonds determines the tensile force capacity of your tendon. As the oxygen levels within the tendon drop, the number and strength of the cross links drops as well resulting in a weakened tendon. Think of the cross links as a twisted rope. Twisting a rope increases its tensile strength. Collagen creates its strength as the cross links twist in much the same way. A weakened rope is often frayed and an injured, weakened tendon looks very similar.

If you follow certain rules, tendinitis is a short term condition lasting no more than three to four weeks in most cases. Stop the offending activity, start low load intermittent motion and protect the area from excessive force. Gradually increase load and motion week by week. The problem is most people fail to follow these rules. The result is a prolonged inflammatory cycle, weakening of the tendon and chronic symptoms.

For every client, think about Sara's four questions. When you answer each one clearly and concisely, your client list will grow, problems will be few and your days will be fun.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

Lost In Space

"I think I tore something, " groaned the middle aged man named Jim lying on the floor grasping his right ankle. "Oh, man it hurts. I don't think I can walk."

A minute earlier he was running the basketball court when he tripped over one of his teammates twisting his right ankle. This was not the first time Jim had sprained his ankle but it was definitely the worst. Two of his friends helped him to his feet. He dangled the right foot off the ground and gingerly set it down. He tried to step on his leg but a nauseating wave of pain galloped up his leg. He couldn't walk. Carried on the arms of his friends, Jim hopped off the court.

His friends took him to the ER just in case he had broken something. He could no longer see his ankle and his foot was fat. A bluish hue was creeping over the outer part of his ankle and foot. "This can't be good," he thought.

The doctor X-rayed his foot. No broken bones but he would have to use crutches for a couple of weeks. The ER tech wrapped his foot and ankle in an elastic bandage, gave him a pair of crutches and said, "Use these for about two weeks or so and keep your foot elevated. You'll be fine after that," and left the room.

Three months later, Jim was not fine. While he could walk, sort of, he could not run, jump or cut. His ankle hurt. All he could do on a basketball court was shoot free throws. He had been back to his family doctor a couple of times but always heard the same brief advice, "Wait. You'll get better. You just have to wait."

Jim had been diligently following the instructions issued by his doctor. He stretched his ankle several times a day and "spelled the alphabet" with his foot in the air. He strapped an elastic band to his foot and pulled his foot up, down and to the side trying to strengthen it. He tried to jog every few days but was met with the same frustrating response. He began to wonder if he would ever run again.

Jim's problem, a sprain of the outer or lateral ligament complex of the ankle, is the most common injury in sports comprising approximately 20% of all sports injuries. A ligament sprain is a stretch injury of the ligament. Since ligaments are generally inflexible and tend to resist stretching, a sprain is really a tearing of the ligament. The question is how badly is it torn. Ligament sprains are subdivided into three classes: Grade 1, Grade 2 and Grade 3. Each grade represents an increasing amount of damage with Grade 3 being a complete rupture of the ligament.

Chronic ankle instability often follows a Grade 2 or Grade 3 injury. Instability refers to the inability of the body to maintain control of the joint. All joints of the body move around an axis of rotation. When the axis remains relatively fixed, motion appears smooth, graceful and is pain free. When the axis drifts or slides, as in the case of an instable ankle, normal movements hurt (Imagine the wheel of your car as it turns. The center of the wheel is the axis of rotation. When the wheel is "out of alignment", the ride is rough. When the wheel is balanced, the motion is smooth).

Jim cannot make his ankle do what it should no matter how hard he tries. His ankle is controlled by regions of the brain not under his conscious control mainly the motor cortex and the cerebellum. His treatments, moving his foot around spelling the alphabet, stretching and using an elastic band, are all voluntary motions. He can do those. What he cannot do requires subconscious control.

Joints possess something very cool called Joint Position Sense (JPS). Tiny sensors in the joint relay information to the brain about where the joint is in space. The brain then coordinates an orchestra of output firing muscles at the appropriate time. Brilliant. This is how you can walk and not constantly stub your foot. Your foot only needs 5 mm of clearance from the floor. Your JPS does the job for you. Imagine how difficult it would be if with every step you had to think about how much to pull up your foot to clear the floor. I suspect you would not walk very much. Too much work.

People with chronic ankle instability (CAI), have ankles that are lost in space*. The ankle joint sends information but it is incorrect. So, the brain, using the data to develop the motor plan, sends the sequence of muscle contractions, which of course are incorrect too. The result is delayed contractions, slip sliding of the axis and pain.

To retrain the JPS, you have to train on your foot. Something as simple as standing on one leg (which you should be able to do for 30 seconds without arms flailing and body teetering). If you cannot stand on one leg with control, how will you ever control something as dynamic as running?

Our approach with clients with CAI is this:
1. Master balancing drills with the goal of 30 seconds on one leg.
a. single leg, no additional perturbation, no other movements
b. single leg, with perturbation such as an unstable base of support
c. single leg with perturbation and with other limb movements such as playing catch or light saber fighting with a PVC pipe
2. Jump, run, hop at loads which are not painful but are challenging and difficult to perform (see the View "When Can I Run Again" for details on tools and tests).

For Jim to run, play basketball and enjoy life again, he must retrain his JPS. Sitting down, stretching and spelling the alphabet might be a good start (well, I never have understood stretching something that is torn so strike the stretching), but eventually Jim must train himself by doing the very things he cannot do. He can only do that by adjusting the load due to gravity. When he weighs less, everything is easier and his body learns faster. He will no longer be lost in space.

Make today count.

Doug Kelsey

Reference: *Konradsen L. Factors Contributing to Chronic Ankle Instability: Kinesthesia and Joint Position Sense J Athl Train, Dec 2002, 37(4) p381-385.