How I Beat My Chronic Achilles Tendinopathy: Eccentric Strength Training

Discussion in 'Health & Fitness' started by ChicagoJack, Oct 14, 2006.

  1. ChicagoJack

    ChicagoJack Hall of Fame

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    1. I made a promise, if ever returned to the game of tennis, I would also return to the tt board to share how I did it. 3 months ago, at the low point of my 14 month struggle, playing tennis seemed a remote possibility. I was then 8 weeks post surgery from a knee operation that left my cracked and chipped patella smooth as a baby’s bottom, but the kneecap wandering off on its own accord, apparently unaware of the muscle tissue I was laboriously rebuilding around it, via the utilization of torture devices known as balance mats, surgical tubing, physio balls, leg press machines, standing hip machines, and free weights. The examination MRI’s of my lower back have never failed to instantly change the mood of any room. You might not understand what a grade 2.5 spondylolesthesis at L4/5 means, but let’s just say it doesn’t take a trained eye to see there’s a problem from a quick glance at a set of films. My Achilles problem, a triple scoop sundae of tendinitis, bursitis, and a partial tear, was stubbornly defying all attempts at repair. I’d started experiencing pain in my achilles early last summer, and by september had made the decision that perhaps the way to beat all my injuries was to quit tennis, in order to focus on my physical therapy full time. This was an easy decision to make, as my lower back was sending sciatic pain to both legs, my left knee was killing me, and now my right achilles was out of commission. I would have limped around but didn’t have any good side to lean on. After 14 months of battling this bevy of injuries I’m back to my usual routine of practice matches 2-3 times mid week, then playing competitive matches with team matches on the weekends. How I manage my back and knee issues are topics best saved for another post.


    2. The information provided is not intended as substitute for medical guidance or diagnosis. I wish to share what was effective for me, and for those who wish to learn more on the topic, a few quotes and links. While it is irresponsible for even qualified medical professionals to attempt diagnosis without direct physical examination, standard medical text is replete with the the practice of citing individual case histories to illustrate symptoms, progression and possible course of treatment. It is in that spirit, in that context, that I present my case history.


    3. How my Initial Symptoms Appeared, and Progression: Pain in the area at back of heel, from as low as .5 inch from the ground when standing to as high as 3.5 inches from ground when standing. Center of pain is mostly at the small pea sized point where the achilles arcs over heel bone and bursa at 2.5” up. Pain occasionally radiates around heel area to sides of heel at about 1 inch up and 2 inches towards front of foot. Pain at this specific location would suggest classic insertional achilles tenditinitis, tendinosis, or retrocalcaneal bursitis. Pain initially began as mild morning tenderness that would dissipate as day progresses. First occurrence was the morning after a 4 day tennis camp, which passed on its own after a few days. Second occurrence was a few months later, occured the day after 5 straight days of intense practice sessions followed by two days of multi-match tournament play. Pain began to appear with more increasing regularity over the course of the next 3 months to the point where I was sore during, and after every time I played, still most intense in the morning. Sought treatment when symptoms grew to a point where normal everyday activities were producing symptoms.


    4. Initial Diagnosis, timeline of my unsuccessful traditional physical therapy, followed by very effective eccentric training: Achilles Tendinitis, Retrocalaneal Bursitis, and Partial inter-tissue tear of Achilles Tendon. This was the conclusion of two orthopedic surgeons, and a 3rd opinion from the best sports doc in the city of Chicago. I am a 45 year old male, 6ft 0”and 158 lbs. I have been a multi-sport athlete my entire life, participating heavily and consistently in judo, cycling, volleyball, and tennis. Lower back issues narrowed my focus to tennis exclusively and have been playing 3-5 times per week for last 8 years.

    My initial diagnosis was singular as achilles tendinitis. On the second week of my professionally guided physical therapy I quit tennis entirely, and the next 8 weeks of guided physical therapy proved ineffective. At this point I got an MRI which revealed a partial tear, and bursitis. I was then instructed to wear a walking boot/plastic and velcro cast from shin to toe for 6 weeks. After removal of cast, walking was very difficult for the next few weeks, and I lost faith at that point. 10 weeks of excercise did not work, 6 weeks of immobility did not work. Shortly thereafter I had surgery performed on my opposite knee, and of course post surgical physical therapy was required. I declined all PT directed at my achilles, [I’d lost faith ]and focused on getting my knee working right for the next 6 weeks.

    During that time period, when I was doing nothing but icing and resting my achilles, the pain diminished significantly. I could not run or even lightly jog, I’d get symptoms if I tried to hit against a backboard for longer than 5 minutes, but the pain was minimally present with my normal daily activities. I decided this was a golden moment, and could now proceede into physical therapy again, but I did not trust anything I had tried before. I wanted a fresh approach.

    After weeks of research, I came across the university hospital of umea sweden study which involves eccentric calf muscle training for the treatment of achilles tendinosis. The test group was small, but the results were impressive. Interestingly enough, I was already working eccentricly with my knee rehab, per my sports doc/surgeons direction. My sports doc is the team physician for the Chicago Black hawks Hockey team, and has worked with the USA volleyball team. He’s big on eccentric PT, his endorsement of the concept was good enough for me. I showed the Umea study to my physical therapist and he gave me the thumbs up to proceede on my own. In The Umea sweden study, all 15 in the study group were able to return to running at the end of 12 weeks. I was able to return to light hitting for half an hour at 6 weeks, 1 hour at week 7, then twice per week by week 12.


    5. I’m currently back on the court, playing practice matches 2-3 times per week for 1.5 hours each, then competitive team matches every weekend. It’s not a complete victory by any means. I still do the calf strengthening and lateral stability excercises, 3 days per week. For now this is the right balance of PT, tennis and rest. If I start to flare up again, I rest for a few days, reduce the court time for the next few weeks, and replace those days with building strength up. In this time period of successful PT I also discovered an anti-inflammatory that does not irritate my stomach, celebrex. I used 400-600 mg per day for the first week or so of doing the swedish routine, currently all that is needed is 100-200 mg per day, and some days is not needed at all. I’m not home free, but I am effectively managing it. I’m committed to making my achilles-calf complex into a rock of gibraltar where chance of injury is extremely low, and to that end my work has only begun.


    6. I wish to thank the following kind hearted persons who have gave me advice in my moments of confusion, hope in my moments of despair. I could not have done this without you. NobadMojo, Marius, Chess9, Phil, Ronaldo, Blabit, KevinT, Jonolau, Vamazona, Chrisd, Scotus, Physioam, TennisLady.


    Best regards
    -Jack
     
    #1
  2. ChicagoJack

    ChicagoJack Hall of Fame

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    Quotes & Links Part 1

    Here is the clinical abstract of the 1998 University Hospital of Sweden Study which suggests that a 12 week program heavy load, eccentric calf muscle training is superior to conventional treatment, i,e., rest, anti-inflammatory drugs, changes of shoes or orthosis, and traditional physical therapy, in the treatment of chronic achilles tendinosis. The 30 patient study was quite small, but the results were impressive.
    "We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 ± 7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional non surgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the non injured side. After the 12-week training period, all 15 patients were back at their pre injury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the non injured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, non steroidal anti-inflammatory drugs, changes of shoes or orthosis, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties." [1][2]

    [1] Heavy Load Eccentric Calf Muscle Training For The Treatment of Chronic Achilles Tendinosis
    Hakan Alfredson, Md, Tom Pietla, RPT, Per Jonsson, RPT and Lonny Lorentzon, MD Phd
    Sports Medicine Unit, Department of Orthopedic Surgery, University of Northern Sweeden, Umea, Sweeden
    American Journal of Sports Medicine
    http://ajs.sagepub.com/cgi/content/abstract/26/3/360

    [2] National Center for Biotechnology Information
    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=9617396



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    A letter to editor of the American Family Physician, describing the effectiveness of eccentric calf muscle training. " The result of the study was that all members of the treatment group were running pain-free in three months, and none of the patients in the "conservative therapy" group had regained full function. Although the treatment group was small (15 patients), the results were compelling. These results are supported by similar studies of eccentric calf training. Heavy-load eccentric calf muscle training appears to be an effective, safe, and reasonable treatment of a difficult chronic condition. The patient population I serve here at the Womack Army Medical Center at Fort Bragg, N.C., is an active one, and Achilles tendinosis is a common complaint. My experience with using this technique of calf muscle training in the treatment of chronic Achilles tendinosis has been that it is effective and superior to conservative measures. One of the greatest values of this treatment is that people can continue to run during therapy. " [3]

    [3] Sean Mulvaney, M.D.
    Womack Army Medical Center Fort Bragg, NC
    American Family Physician, March 1, 2003, Letters to the editor
    Link Updated 2012:
    http://www.aafp.org/afp/2003/0301/p939.html

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    Photo examples, a word of caution, and specific instructions for performing eccentric calf strength training. This article is written primarily for readership within the medical community: " Eccentric exercises have the potential to cause damage if performed inappropriately or excessively. The exercises should be preceded by an adequate warm-up and stretch and commenced cautiously. The patient should expect pain when beginning the strengthening program, and at each new load. The patient should only progress to the next exercise when the previous activity is pain-free during and following the activity.[4]

     "The standard exercise used in the rehabilitation of Achilles tendon injuries is the heel drop. Heel lowering requires an eccentric (muscle lengthening) contraction. The patient should perform this heel drop exercise with both the knee extended (to strengthen gastrocnemius) and flexed (to strengthen soleus) Here is an example of exercise progression.” [4]

    [4] Clinical Sports Medicine
    Chapter 28, Pain in the Achilles Region
    http://www.clinicalsportsmedicine.com/chapters/28d.htm




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    An overview of eccentric calf muscle training, and specific instructions regarding technique. Written primarily for readership of those who are currently experiencing achilles pain: " The heavy-load eccentric calf-muscle training proceeded as follows: athletes stood on a step, with the front edge of the step touching the soles of the athletes' shoes about one-third of the way from the toes to the heel (so that the heels were basically hovering in mid-air). Body position was upright, legs were straight, and all body weight was supported by the forefeet. The athletes then used their good calf muscle (the one not associated with a hurting Achilles) to lift the body upward and plantar flex the ankles, bringing the heels upward while the forefeet remained in contact with the step. Then, the healthy leg and foot were removed from contact with the step, and as the unhealthy leg remained straight the patient slowly lowered the heel of the unsound leg to below the level of the step, eccentrically loading the calf muscle attached to the throbbing Achilles tendon. That constituted one rep! Speed of movement (the velocity with which the heel moved downward) was kept slow throughout the overall training period. Three sets of 15 straight-leg reps were conducted per workout, and there were also three sets of 15 reps performed with the unhealthy leg bent at the knee, to activate a deep-calf muscle called the soleus (when the leg is straight, the well-known gastrocnemius is forced to bear most of the load). These straight-leg and bent-leg series of sets, which really didn't take long to carry out, were performed twice a day, seven days a week, for a total of 12 weeks."[5]



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    A discussion of the importance of lateral stability. I began incorporating these exercises on the 6th week of the Swedish eccentric program. "While the Swedes' eccentric routines worked remarkably well, they're actually not the best exercises for the Achilles tendons. As you're probably aware, they work the Achilles eccentrically - but in only one plane of motion - the sagittal plane of straight-forward, straight-backward motion. That's not bad, but the truth is that the Achilles tendons and calf muscles must move and work in three planes, the sagittal, frontal (side-to-side), and transverse (rotational) planes during running. If they are weak in any one of these planes, injury can result. We can confidently make that statement because the ankles don't work in a squeaky clean, straight-front, straight-back manner when you run. When your ankle pronates during the stance phase of the gait cycle, as almost all ankles do, the foot rolls inward, moving the Achilles in a frontal plane (from side to side) and also producing a rotational movement of the Achilles (again, try this in slow motion to see for yourself). As the ankle supinates, the Achilles again is stressed in both frontal and transverse (rotational) planes, in addition to the well-recognized sagittal plane."[6]

    [5][6] "Achilles Tendonitis Treatment - How can Tendinitis Be Prevented - Or Cured once it develops?"
    By Owen Anderson, Sports Injury Bulletin
    http://www.sportsinjurybulletin.com/...tendonitis.htm

    -Jack
     
    Last edited: Jun 28, 2012
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  3. ChicagoJack

    ChicagoJack Hall of Fame

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    Quotes & Links Part 2

    Achilles tendonitis treatment - two research programmes for rehabilitating Achilles tendon injuries: “One well-designed study led by Jean McCrory at Wake Forest University, North Carolina, involved an in-depth examination of a group of runners suffering from chronic Achilles tendonitis compared to a group of symptom-free runners. McCrory’s team compared anatomy, flexibility, strength and the degree of rear foot motion and contact forces during running. The two significant differences between the two groups were: the strength of ankle dorsiflexors and plantarflexors (as measured on an isokinetic dynamometer); and the amount of pronation. The runners suffering from Achilles problems were weaker and had greater pronation. All the other factors were not significantly different between the groups. From these results, McCrory concluded that strengthening exercises and orthotics to control the degree of rear foot pronation would be the priority treatments for athletes suffering from Achilles tendonitis.Lack of strength in the calf muscles (to which the Achilles tendon attaches) may mean insufficient control of the ankle when the foot makes contact with the ground. When you run, the calf muscles are most active during the first half of the contact phase, when they are absorbing the impact with the ground. At this point the calf muscles are working eccentrically to control the forward motion of the lower leg. When a muscle works eccentrically, both the muscle and its tendon are lengthening. The anterior tibialis muscle (responsible for dorsiflexion and inversion of the foot) is also active during the contact phase, working eccentrically to control the degree of pronation that occurs.”[7]
    [7] http://www.sportsinjurybulletin.com/archive/achilles-tendonitis-1.html



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    “As your reduced exercise schedule allows your tattered tendon to heal, you eventually give yourself the green light to return to training gradually. But, of course, there's one major problem: all of your rest and therapy have merely returned you to the activity which caused your Achilles problem in the first place. In essence, you're back to square one - ready to re-injure your Achilles. Since you haven't identified exactly what caused your Achilles to flare up in the first place, you're bound to repeat your previous patterns. And that lousy old Achilles is likely to get red-hot again very soon. How do you get around this paradox? How do you make sure that all of your careful rest and therapy, the activities which were supposed to solve your Achilles problems, have not now merely brought you back to injury's doorstep? Well, to keep your Achilles tendon from acting up again, you have to identify what caused it to run amok in the first place. You must acknowledge that your Achilles-calf complex simply was too weak - too dilapidated to stand up to the forces being placed on it by your training programme. The solution could be to train a lot less. After all, that Achilles of yours doesn't feel much stress when your feet are propped up on a cushion in front of the telly. But you don't want that. You don't want your training programme to be as weak as your Achilles; you'd like your Achilles to be as tough as your training programme. In fact, you want to make your Achilles strong enough to stand up to whatever it is you're training for - the rigours of intense football practice, the preparation for a marathon, regular participation in squash matches, or competition on the track.Icing won't transform your Achilles into a tougher tendon. Anti-inflammatories won't help the Achilles deal more effectively with the high impacts, twists, and turns of training. Ultrasound isn't the panacea, nor are cortisone or hydrotherapy. Yet all of those interventions are prescribed as the 'cure' for Achilles agony. The truth is that they are merely temporary palliatives; what you really need is a nostrum that will make your Achilles tendons so fortress-like that they won't bother you again - even when you undertake very intensive training.” [8]

    “So, what do you really need? Exercises that force the calves and Achilles to work eccentrically and in concert with the other key muscles of the legs in a manner specific to running, of course! Designed by our strength expert, Walt Reynolds, C.S.C.S., these exertions mimic what actually happens to your Achilles and calves when you run - and will eventually make those tissues so tough and steely that injury will be a very, very remote possibility.... You'll also be glad to know that you need just four achilles tendon exercises, not a full battery of drills and exertions. These fine four will take you just a few minutes each day, a small time investment considering the benefits to your overall athletic performance. The first exercise is called the Eccentric Knee Squat... [continued] “ [8]

    [8] Achilles Heel Pain: These exercises can turn your Achilles heel into a rock of Gibraltar
    Peak Performance Online
    http://www.pponline.co.uk/encyc/0125b.htm

    Note: I did the swedish eccentric heel drop program 3 - 7 days per week, for 6 weeks. By the the sixth week the swedish eccentric heel drops routine was becoming less challenging. Rather than add hand held weights to increase the work load, I began to incorporate the Walt Reynolds eccentric training into my routine. I still do both routines, 3 days per week.



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    One theory regarding how and why eccentric training works. Follow up study using ultrasound to measure tendon structure suggests that eccentric training “remodels” damaged achilles tendon tissue. “Researchers used ultrasound to examine changes in tendon thickness and structure in 25 patients, average age 50 years, with painful chronic Achilles tendonitis. The patients underwent ultrasound before and after undergoing a 12-week regimen of eccentric training, which involves exercises to lengthen the calf muscle as it contracts... continued “ It would seem that the eccentric training induced remodeling of the injured tendon,” said study author Lars Öhberg, M.D., from Umea University in Umea, Sweden. Dr. Öhberg pointed out that areas with tendinosis contain high concentrations of glycosaminoglycans, which make up much of the body's connective tissue. The training may have helped normalize the concentrations of glycosaminoglycans, resulting in decreased tendon thickness, according to Dr. Öhberg.” [9][10]

    [9]“Ultrasound Shows Strengthening Exercises Relieve Achilles Pain”
    By Laurie Volkin and Richard S. Dargan, ASRT Contributing Writers
    American Society Of Radiologic Technologists, March 23, 2004
    http://www.asrt.org/content/News/IndustryNewsBriefs/Sono/Ultrasound040323.aspx

    [10] British Journal of Sports Medicine
    http://bjsm.bmjjournals.com/cgi/content/abstract/38/1/8




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    Another theory why eccentric training works. Btw, this whole chapter is down loadable in pdf form with the link provided, is packed with information, but written for intended readership within medical community. This is the most in-depth, detailed and complete source of information that I have found on the subject in 14 months of searching. “How do heel-drops reduce pain in tendinopathy? There are several possible explanations for the eff ectiveness of heel-drops but none have yet been proven. Heel-drops have an immediate and long-term influence on tendon. In the short term, a single bout of exercise increases tendon volume and signal on MRI.28. Heel-drops affect type 1 collagen production and, in the absence of ongoing insult, may increase tendon volume over the longer term. Thus, heel-drops may increase tensile strength in the tendon over time. Repetitive loading and a lengthening of the muscle–tendon unit may therefore improve the capacity of the musculotendinous unit to effectively absorb load.” [11]

    [11] Clinical Sports Medicine, Chapter 32
    Brunker and Khan, McGraw-Hill Australia, 2006
    http://www.clinicalsportsmedicine.c...arch=" research eccentric achilles sedentary"



    -Jack
     
    #3
  4. ChicagoJack

    ChicagoJack Hall of Fame

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    Quotes & Links, Part 3

    Tendinitis: “The suffix "itis" means inflammation. The term tendinitis should be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation. (Tendinitis is often misspelled as tendonitis, but the preferred spelling used in most of the medical literature is tendinitis.)” [12]

    Tendinosis: “The suffix "osis" implies a pathology of chronic degeneration without inflammation. Doctors prefer the term tendinosis for the kind of chronic tendon injuries that most of us have. The main problem for someone with tendinosis is failed healing, not inflammation; tendinosis is an accumulation over time of microscopic injuries that don't heal properly. Although inflammation can be involved in the initial stages of the injury, it is the inability of the tendon to heal that perpetuates the pain and disability. Most of the pain associated with tendinosis probably comes not from inflammation but from other irritating biochemical substances associated with the injury. “[12]

    Tendinopathy: “The suffix "opathy" implies no specific type of pathology, so the term tendinopathy is more general than either tendinitis (inflammation) or tendinosis (failed healing). The term tendinopathy just means tendon injury, without specifying the type of injury. “ [12]

    Paratenonitis (peritendinitis, tenosynovitis, tenovaginitis): “These terms all refer to injuries of the outer layers of tendons. Tendons are enclosed in a connective tissue covering called the epitenon, which contains the vascular, lymphatic, and nerve supply. The epitenon is surrounded by another connective tissue covering called the paratenon, which in some tendons is lined by synovial cells. The paratenon and epitenon together are called the peritendon. Paratenonitis is inflammation and degeneration of the outer layer of the tendon, the paratenon, regardless of whether the paratenon is lined by synovium. Paratenonitis is a general term that is now preferred to the older terms peritendinitis, tenosynovitis, and tenovaginitis. De Quervain's syndrome is one example of paratenonitis. Tendinosis and paratenonitis can occur separately or together (that is, you can have both degeneration of the tendon itself, tendinosis, and degeneration/inflammation of the tendon sheath, paratenonitis).” [12]
    -- Tendinosis.org
    [12] http://www.tendinosis.org/



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    Insertional Achilles Tendonitis: "Insertional Achilles tendonitis is a separate condition occurring at the tendon/bone interface. It occurs more frequently among older athletes in their 50s and 60s, and these patients tend to be overweight.Often, but not always, you’ll find this condition is associated with a retrocalcaneal bursitis, superficial bursitis and a Haglund’s deformity. The bony prominence predisposes the anterior aspect of tendon to irritation and is even more likely to occur in the cavus foot. It is thought that the combination of chronic overuse with the retrocalcaneal bursitis and bony impingement creates a chronic inflammatory response with chemical degradation and mechanical abrasion of the Achilles with subsequent calcification in the tendon proper."[12-1]
    -- Conquering Achilles Tendonitis In Athletes
    By Patrick DeHeer, DPM, and Stephen M. Offutt, DPM, MS
    [12-1] http://www.podiatrytoday.com/article/981



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    Achilles Bursitis: “You have more than 150 bursae throughout your body. These tiny sacs of fluid cushion movement between bones and muscles and tendons attached to bones, facilitating movement by limiting friction. Bursitis is inflammation and irritation of a bursa. Inflammation can occur in the bursa between your heel bone and your Achilles tendon. This type of bursitis is called retrocalcaneal bursitis. Bursitis involving the area where your Achilles tendon attaches to your heel bone usually begins with pain and irritation at the back of the heel. There may be visible redness and swelling in the area, and the back of your shoe may cause further irritation.” [13]

    Achilles Tendon Rupture “First, there's a pop or a snap. Then an immediate sharp pain in the back of your ankle and lower leg that makes it impossible to walk properly. It almost feels like you've been kicked, or even shot. These are the sensations typical of an Achilles tendon rupture. The Achilles tendon is a large, strong fibrous cord that connects the muscles in the back of your lower leg to your heel bone (calcaneus). Your Achilles tendon — also called your heel cord — helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot. If you overstretch your Achilles tendon, it can tear (rupture). An Achilles tendon rupture can be partial or complete. Usually the rupture occurs just above your heel bone, but it can happen anywhere along the tendon.“Pain and swelling near your heel and an inability to bend your foot downward or walk normally signal that you may have ruptured your Achilles tendon. If you've ruptured the tendon completely, you won't be able to rise on your toes on the injured leg. The pain can sometimes be severe. Often people report hearing a popping or snapping sound when the injury occurs. With a partial rupture, you may still be able to move your foot, and you may experience only minor pain and swelling. “ [13]
    -- MayoClinic.com
    [13] http://www.mayoclinic.com/health/achilles-tendon-rupture/DS00160/DSECTION=2
    [13] http://www.mayoclinic.com/health/achilles-tendon-rupture/DS00160/DSECTION=1



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    Haglunds Deformity “When Retrocalcaneus bursitis exists at the same time as Achilles tendinitis in the same leg, this is known as Haglund's deformity. Retrocalcaneus bursitis is inflammation of the bursa at the back of the heel bone and Achilles tendinitis is inflammation of the Achilles tendon. A bony growth that appears at the back of the heel bone can occur. This growth is called an exostosis (a benign cartilaginous growth) and is known as Haglund's deformity.” [14]
    -- Sports Injury Clinic
    [14] http://www.sportsinjuryclinic.net/cybertherapist/back/achilles/haglunds_syndrome.htm



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    The Second Cousin, Plantar Fasciitis
    http://www.nlm.nih.gov/medlineplus/ency/imagepages/19568.htm
    http://www.podiatrytoday.com/article/pod_200111f3
    http://www.medterms.com/script/main/art.asp?articlekey=3392
    http://www.sportsinjurybulletin.com/archive/foot-orthotics.html
    http://www.sportsinjurybulletin.com/archive/plantar-fasciitis-exercise.html




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    An Editorial Regarding the Current Tendinitis (inflammation) Vs. Tendinosis (tissue degeneration) Debate Within the Medical Community: "Physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology. Light microscopy of patients operated on for tendon pain reveals collagen separationthin, frayed, and fragile tendon fibrils, separated from each other lengthwise and disrupted in cross section. There is an apparent increase in tenocytes with myofibroblastic differentiation (tendon repair cells) and classic inflammatory cells are usually absent. This is tendinosis and it was first described 25 years ago, but this fundamental of musculoskeletal medicine has not yet replaced the tendinitis myth. Tendinosis is not merely a long term corollary of short term tendinitis. Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent.” [15]
    -- British Journal Of Sports Medicine, March 16, 2002
    "Time to abandon The Tendititis Myth"
    [15] http://bmj.bmjjournals.com/cgi/content/full/324/7338/626




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    “The etiology and pathogenesis to chronic tendon pain is unknown, and treatment is known to be difficult. Treatment is often based on opinions and not findings in scientific studies.” Recent research, using the intra-tendinous microdialysis technique, has shown that in chronic painful Achilles-, patellar-, and extensor carpi radialis brevis (ECRB) tendons, there were no signs (normal Prostaglandin-2 levels) of a so-called chemical inflammation. Furthermore, in biopsies from chronic painful Achilles tendons, pro-inflammatory cytokines were not up-regulated, again showing the absence of an intra-tendinous inflammation. Consequently, if the purpose is to treat a chemical inflammation, there is no science backing up for treatment of theses conditions with anti-inflammatory agents (NSAIDs, corticosteroidal injections). “[16]
    -- Alfredson, Håkan
    Strategies in treatment of tendon overuse injury. The chronic painful tendon
    European Journal of Sport Science, Volume 6, Number 2, June 2006, pp. 81-85(5)
    Publisher: Taylor and Francis Ltd
    [16] http://www.ingentaconnect.com/content/tandf/tejs/2006/00000006/00000002/art00001



    -Jack
     
    #4
  5. ChicagoJack

    ChicagoJack Hall of Fame

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    Quotes & Links Part 4

    What Is Collagen? "Collagens are proteins that help strengthen the structure of tissues such as bones, tendons, cartilage, ligaments, vertebral disks, skin, and blood vessels. These tissues all contain collagen, but they have different proportions of different kinds of collagen (as well as various other constituents) and their structural characteristics vary.The collagen in tendons and ligaments is arranged in bundles of parallel fibers, giving tendons and ligaments a rope-like structure. Some of the fibers in tendons and ligaments also run transverse to the parallel bundles, forming cross-links that add strength to the structure. The collagen in cartilage is arranged in a mesh with a large amount of gel-like substance between the collagen fibers, making the structure of cartilage more like a sponge. The characteristics of collagen-containing tissues also vary with position within the structure; for example, tendons and ligaments are different at the point of insertion to the bone than they are in the middle of the tendon or ligament." [17]

    Collagen represents 65-80% of the dry weight of tendon and is by far the most abundant component of tendon: " Normal tendons and ligaments consist mostly of Type I collagen, with smaller amounts of Type III collagen. When you get tendinosis, some of your collagen is injured and breaks down. Your body tries to heal the tendon, but when you have chronic tendinosis your body doesn't repair the collagen properly. Usually you can't see the tendinosis injury from the outside of the body; swelling, heat, and redness are symptoms of an acute injury, not a chronic tendinosis injury. However, the tissue often looks different to the naked eye during surgery, with tendinosis showing up as tendon that looks dull, slightly brown, and soft instead of white, glistening, and firm. Researchers have analyzed samples of tendons and ligaments under the microscope to discover the abnormalities that occur on a cellular scale in overuse injuries."[17]

    Collagen: the tendinosis cycle begins when breakdown exceeds repair. "Repetitive motion causes microinjuries that accumulate with time. Collagen breaks down and the tendon tries to repair itself, but the cells produce new collagen with an abnormal structure and composition. The new collagen has an abnormally high Type III/Type I ratio. Experiments show that the excess Type III collagen at the expense of Type I collagen weakens the tendon, making it prone to further injury. Part of the problem is that the new collagen fibers are less organized into the normal parallel structure, making the tendon less able to withstand tensile stress along the direction of the tendon. Therefore, tendinosis is a slow accumulation of little injuries that are not repaired properly and leave the tendon vulnerable to yet more injury. This failed healing process is the reason many people with tendinosis don't completely heal from it and can't go back to their previous level of activity.

    Although rest is an essential part of the healing process for tendinosis, too much rest causes deconditioning of muscles and tendons. The weaker muscles and tendons leave the area more vulnerable to injury. Thus, the area becomes weaker on a large scale as well as on a cellular scale. This cycle of injury/rest/deconditioning/more injury can be difficult to break. Gradual, careful physical therapy exercises can help; see Current Treatments." [17]
    [17]Tendinosis.org
    http://www.tendinosis.org/injury.html



    [..]....................................



    Footwear and Achilles Tendon Injuries: "The greater a shoe’s cushioning and heel height, the less stretching the Achilles tendon does with each stride and the smaller the calf muscles’ range of motion. Less stretching and a smaller range of motion can be temporarily helpful when recovering from an injury, but permanent use of added cushioning and heel height reduces the length of the Achilles tendon, which can lead to later injury. Too short a range of motion promotes calf muscle shortening, disproportionate weakness in the parts of the calf muscle that are not stretched with each step, and possibly a general weakening of the calf muscle."[18]
    -- Achillestendon.com
    [18] http://www.achillestendon.com/Footwear.html#Footwear and Achilles Tendon Injuries


    Footwear and Achilles Tendon Injuries: "If the sole of the shoe is too rigid, it may not allow for enough motion of foot and shock absorption. This could place additional stress on the Achilles tendon. Another common problem is a shoe that fits too small and creates friction between the Achilles tendon and the heel counter of the shoe." [19]
    -- ACC Sports Sciences, Wake Forest University Sports Medicine, Women's Tennis
    [19] http://www.theacc.com/sports/w-tennis/spec-rel/070705aab.html


    Custom Insoles: Biomechanical foot defects stress the Achilles Tendon by forcing it to twist as it crosses the ankle into the foot, rather than allowing it to run straight. The two main causes of this twisting of the tendon are pronation lor supination. The twisting of the Tendon makes it weaker and more susceptible to over-utilization stresses and injuries, which causes the tendon to become inflamed and painful. Custom-made orthotics can comfortably maintain the foot in its normal position, in relationship to the ankle and lower leg, thus preventing the foot from pronating or supinating. This allows the Achilles Tendon to run straight into the foot without twisting, which would aid in allowing the Achilles Tendinopathy to dissipate, and helps to prevent it from returning.
    [20] http://www.yoursole.com/index.htm
    [21] http://www.footsmart.com/P-ArchCrafters-Custom-Insoles-10052.aspx
    [22] http://www.ourfootdoctor.com/sportsorthoses.shtml
    [23] http://www.archcrafters.com/cusin.html


    My suggestion for a court shoe: Addidas Barricade II If you remove the stock insert, the barricade is a fairly neutral stability shoe in terms of pronation correction. This makes it a good platform for holding an off the shelf correction insole or better yet, a custom insole that will match the needs of your feet. I've noticed that some stability oriented shoes can have quite a bit of posting out at the edges of the shoe, they are very stiff at the edges which makes them prone the catching an edge syndrome. I suggest when trying shoes on, you test how easy it is to roll your ankle. Grab the back of a chair for support, weight the oustside of one foot and see how far you go to find "the tipping point" barricades score very favorably on this test. Better you find out now than on the court. I've worn since them they first came out 7 or so years ago, and have never even come close to rolling an ankle. You can get them right here at TW.
    [24] http://www.tennis-warehouse.com/catpage-msadidas.html
    [25] http://www.tennis-warehouse.com/catpage-wsadidas.html


    [..]...........................



    -Jack
     
    #5
  6. chess9

    chess9 Hall of Fame

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    Wow! Jack is almost back. :)

    Well, I do calf raises, which seem to be an eccentric calf exercise on my machine. And, I do them at the max weight on the machine, 60kgs. I've had ankle problems in the past, because the lateral flexibility of them is great, so I've tried to strengthen the plantar and calf/soleus with the calf raises. No problems so far. :) (except for some plantar fasciitis that is gone)

    Very thorough post and it will probably help someone else.

    -Robert
     
    #6
  7. Marius_Hancu

    Marius_Hancu G.O.A.T.

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    Glad to see you're back in tennis.

    Do you have some pictures of those exercises?

    A picture tells a thousand words ...

    Also, perhaps you edit your original posting to say upfront what "eccentric" means here.
     
    #7
  8. Fred132

    Fred132 Rookie

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    Thanks for all the effort in posting this information, Chicago Jack.

    I'm in the process of fighting achilles tendinosis, and I am finding a lot of interesting reading here.
     
    #8
  9. ChicagoJack

    ChicagoJack Hall of Fame

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    Hi Marius, the links to the photos are already posted, see quote and link:

    Photo examples, a word of caution, and specific instructions for performing eccentric calf strength training. This article is written primarily for readership within the medical community: " Eccentric exercises have the potential to cause damage if performed inappropriately or excessively... [continued] Here is an example of exercise progression.” [4]

    [4] Clinical Sports Medicine
    Chapter 28, Pain in the Achilles Region
    http://www.clinicalsportsmedicine.com/chapters/28d.htm

    I'll revise top post to more clearly define eccentric, thanks for pointing out that info was missing.
    -Jack
     
    #9
  10. tennislady

    tennislady New User

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    Wow, I just spent one hour reading all your materials and links. I have ran accross some of this material myself, and tried to do some of the exercises. I have spend my entire medical deductible on PT for my achilles tendinosis. Still battling it and trying to play tennis through it all. Thanks for posting the research, I printed it all out, and will read through more carefully, and try again to find something I may have missed. Otherwise, I may just be headed for surgery in the distant future. But you have given me new hope, and I am going to keep a journal and do the eccentric heel drops, and gradually add the difficulty for another few months.
    I am happy for you that you can be on the courts again, I am just hoping I am not doing permanent damage playing with some degree of pain, and the never ending stiffness when my foot has been immobile for short periods of time-(car rides, movies, dinner, sleeping etc)
    But your post is encouraging, thanks again.
     
    #10
  11. ChicagoJack

    ChicagoJack Hall of Fame

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    Tennislady, Good to hear from you again. I do remember our conversation 3-4 months ago. Surgery was my next option as well. I'm glad I declined the offer.

    I did the heel drops very, very, conservatively at first. I stood facing a tall kitchen counter and used both arms to power up, and then both legs to drop down, I used my arms as well to off load some of my body weight on the descent. I never went past the horizontal point at first either. I only graduated to single legs after knowing I could do the double heel drop without experiencing pain. Once I was confident with that, I was ready to do single legs, and the heel drop past horizontal. The key is to s l o w l y control the descent. If you just drop quickly you are not getting the full benefit. I used a count of 5 seconds to the horizontal drop then progressed to count of 8 seconds with the full drop, past horizontal. The exercises seem ridiculously easy when you do them, but after the 3rd or 4th day of doing them every day, I had a pretty noticable fatigue burn going in my calves.

    My initial entry approach to the training was way more conservative than the participants in the original study, but I was on the slippery slope for so long that I had great fear this eccentric stuff was going to get me sliding again. I'd seen the photos of the exercise over a year ago, and they scared the beejesus out of me just to look at them. I did not understand the context back then, but I do now. I was determined to make slow, steady progress, and to never go backwards again. Slow and steady won the race for me.

    It was about this time that I was able to find an anti-inflammatory that I could take higher doseages of without irritating my stomach. I took 400-600mg per day for the first week, then tapered off to 100-200 per day after that. I currently using only using about 300-500 mg per week as needed. It the 400-600 mg per day range really opened a whole new ballgame for me. I think it played a key role in keeping the inflammation aspect in check this time round. I also do a full ice bath after every court and PT session. Cannot overstate the importance of this with my success as well.

    I've also got one foot in the "no stretching" tent with NoBadMojo. I do however make a distinction about the dynamic stretch you get at the bottom of the heel drop versus a static stretch that most people do. The heel drop was the meat and potatoes of my recovery, but it does produce a natural stretch at the bottom, which makes it difficult for me to state that stretching is bad. I view recovery in 4 phases. Phase 1. Cool off the pain, let the inflammtion fire die down, and or, let the scrambled attempt at tissue repair take place at its own pace, without you mucking it up. Get the pain level manageble with the activities required for daily life. When you have your pain meter set to zero, you then have a good feedback loop, you will then know how to correctly go about the task of carefully ramping up the challenges of pt. if you are getting pain signals all day every day, you will have no way of knowing which stuff is working and which is not. Phase 2. Conservative Physical Therapy. Phase 3. Gradual re-entry to sport. Phase 4. Ongoing Injury prevention. My experience informs me that stretching is not appropriate for phase 1, might be usefull In small measured amounts in phase 2, a bit more usefull in phase 3, and an absolute imperative in phase 4.

    Best regards to you, and take care
    -Jack


    [..]...............


    Chess9, I'd imagine your achilees-calf complex are pillars of steel with that workout. Thanks again for your personal support and your consistent presence here in this section of the board.

    Fred132, Welcome, I stumbled into the key element of my recovery by google searching my way into a forum for ultimate frisbee players discussing how effective this eccentric calf muscle training was for fixing chronic tendinopathy. It was an odd place to find a turning point, but reading their ongoing conversation gave me a glimmer of hope, inspired me to research it more fully, and I'm sharing some of the results of my research here.

    Best regards, and take care
    -Jack
     
    #11
  12. Phil

    Phil Hall of Fame

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    Fantastic news, Jack! The hard work (and, I would guess, quite painful) and pure desire to normalize your life, has paid off. This is an inspiration for anyone who has to go through similar physical trauma...and thanks for all the useful information...as Robert said, this will benefit others.

    Good luck in your continued rehab. And, make sure you take some time off tennis when necessary...sounds like you're playing quite a bit...don't overdo it!:)

    Take Care, bud, and again, congrats on all your hard work and will to get strong again.
     
    #12
  13. ChicagoJack

    ChicagoJack Hall of Fame

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    Well kiss my grits and call me spanky, darned if it ain't our resident razor-toungued, cantankerous, irascible, loveable kurmudegeon Phil!

    Yes, you've nailed my dilemma perfectly. I'm like a kid in a candy store right now, the hardest part is keeping myself off the court for quality rest time. I'm determined to keep getting stronger, to never let this happen again. You folks were here in my darkest hour, this thread is partial repayment of my gratitude. I hope it will make somebody elses road back a bit easier than mine was.

    Take care, best regards to you
    -Jack
     
    #13
  14. tennislady

    tennislady New User

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    Thanks again for spelling out the specifics on your recovery. It fits my dilema to a T. Just a quick question. Do you have absolutely no pain now, or stiffness after a tough say 2 hour match? And do you have any visual abmormalities left on your heel?
    You absolutely know more about this subject than 2 PT's that have tried to help me. I hope my results will be as good as yours. I am determined today.Have been doing the heel lifts on my stairs a lot, and have to watch out I don,t overdue them, because I am soooo sick of this situation, and want it resolved in the worst way. Thanks again for all your detailed workup.
     
    #14
  15. ChicagoJack

    ChicagoJack Hall of Fame

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    Hello again tennislady,


    The pain level when playing question: I currently have absolutely no pain during court play. On saturday for example, I played a practice match for two hours, then did my eccentric rehab for 20 minutes, followed 20 minutes of lap swimming, and a hip deep soak in the ice water spa for 20 minutes. My wife and I went to a 1.5 hour yoga class in the late afternoon. I felt no pain during any of this. This was by far my most strenous day, and after days like this, I do a little stiff and sore the next morning. On days I do feel pain, I would rate it a 2 on the scale of one to ten. I am able to get this back to close to zero with a day or two of quality rest, icing, and as I've mentioned before, 100-200 mg of celebrex if needed. The 400-600mg per day range is my ace in the hole if If I've really overdone it, but I to keep out of that danger zone as much as possible. I'm not 100% pain free, I'd say about 90% percent pain free, and improving every week. The use of anti inflammatory meds for chronic tendinopathy is controversial. it will either work for you or it won't. For me, it helps cool off minor flare ups when I've miscalculated the proper ratio between rest, PT and court time.

    My biggest challenge right now is to limit my court time to 3 days per week. I've gone a year without playing, tend to overdue it occasionally, but I know exactly how to get myself back on track again. I cut back on court time, increase the rest, ice and PT, then gradually build back to more court time. No, I have no visible signs. The redness and swelling at the back of my heel at around 2.5 "up are gone.

    Pain Levels Prior to Starting The Eccentric Training: Pain was minimal with normal daily activities. Walking fast or light light jogging would produce immeadiate pain. Could hit against a backboard for 5-10 minutes max. As stated previously the whole period ( 4 months) before during and after my knee surgery I only iced and rested my achilles. This got me out of the acute pain phase, but seemed to not prepare me well for a transition to the rigours of court play.

    Pain levels when doing the eccentric training: When I started the training I did have moments of pain, while perfoming the exercise, and these always occured when I would ratchet the reps, or the load up a notch. In the original study, patients were told to expect this at each new load, each new bump in the level of difficulty. I, however, was not so committed to feeling pain as a normal occurence. Like you, I was scared the heel drops were going to send me back down the slippery slope again. If I felt pain, that was the sharp kind, I stopped immeadiately. When I experienced the lactic acid burn, fatigue kind of pain, I worked through that with confidence. I encourage you to keep your determination not to backslide. That is absolutely the right frame of mind.

    The theory regarding how this works, in plain english, Is that tendinosis is caused by the body's failed attempt to rebuild muscle tissue. Every body builder knows that they are doing is controlled destruction of muscle tissue so that bigger, better, stronger muscle grows in its place. Tendinosis occurs when (as one theory suggests) when you ask your body to both repair itself and perform at a high level, such as an instance where you play heavily for 4 days in a row. It can't do both, so the attempt to rebuild is faulty. The muscle tissue gets scrambled. The theory is that eccentric motion (contracting while lenghtening) "remodels" the tissue into more organized bundles. What I am pointing to is the notion that remodeling is the key early on. Do light weight, light rep, limited range of motion early on. Once you get confident this stuff is working, then feel free ratchet up the reps, the weight in small graduall increments. Once I got the tissue remodeled / repaired then my focus became a bit more body-builder like to add muscle mass to the area.
    [Refer to my quotes and links [15][16][17] in the top post, this is a very loose translation]

    Don't over do it. with the heel drops, I used both legs at first, which gave the bad leg half the body weight. Once I was 100% confident this was something I could handle, I moved on to work the injured side in solo mode. Make sure you count at least 5 seconds on the descent. 10 is better when you can build up to it.


    I wish you slow and steady progress,
    Best regards, to you and take care
    - Jack
     
    #15
  16. ChicagoJack

    ChicagoJack Hall of Fame

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    Tennislady - I have a question for you.

    As I recall you have a bit of a calcium build up on your heel, one of the unfortunate spin-offs from chronic tendinosis. I have the same question for you as you had for me. From your last post, it seems you are currently giving the eccentric training a try. What was your pain level before the you started doing the training? Calcium on the heel is a bit different from tendinosis caused by faulty tissue rebuilding from overuse. It has me wondering about the effectiveness of heel drops with this type of thing.

    You've stated that surgery was the next surgery option, as it was for me, and buried within that impending choice you get the gift of freedom to try something new or different. I've learned that eccentric therapy is actually pretty accepted among MDs but there seems to be a bit of a disconnect with the PTs as none of the first half dozen I saw put an emphasis on eccentric exercise.

    I find myself wondering how you are doing, and I wish you well.
    -Jack
     
    #16
  17. tennislady

    tennislady New User

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    Chicago Jack- answers to your questions.

    My pain level before starting the exercises has been all over the board. This episode started with me about 1 1/2 years ago. I used to be an RN so of couse I, like you started researching on the web diligently, since this is not an injury I have ran into before. I play pretty competitively, 4 times a week in southern Cal. so not playing is totally taking me out of my routine. I have been to podiatrist, (surgery he said). Been to GP, PT for 8 week, mostly stretching, icing, and the ultrasound thing they do. Laid off for 2 months. Some relief but immediatlely back to pain after play resumed. Went next to an excellent ankle foot, sports ortho, in this area. More PT, orthotics with heel built up in them.
    On my web search early on I did run into eccentric exercise article from Sweden. Actually printed it out, took it to my PT, but was not persuaded.
    After your testimony here, I am revisiting this whole issue with renewed hope and vigor, and believe it or not, even after just 2 weeks, I am feeling some relief. My husband keeps finding me on the stairs, doing the loading, of the heel, but it is starting to feel better. No imagination.
    I do have visible damage, 1.5" up on back, and inside heel. Bump is raised and calloused looking.. I know I do not have midportion tendinopathy, but probably the insertional kind. From the readings I know this is the more difficult kind to treat. The podiatrist said, Haglunds deformity, the ortho said no, just retrocalcaneal bursitis. So that is what I am going on. I am hoping the bump is just the faulty unorganized collagen repair tissue. My PT some time back said this would probably no go away.
    I have printed all your material, and read it a few times now, to make sure I understand it all. It is almost a book. I like you have been and still am on that slippery slope. I can tolerate the pain, when I play and warm up properly it is fine. Until afterwards when the stiffness comes back with some pain. Maybe a 3 on 1-10 scale. But I am fine with that. I am going to contunue with the exercises, I have tried the eccentric knee squat as well, that is pretty painfull yet, and not easy for me to do. And also the Balance and Eccentric Reach with Toes. Just experimenting.
    Right now I hope I am not doing permanent injury, and finding the right balance. I also hope the heel lifts will not shorten my achilles or calf muscle, but am going to check that out next.
    I love tennis too much to stop, but I think I am wise enough to retire when the time comes. It has been a way of life for me for over 20 years. A great way to get exercise, and I love the competion. But I am afraid I have ran up to the net a few too many thousands of times. and thinking back I may have had a Nike shoe that was very tight in the heel. A light shoe, that really grabbed and irritated the bursa. and with my personality and tall, lanky build it was my achilles heel. Lots of Advils, Alleves, and stupidty led me to this day. But I am really encouraged by your success story, and I AM NOT HAVING SURGERY, unless I cannot walk anymore. I think I can actually kick this thing in the butt once and for all. So, excuse me, I am going to my stairs for a few more heel lifts before going to bed.....
    I cannot thank you enough, I know you have felt the utter frustration as well, and hope you will never be on the slope again.
    take care, and let me know if you learn anything new.
    tennislady
     
    #17
  18. tennislady

    tennislady New User

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    ChicagoJack
    Did you also do the other exercises the article mentioned. Like the knee presses against the wall, etc. Or did you just stick to the eccentric heel drops?
     
    #18
  19. NoBadMojo

    NoBadMojo G.O.A.T.

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    That's great news Chicago!

    Tennislady, I had a 7 year or so dance with achilles tendonitis in both of mine..one was chronically bad and the other would come and go. I managed to make it go away finally after a bunch of trial and error. It's a frustrating injury. What also helped me, and maybe it wasnt mentioned before, would also be to try and isolate any particular motion/move that causes your achilles angst..for me, it was the push up and into the ball on my serves and the next step in if playing serve/volley. i changed my motion a bit to alleviate and dont play much serve/volley anymore (it's tough to play that style these days anyway), and I am good to go. I'm odd for an older guy in that i can still play singles w. the young crowd but cant play doubles because of the serve/volley and no way i am going to play dubs by serving and staying back. For me, custom sports orthotics were what put me over the top, and i had the doc build in fairly rigid lifts on the heel to keep my achilles from hyper extending on that axis. so there is hope...it takes a lot of patience and i would avoid stretching other than the most benign. icing the moment you get off court is good to do.
    These days. I still manage my play so i dont get a reccurence and try not to schedule difficult matches on consecutive days..it's impt to be objective and realistic with these types of injuries..good luck with yours, and once again...good go CJ! here's to good health
     
    #19
  20. NoBadMojo

    NoBadMojo G.O.A.T.

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    i really would avoid the heel drops on the stairs and anything more than the most benign stretching of the achilles..while it may serve to make it elongate and loosen up a bit, you could also be microtearing the tendon by doing this and injuring it more....pain is telling you to not do this..seriously....what you neeed to do is rest it as much as you can and if you have orthotics or something with heel lifts you can wear throughout the day that would help as well...mine were inflammed in the same place as yours...you want to avoid hyper extending it and extending it too vigourously..good luck
     
    #20
  21. ChicagoJack

    ChicagoJack Hall of Fame

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    Here is the sequence of events regarding the achilles tendinopathy as best as I can remember it. It does not make sense unless you get the whole story in context, and in sequence. The short answer is starting in july of 06 I did no stretching, the Heel drops were the meat and potatoes of the PT. I knew from past experience that the stability stuff fired up my symptoms big time, so I only incorporated them after I was sure the eccentric stuff was beneficial. This occured on week 5 or so. My problem the first time around was doing to many different exercises, and too inconsistently. Had no idea what was helping or hurting me. Was determined not to make this same mistake this time around.

    MAY-AUG 05: Symptoms started appearing in greater frequncy over course of 3-4 months.

    SEPT-OCT 05: 6 weeks guided traditional PT - No Improvement overall

    SEPT-OCT 05: Stopped playing tennis at week 2 of PT.

    OCT-NOV 05: Another 4 weeks guided traditional PT - Condition worsened

    DEC-JAN 06: 6 weeks in a cast ( MRI revealed partial achilles tear) - conditon worsened, very difficult to walk after removal of cast.

    FEB-MAR-APRIL-MAY 06: Just rest, and ice daily - At this point, I was flummoxed, 10 weeks of PT had made my condition worse, and 6 weeks in a walking boot seemed to make things worse still. Ice and rest was the only thing I had not tried full time yet, so I gave that a shot. Plus I had no money left in my HC plan for 05. During this time period, I saw much improvement in pain levels, with the movements of ordinary daily life. Could walk without pain, but could not even lightly jog. Hitting against a wall for 5 minutes would produce symptoms.

    MAY 06: Knee Surgery (right achilles problem, and left knee problem were coexisting )

    JUNE-JULY-AUGUST 06: Guided Post Operative Physical Therapy for Knee, I declined PT for achilles at this time. Did not trust traditional methods, as the 10 weeks 05 in only made my achilles condition worse. However, I had a golden moment that i was determined not to screw up. I had minimal pain with my normal, non tennis playing life, remember I had not played since September of 05. I figured now that I had minimal pain, I could let my pain levels determine the steepness of my "ramp up" in my fresh approach to physical therapy. If you are experiencing pain all the time, you don't know what is working and what is not. This is basically what was going on for all of the year 05 the first part of 06. Took me a long time to learn that lesson, but I finally got it.

    [..].............................


    JULY 06: Start of Eccentric Calf Training.

    Note: All training sessions began with 10 minutes warm up on an exercise bike, and ended with 10-20 minutes of Ice. I also used between 200-400 mg celebrex daily for this time period. The effectivness of anti inflammatory medication for the treatment of chronic tendinosis is a subject of debate within the medical community. This topic is covered in detail on my page one links and quotes.

    WEEK 1, JULY 06

    Day 1: 2 sets of 8 heel drops using both legs, and on the flat floor. I used my arms to power up to start position. No pain during, or day after.

    Day 2: 3 sets of 8 heel drops using both legs, and on the flat floor. I used my arms to power up to start position. No Pain during, or day after.

    Day 3: 2 sets of 8 heel drops. using both legs, standing on balls of feet over edge of stairs.

    Day 4-7 Just repeats of day three. That was my first week. I was just sort of putting my toe in the water, making sure this did not put me backsliding on the slippery slope again.

    WEEK 2, JULY 06: 2 sets of 8 heel drops, one set straight leg and one set with knee slightly bent. Using the good leg to power up to toe stand and injured side to control the decsent to a count of 8 seconds. I did these over a platform, extendend my heel past horizontal. I had my first moments of pain in week 2 at this progression. In the original research study patients were told to expect pain at each new progression, to work through it, but to only progress to the next level after you were in control of the current level and pain free. While knowing what the original patients were told was comforting to me, I stopped for the day at the first twinge of pain. Again, my guiding principal was never go backwards. By the end of week two, I could do these without pain.

    WEEK 3, JULY 06: Same as week 2 but increased to 2 sets of 12 single leg Heel drops. Stopped for the day when I experienced twinges of pain, and I recall taking a few days off for rest somewhere in this time period.

    WEEK 4, JULY 06: Increased to 4 sets of 16 ( two bent leg and two straight. At this point I was finding doing these daily was not going to work. As the work load progressed I spaced in more rest days. Something like PT 4-5 days per week and 2 or three rest days.

    WEEK 5, AUG 06: After I could do 4 sets of 16, with a good lactic acid burn, but no injury related pain, the next progression would be to add hand held weights to the scenario. I instead began to incorporate the stability exersise in 4 directions. You stand on the injured leg, extend the other leg forward 12-16 inches while you slightly bend the standing leg, the return to starting postion. you do the same thing side-back-and crossing behind. Basically you are just forcing the stablizing muscles to work in all directions as you struggle to keep your balance.
    4 sets of 16 heel drops + 5 minutes of achilles stability work, 4 days per week and three days of rest. I Hit against a back board for once that week for 10 minutes.

    WEEK 6, AUG 06: 4 sets of 16 heel drops + 5-10 minutes lateral stability work 3-4 times per week. Had a once per week on court workout that consisted of hitting against a backboard for 10 minutes, followed by serving a basket of balls for 10 minutes.

    WEEK 7, AUG 06: Same as week 6, but the one on court day was light hitting session with a partner for 1/2 an hour, and 15 minutes working on my serve.

    WEEK 8, AUG 06: Same as previous week, but the one on court day of light hitting was increased to one hour.

    WEEK 9, SEPT 06: Same as previous week, but my one hitting day was increased to 1.5 hours. At this point, my biggest issue was finding the right ratio of rest, continuing PT and court time.


    [..]...........................................



    WEEK 10-PRESENT, OCT 06:

    Mon & Wed Core strength and stability

    Tue & Thu: Eccentric Calf, Lateral Ankle Stability, Eccentric Quad, Rotator Cuff, Team Practice, followed by 20 Minutes Ice.

    Fri: Easy Cardio, Easy Stretching

    Sat: If no match on sunday, this is my go to the club at 8 am and leave at 2pm day. I do everything. Tennis, eccentric calf, core, physiobands rotator cuff, weights, spinning, swimming. My wife and I do 1.5 hour yoga class late afternoon.

    Sun: Team match every other sunday. Warm up with physio band upper body, eccentric calf, eccentric quad and lower limb stability.

    Not enough days in the week to do everything I want to do and still keep a full time job, and a marriage together. I'm surely not the only tennis player who faces this problem.

    Take care,
    -Jack
     
    #21
  22. Swissv2

    Swissv2 Hall of Fame

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    wow, lots of info here. Saving as a favorite.
     
    #22
  23. tennislady

    tennislady New User

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    Thank you ChicagoJack
    Appreciate all the info, have it filed for future references. I am going to measure my improvement in months and years, not days or even weeks. I can tell it is just that kind of injury. Meanwhile, try to manage my tennis and not let my team down, or tear the achilles totally, which always is a thought that lingers in the recesses of my mind. Very occassionally I get a sharp, knife like pain in achilles insertion area when I really pound on that foot for a lunge or something and I just have to stop for a minute till it goes away. Scary stuff! Thank you again. The best to you as well.
    tennislady
     
    #23
  24. VAmazona

    VAmazona Rookie

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    Congratulations on your return!
     
    #24
  25. Safino

    Safino New User

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    hi

    i've read entire post, trying to understand everything but i'm italian and i dont speak english so well.

    whatever thanks a lot to chicagojack for his experience.

    im suffering of the same problem.
    heel pain in the morning and now i have a pain on the back at the same right of heel pain.

    i've a bad foot...with very high arch and in my life i wear plantars but not when i play tennis.

    so i'd like to know:

    1) my pain in the back is caused from the heel too?
    2) i 've read u wear orthotics...i must do the same and wich kind of ortothics i need having a very high arch?

    i hope in ur helping.

    regards
     
    #25
  26. tennisee

    tennisee Rookie

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    Hi - I've been laid off tennis for three months with Achilles tendinits and bursitis (Haglund's deformity) This was after slow increasing pain over a period of six months, which initially was managed by eccentric stretches as oultined above, and then not. I've just completed a course of ESWT so we'll see how that goes. At the moment I have constant pain, can walk with a limp and am able to gently hit against a wall for 30mins or so.
     
    #26
  27. sandraC

    sandraC New User

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    I am not a tennis player, just an insertional achilles tendinitis / bursitis sufferer (both feet) who luckily ran across this post about 6 weeks ago. After thoroughly going through ChicagoJack's experience and treament, I decided to try a very similar approach to treating my injury. I have been having a lot of pain since early April 2010, tried PT from June to mid August with no improvement. I started out with the heel drops very cautiously at first, I was scared of making my injury worse. I actually started doing them in the pool after a warm up of deep water jogging, and a thorough ice massage after the heel drops. I have progressed from then until now, and I am now doing 4 sets of 15 reps one legged heel drops per foot (2 sets straight knee and 2 bent - I do not drop my heel below horizontal yet, maybe in a few weeks). I used to think I would never get better, but now, I am feeling better every week. I am no longer coming home from work limping, or awkwardly tackling the stairs, I am starting to walk normally again.:) I do have a small heel lift in my shoes and I also wear Silipos achilles tendon socks that has gel pads at the back of the heel as I am very sensitive to the shoe rubbing on the back of my heel. These socks really help. I really wanted to thank ChicagoJack for taking the time to detail his sucesses and his failures here. Without his posts, I am sure I would be doomed to struggle with these injuries for a very long time. I can't thank you enough ChicagoJack. :)
     
    #27
  28. jwbarrientos

    jwbarrientos Hall of Fame

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    still working on my achilles tendinopathy, excelent original post, info, details.

    thank you
     
    #28
  29. drak

    drak Professional

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    Hey Chicgao congrats on the recovery and thanks for the great info. I have been doing some eccentrics and they have helped manage my achilles. I usually do them on a slant board, did you ever use this or come across research on using it when doing eccentrics?

    Drak
     
    #29
  30. ChicagoJack

    ChicagoJack Hall of Fame

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    Very cool! I've been away from the board for about 6 years, and it really warms my heart to hear that I left something behind that helped somebody out. Kudos to you for taking it slowly at first. I think that is the key with this injury. It's especially difficult to take things slowly for those of us who arrived at their achillies issues from playing too much tennis :)

    I'm looking back at this post of mine and can see just how embarrassingly tennis obsessed I was, (yikes) and how that was most likely the root cause of the injury (doh) The only additional nugget of info I can really give to anybody, is give your body time to to repair itself. That means rest, you fellow tennis addicts out there. PT is intentional destruction. You break down muscles so that they grow back stronger. That growing back part is really important if you are attempting to PT your way out of repetative use injury.

    - Jack
     
    Last edited: Nov 12, 2011
    #30
  31. drak

    drak Professional

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    Chicago, I asked you in a recent post if you ever used a slant board when doing your eccentrics? Did you or do you have toughts on that.

    Drak
     
    #31
  32. ChicagoJack

    ChicagoJack Hall of Fame

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    Hey Drak -

    I've not used a slant board, seems like a great idea but I couldn't really comment from personal experience. I have used a balance board, and a balance cushion. It's a way to work those little muscles that you engage naturally when attempting to balance on one foot. You can also engage those lateral stabilazation muscles with no special equipment at all. Just do your heel drops and challenge your balance a bit by trying to toss and catch a tennis ball against the wall.

    Hope this helps :)

    -Jack
     
    #32
  33. DrewRafter8

    DrewRafter8 Professional

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    Jack,

    Looks like I will be following in your footsteps. I was diagnosed yesterday with a small heel spur and Achilles tendinopathy. Right now I'm doing PT plus starting prednisone. The doctor told me to increase the PT and use the steroid to fight inflammation. I can play tennis with little pain. I feel more pain when I stand on my feet at work. He's told me to continue using my superfeet and invest in a more supportive shoe for work. I'm going to try your methods listed above and I'll report back my experience as well. Thanks for the informative post here!
     
    #33
  34. Torres

    Torres Banned

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    Excellent posts, Jack. Thanks for all the detailed info and links.
     
    #34
  35. ChicagoJack

    ChicagoJack Hall of Fame

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    Good luck to you drew, I wish you a speedy and complete recovery. On the topic of shoes, I found it was important to wear shoes that are not too tight at the heel. I'm buying my tennis shoes just a bit longer than than I used too, and am very careful about getting just the right thickness of sock for a perfect fit. Too loose and my heel is slipping/sliding in the shoe, but too tight is to be avoided as well.

    :)

    Jack
     
    Last edited: Jun 21, 2012
    #35
  36. ChicagoJack

    ChicagoJack Hall of Fame

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    Thanks Torres, I always peek in if I see you've posted something in the string section, always good stuff from you there. Seeing this thread again is making me feel immense gratitude for my health. Man... it was hell not playing, and not getting exercise. Thought I might never get on the court again.

    The body is amazing. It wants to heal. It knows how to heal. I went on to have a 3 level back fusion circa 2009. I was almost completely disabled for 6 months. My PT for the 1st 6 weeks consisted simply walking three times around the living room, three times a day. Then I walked around my yard, then around the block, then around the neighborhood. Now I am back playing tennis 3-4 times per week entirely pain free. The body knows how to heal.

    Jack
     
    Last edited: Jun 21, 2012
    #36
  37. Torres

    Torres Banned

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    #37
  38. DrewRafter8

    DrewRafter8 Professional

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    Thanks Jack, it's not going so well right now. I've had the pain come and go. If I'm on my feet for any period of time, the pain seems to travel up and down the heel. I'm scheduled to go back to the podiatrist tomorrow. I've only played tennis 4 times this month, but each time the pain was not that bad. I've only played that much due to other reasons. Curious to see what my Doc says tomorrow. On that subject, did you have custom insoles made for you?
     
    #38
  39. ChicagoJack

    ChicagoJack Hall of Fame

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    Hi Drew,

    I did have custom insoles made. In my particular case, they made very little difference. The one thing that jumps out at me when i read your story is that you feel little pain when playing tennis, that mostly the pain increases by standing at your work place. Thats a significant piece of the puzzle, and im sure this is why yer doc is suggesting orthodics, and that makes total sense to me.

    Hang in there man, i know this is tuff. Things can get a whole lot better even when nearly all hope is lost

    Jack
     
    #39

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