Know Exactly Where Your Achilles Tendon Hurts

Back view of L calcaneus 

I had right Achilles tendon pain earlier in the year. After doing some Alfredson protocol exercises, wearing the Strassburg sock and getting my colleagues and wife to treat me, I could run pain free. 

Yes, I still ran twice a week even though I had some pain while running. Some of that same pain came back during our recent holiday in Japan. I did not cycle nor run during the trip but did some skipping for the first few days of our trip. 

Then I came across an article (with nice pictures) of what makes up the Achilles tendon and how it attaches on the calcaneus (heel bone), pictured above. While skipping, my gastrocnemius (or calf) muscle, was used more than the soleus. I realized that this was what led to the recurrence of my Achilles pain.

The Achilles tendon is the largest/ longest tendon in the human body and is formed when the medial (inner) and lateral (outer) parts of the gastrocnemius and soleus muscles merges.

The authors dissected 12 fresh frozen leg specimens to find where the Achilles tendon inserts (or finishes) on the calcaneus in relation to their corresponding muscles. They also examined 10 embalmed specimens to confirm an observation on the retrocalcaneal bursa.  A bursa is fluid filled sac/ pouch that acts as a cushion and gliding surface to reduce friction.

The superficial part of where the Achilles tendon finishes is where the medial head of the gastrocnemius muscle attaches (in light blue) on to the lower facet of the calcaneus. The authors (like previous studies) found evidence that tendon of the medial gastrocnemius forming the superficial part of the Achilles tendon is continous with the plantar fascia. Like I written before, in order to get the Achilles tendon better, you need to treat the plantar fascia and vice versa.

The deep part of where the Achilles tendon finishes is where the soleus muscle attaches on the inner part of the middle facet of the calacneus, while the lateral head of the gastrocnemius muscle attaches (in red) on to the outside part of the middle facet of the calacneus.

In the space between the calcaneus and the Achilles tendon, a distinct 2 chamber bursa was present in 15 out of 22 examined specimens (9 out of 12 fresh frozen specimens and 6 of the 10 embalmed). The smaller shallow medial chamber is located in front of the soleus tendon whereas the lateral chamber is in front of the lateral head of gastrocnemius tendon.

Here's what amazes me. From the dissections, the authors found that the Achilles tendon rotates as it goes down the leg. Meaning the fibers from the medial gastrocnemius head forms the back aspect of the tendon while the anterior part of the tendon is formed by the lateral gastrocnemius head and soleus muscles.

This article was helpful as it helped me pinpoint exactly where my problem was and most importantly it helped deepen my understanding of the function of each muscular, connective tissue part of the gastrocnemius, soleus and the Achilles tendon and their clinical relevance in the treatment of Achilles and plantar fascia problems.

So, if you are still having problems with your Achilles tendon and it does not seem to be getting better, show your healthcare practitioner the topmost picture so they know exactly which part to take note of. If they don't you can always come to our clinics.

Reference

Ballal MS, Walker CR and Molloy AP (2014). The Anatomical Footprint Of The Achilles Tendon: A Caderveric Study. Bone Joint J. 96B: 1344-1348. DOI: 10.10=302/0301-620X.96B10.33771

Toe Spring And Plantar Fasciitis

Ever wonder why so many people other than runners are getting plantar fasciitis? It may be because of the amount of 'toe spring' in your shoes.

You may have already noticed this in your running (or other) shoes, most of them seem to have 'toe spring'. Toe spring is how much the front of the shoe is curved upwards. This curve allows your foot to roll off the front of your foot more easily compared to wearing flatter soled shoes.

Hence, the toe spring allow your foot muscles to work less hard when you are walking or running. The more toe spring in the shoe, the less work your feet have to do.

However, this may lead to weaker foot muscles according to research (Sichting et al, 2020).Weaker intrinsic foot muscles may increase your chances of sustaining injuries like plantar fasciitis.

In the research which includes famed Harvard evolutionary biologist / barefoot running researcher, Daniel Lieberman, had subjects walk on a specially designed treadmill that had force plates and infrared cameras to measure how much power was put into each step.

The subjects walked barefoot in four different pairs of custom made sandals. The sandals had varying angles of toe spring from 10 to 40 degrees. These ranges of curvatures were designed to be similar to modern footwear.

Sandals were chosen as they allowed the researchers to see the exact motion of the subjects' feet as they walked. The different degrees of toe spring can be filmed to see how they affected their gait with special attention paid to the metatarsophalangeal (MTP) joints at the base of their toes. This is where the toe bones join to the foot bones.

The results showed that the more the shoes curved up front, the less propulsive force was generated with their MTP joints. This means that your intrinsic foot muscles are working less to maintain stability when you move making walking and running easier. However, it also decondition your foot muscles over time, making them weaker and not able to protect other structures in your foot.

Weaker intrinsic foot muscles make one more susceptible to conditions like plantar fasciitis as people rely on their plantar fascia to do what the intrinsic muscles normally do. This may also explain why people get injured if they transition too quickly minimalist type barefoot style running shoes.

Many of my patients who do not run with plantar fasciitis have been told to wear more 'supportive' and comfortable shoes while outside or even at home. This may be worse as their intrinsic foot muscles continue to weaken.

This is why shoes with more toe spring are popular because they are more comfortable and prevent your feet from tiring. This is great in a race and it may be why most racing shoes have a lot of toe spring (see picture below).

More research needs to be done with toe spring and foot injuries as other elements of footwear like stiffer soles and amount of cushioning can impact how our intrinsic foot muscles work.

So what should a runner do? Some physiotherapists and podiatrists often suggest doing intrinsic foot exercises like towel scrunching or pulling your toes toward your heel.

I suggest going barefoot more often. Either at the beach, or when you're at the playground with your kids. In Singapore we are generally barefoot while we're at home. That's better than wearing shoes with lots of toe spring at home. 

While training, look for running shoes with little or no toe spring when you train. 

For my patients who have plantar fasciitis, I tell them to wear flat slippers like Havaianas to minimize the effect of toe spring and for their intrinsic foot muscles to get stronger. 

That is totally different from what some other physiotherapists or podiatrists may suggest. Of course, I also treat plantar fasciitis differently from them.

Reference

Sichting F, Holowka NB, Hansen OB and Lieberman DE (2020). Effect Of The Upward Curvature Of Toe Springs On Walking Humans. Sci Reports 10, 14643. DOI: 10.1038/s441598-020-71247-9.

Asics Metaracer Tokyo - a racing shoe with lots of toe spring

What Supports The Medial Arch

I've been trying to keep myself busy during the circuit breaker and catch up on my reading and watching. Not watching Netflix, mind you. I don't have a Netflix account. At the risk of sounding like a dinosaur, I have never watched anything on Netflix.

Anyway, I've been trying to learn about the human body and how to best treat it when it's under duress. So here's sharing what I've learnt about the medial (or inner) arch and also by putting whatever I've learnt down, I can always refer back to this.

The human medial arch has a four muscles supporting it. Namely, Tibialis Anterior, Tibialis Posterior, Flexor Digitorum Longus  and Flexor Hallucis Longus (the last 3 are also known as Tom, Dick and Harry).

Back of R leg

Tom, Dick and Harry start from the back of the leg as seen in the picture above. Flexor Hallucis Longus (FHL), or Harry goes under the talus to the bottom of the big toe. This muscle carries the whole weight of the body while we push off while walking. This is also the same muscle that can cause bunions, as it puts undue pressure between the sesamoid bones under the big toe. But that will have to be another much longer post.

FHL goes in between the sesamoid bones under the big toe

I'm especially fascinated with the Tibialis Posterior muscle, especially how it attaches at the bottom of the foot in the picture below. See how wide and diverse the attachments are. It attaches to the calcaneus, the navicular bone, the 2nd - 4th metatarsals and also the cuboid.

Bottom of R foot

Other than the muscles, there is also the plantar fascia, helping to support the medial arch. Much more important than the muscles are the deeper arch support consisting of the Long Plantar Ligament (which attaches to the base of metatarsals and cuneiforms) and especially the Spring Ligament.

a = plantar fascia, b = long plantar ligament

The spring ligament is also known as the calcaneonavicular ligament (c in the picture above). It goes from the sustentaculum tali to the talus. It really acts like a trampoline to prevent your talus from flattening when you weight bear. This is most important for lifting or supporting our arches.

Typically, when we talk about arch support, we would think of taping the arch, changing our shoes, putting arch supports or orthotics into our shoes. But as you can see from the picture above that none of them can really help the spring ligament in supporting our arches.

We can really only affect/ or treat the muscles and the plantar fascia. Remember this. You may not need to buy anything fancy to support the spring ligament.

Another look at the dissected medial arch. 9 is the Long plantar ligament, 10 is the plantar fascia and 11 is the spring ligament.

Now you know.

McConnell Taping Versus Kinesio Taping

Me holding court

Day 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques started with me reviewing material we had gone through yesterday on Day 1.

After that we went straight into material for Day 2 and some of the questions the participants asked was how Mechanical Correction taping from Kinesio Taping would fare against Jenny McConnell's McConnell taping for the knee. Yes, Jenny McConnell's taping technique was first published (and made famous) in the Physiotherapy Journal way back in 1986. I remember reading the article and using the taping technique before.

McConnell's taping (L) vs Kinesio Taping

Here's a close up of what I did for Michelle's knees.

McConnell's on the (L)

No prizes for guessing which came out tops.

Michelle's happy

We had many fruitful clinical discussions on applications for the Medial Collateral Ligament (MCL), pes anserinus area, the Achilles tendon and of course the plantar fascia.

With the physiotherapy students

The four Physiotherapy students from SIT requested taking a picture with me after the course. Thanks for coming Sara, Mark, Priscilla and Dominic. The pleasure is all mine.

Group picture

A big thank to all for coming, especially to Nada and Faisal from Saudi Arabia, Tim from Loue Bicycles, Nisa and the Physiotherapy students and teachers, hope it was useful for everyone.

Patient With Plantar Fasciitis Who Saw Me 3 Days Ago Won 100 km Race

My patient who had been having plantar fasciitis came to see me 3 days ago in the clinic just won the 100  km Cameron Ultra-Trail race.

It was quite a last minute request and I could only fit her in for a 30 minute session during my lunch break (new cases usually have an hour's appointment in our clinic).

Have a look at our WhatsApp exchange.

Not bad for half an hour's work. Now at least I get a full hour to sort it out properly next week. What did I do to treat her? Let me review her case when I next see her and I'll do a follow up post if I find something interesting.

Achilles Tendon Length And Running Performance

My patient's L Achilles

Two years ago, after my marathon running patient tore his left Achilles tendon (AT) and had it repaired. About six weeks after the surgery, his surgical site got infected. The surgeon had to remove the repaired tendon. After the infection was cleared, the surgeon grafted the lateral gastrocnemius (calf) muscle to repair the tendon. 

Needless to say, he couldn't really run let alone think of finishing another marathon. After trying traditional Chinese medicine (TCM) and seeing another physiotherapist for over two years with not much improvement, a fellow runner I've treated before suggested he come and see me.

For runners, the hips, knee and ankle joints generate large amounts of forces during running. The ankle joint (via the Achilles tendon ) contributes remarkably to supply the power required while running.  

R calcaneus bone, where the Achilles inserts

The AT plays an important role in storing and returning elastic potential energy during the stance (foot flat on the ground) phase in walking and running. 

L Achilles inserting on calcaneus

I was wondering how else to help my patient when I came across a research paper investigating AT length and running performance on male Japanese 5000 meter runners (between 20-23 years of age). Their personal best times range from 13:54 minutes to just under 16 mins.

Their running economy was tested by calculating energy costs with three 4 minute runs at running speeds of 14, 16 and 18 km/h on a treadmill with a 4 minute active rest at 6 km/h.

Ready for the results? The researchers found that absolute length of the medial (inner) gastrocnemius (or calf), but not lateral gastrocnemius and soleus muscle correlated with a faster 5000 meter race time and lower energy cost during the submaximal treadmill tests at all 3 speeds tested.

This is after normalizing medial gastrocnemius muscle length with the subject's leg length. That is, the longer the medial gastrocnemius muscle, the better the running performance in endurance runners.

For the medically inclined, note that each AT length was calculated as the distance from the calcaneal tuberosity to the muscle tendon junction of the soleus, medial and lateral gastrocnemius respectively.

Possible reasons to achieving superior running performance may be that the longer medial gastrocnemius and AT store and return more elastic energy (and potentially reduces energy cost) from the ground reaction force compared to a shorter AT.

Have to treat both R and L leg

Reading that paper definitely gave me more clues to treat my patient (and other patients with Achilles tendon and plantar fascia problems). I am happy to say that my patient has since progressed to running up to 12 km.

He is now definitely looking forward to running his next marathon.

Reference

Ueno H, Suga T et al (2017). Relationship Between Achilles Tendon Length And Running Performance In Well-trained Male Endurance Runners. Scand J Med Sci in Sp. 28(2): 446-451. DOI: 10.1111/sms.12940.

Pregnant Mum Comes To Kinesio Taping Course

We have a pregnant mummy coming to our Kinesio Taping KT 1,2 course over the last 2 days. Now, not just any pregnant mummy, Li Ting is a postgrad trained physiotherapist (who came along with hubby Mathias- also a postgrad trained physiotherapist).

Li Ting and Mathias sharing thoughts on Mechanical Correction

Giving mummy Li Ting a rest while modifying the taping technique

After some revision in the morning (for yesterday's KT 1), the participants proceeded to learn six Corrective Techniques for KT 2.
Abdulla, one of the participants who flew in for the course specially from Maldives showing the class his version of how he kicks....

Edmund wondering .....

Hey, take a photo of my button hole cut 

Jason explaining how black and blue go together

Let's see who can do this better

Class photo

A big thank you to all the participants. Next Kinesio Taping Level 1 and 2 course will be held on June 22-23 at Progress Healthcare.

Please also see this..

Do You Need That Cortisone (Steroid) Injection?

Have you got any pain in your elbow, patella or Achilles tendon? I've seen many cases of what used be called tennis elbow or lateral epicondylitis and Achilles tendinitis in our clinics recently. What is now known as tendinopathy (or diseased tendon) of the elbow or Achilles as these cases are actually due to degenerative change rather than inflammation as numerous studies have shown.

Most of the time patients with tendon problems were given a cortisone (or corticosteroid) injection to treat the pain (rather than treating what caused the pain). Cortisone, an anti-inflammatory agent used to be one of the preferred treatments for overuse injuries of tendons (like tennis elbow, patella and Achilles tendinitis) which were notoriously resistant to treatment. Cortisone is often used to treat plantar fasciitis too. 

Pain wise the injections were effective, but as soon as the patients returned to the their sporting activity or even their daily activities, the pain returned. In adverse cases the tendons can even rupture. This happened on a few occasions when I was working at my previous job at the Singapore Sports Council with our national athletes after receiving the corticosteroid injections. They subsequently needed surgery to repair their ruptured tendons resulting in more time off. So for all you athletes out there, think three, four or five times and not just twice about taking that cortisone injection.

A major new review article published in the Lancet just last week raised major doubts on the efficacy (or wisdom) of using cortisone on tendon problems. Yes, the authors found plenty of evidence (in over 4 dozen high quality randomized controlled trials) that corticosteroid injections reduced patients' pain in the short term, but the effects were not great in the intermediate and long term. In fact patients receiving the injections had a much lower rate of recovery than those who did nothing or received physiotherapy (at 6 and 12 months). This was especially true for patients with tennis elbow pain, rotator cuff (swimmer's shoulder) pain and Achilles tendon pain.

There are more evidenced-based treatment for tendinopathy other than cortisone injections, ultrasound, massage, interferential currents etc. We at Physio and Sports Solutions practice evidenced-based physiotherapy (neural stretching, Mulligan MWM's, eccentric muscles strengthening exercises and Maitland joint mobilizations etc) to treat you. Come let us help you with your tendon injuries.

Reference


Coombes BK, Bisset L, Vicenzino B (2010). Efficacy And Safety Of Corticosteroid Injections And Other Injections For Management of Tendinopathy: A Systematic Review of Randomised Controlled Trials. The Lancet. Epub on 22 October 2010.


*Picture by Ballyscanion/Getty Images.