Lower leg, ankle, foot

Nick is an assistant coach and runner (miler) for Stotan Racing, a Nike sponsored running team located in Central New York.  Over the course of a year’s time, Stotan runners often present at different times for different injuries.  In this particular instance Nick called me complaining of L Achilles tendon pain that was rendering him unable to train.

I usually have some conversation with my clients regarding their client history.  In this case, I wanted to see if I could develop some information about Nick’s foot strike, especially regarding heel/mid-foot/forefoot foot strike.  Nick was pretty straight forward about being a forefoot striker.  I also asked him about any previous medial tibial (shin splint) symptoms.  Nick revealed that he had often experienced ‘shin splint’ pain secondary to Achilles pain.

From the standing postural assessment, I observed that Nick was a bit of a pronator at both ankles, but more so on the left.  I got him on the table, in the prone position, and palpated his L calf.  There was no redness or swelling in the Achilles area, so I thought we were probably dealing with an –osis condition, as opposed to an –itis condition.

Achilles tendon pain typically arises from a posterior compartment problem.  The posterior compartment includes the gastrocnemius, soleus, posterior tibialis, flexor hallicus longus, and flexor digitorum longus.  My first action was to test the four primary movements of the ankle joint.

Summary:                           AROM                   PROM                   RROM

Plantar flexion                   40˚WNL                soft/lig                  pain

Dorsiflexion                        20˚WNL                soft                        no pain

Inversion                             40˚WNL                soft                        no pain

Eversion                               20˚WNL                B.O.B.                   no pain

Keeping in mind the architecture of the superficial back line (from the waist down), I began the Tx by lengthening Nick’s L hamstring group, hoping to release any excessive fascial tension that might be effecting the posterior compartment of the lower leg.   I then continued with the gastrocnemius protocol. Nick’s gastroc responded well, but my pressure on his soleus became uncomfortable.  I reassessed his soleus with a resisted muscle test and Nick put his finger on a painful spot, which was right on the midline of the calf just below the heads of the gastroc. This typically indicates a soleus muscle strain.  I decided to work this area last.

A shortened and contracted soleus is the number one cause of Achilles tendinosis, so I shifted my focus to his soleus.  I spent a good amount of time with myofascial release and cross-fiber gliding, working slowly, superficial to deep and proximal to distal.

I already knew where the muscle strain was, so I continued with multidirectional friction to the strained fibers of Nick’s soleus.  After a couple of 30 second sequences, Nick was able to achieve pain-free movement (plantar flexion).  We moved on to eccentric scar tissue alignment, and it took a couple more sequences of multidirectional friction, working slower and deeper, to achieve a pain-free eccentric contraction.

For the last piece of the Tx, I wanted to lengthen the connective tissue to create myofascial unwinding around the Achilles tendon. I decided to try to directly release the fascia surrounding the Achilles tendon.  For this part of the protocol, I placed Nick in the prone position with his knee extended. In this position, his ankle appeared to be in the neutral position, so I utilized a two-finger gliding stroke working proximally to distally.  Initially, I passively dorsiflexed Nick’s ankle, with my knee, as I performed the gliding strokes.  Eventually, I had Nick actively dorsiflex, as I worked the tendon.

To finish the session, I made sure that Nick was familiar and competent in stretching the gastroc and soleus.  Specifically, I worked with him so he would be able to utilize the PNF techniques, which I think are much safer and more effective than just trying to lengthen the muscles by trying to pull them apart by force.  Nick took my advice and stretched for 21 days straight.  At the same time, I had him work on strengthening his dorsiflexors and inverters, especially the posterior tibialis.

Nick is currently training and racing pain-free.

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