Ankle and Foot: Part 4 (Insufficient Dorsiflexion)

According to some pilot work, what may be key to treating insertional calcaneal tendon pain?

-avoiding end range dorsiflexion -avoid compressing the insertion site

What are the contributing factors to insufficient dorsiflexion?

-limited dorsiflexion -short gastroc/soleus -limited accessory motion -recent change in footwear

What mobilizations can you use to increase dorsiflexion?

-mobilization with motion AP glide with a lunge -AP glide of the talocrural joint in supine/sitting

When are you able to use insufficient dorsiflexion as an MSI diagnosis?

-only if they don't have pronation or supination -it is a diagnosis of exclusion

What are the key tests and signs of bursa involvement?

-pain with direct pressure (palpation) -local edema

Describe the Stevens eccentric overload for calcaneal tendon and muscle belly treatment

-similar to Alfredson with a couple exceptions -do as tolerated -perform a volume that is tolerable less intensive, still performing many reps per day, symptoms matter more, overall no difference in outcomes

Describe the Alfredson eccentric overload for calcaneal tendon and muscle belly treatment

-single leg lowering below toe level (on stairs) -perform with knee straight and knee bent -perform 2x/day -perform 3 sets of 15 reps -perform 7 days/week -perform for 6-12 weeks -add weight to progress very intensive, 180 reps/day, doesn't worry much about symptoms

What are the differential diagnoses for gastroc/calcaneal tendon involvement?

1. DVT 2. Compartment syndrome 3. low back pain

What active and passive movements may cause pain if the bursa is involved?

1. Passive or Active DF 2. Resisted or Active PF 3. end range Passive PF (maybe)

What appear to be the key components to tendon dose and load dependent protocols?

1. overload 2. rest relative to load 3. monitor symptoms carefully

What is the specific treatment of pain with bursa involvement?

1. remove the irritant 2. may need to modify footwear 3. use a pad with a donut to remove force

Other than muscle/tendon pain, what are some additional findings associated with calcaneal tendon & gastroc/soleus muscle involvement?

1. short/stiff gastroc/soleus/achilles complex 2. early heel rise during gait

How much rest between loading has been shown to keep a positive net balance of synthesis over degradation?

24-48 hours

What pain number is the highest acceptable pain when performing eccentric heel raises?

Mary says up to 5 is okay

How should you treat insertional calcaneal tendon pain?

Protect it -heel lift -tape -boot maybe Stretch Correct movement impairments

Which takes longer to adapt to loading? a. muscle b. tendon

b (tendon)

What is prolonged dorsiflexion?

compression of the anterior talocrural joint from being in dorsiflexion too much or too long

T/F insertional calcaneal tendon pain responds well to eccentric loading

false

What is a common movement fault during a squat test for limited dorsiflexion?

heels come off the ground

What populations might benefit from 24-48 hours rest between loading instead of performing these heel raises everyday?

older, non-athletes

What are contributing factors to prolonged dorsiflexion?

poor recruitment of the plantarflexors

Where are symptoms located if the bursa is involved in the patient's pain?

the posterior calcaneus

Mid-substance calcaneal tendon and muscle belly treatment

there are a couple different thought processes: 1. eccentric overload with no rest (Alfredson) 2. eccentric overload as tolerated (Stevens) don't forget stretching, heel lifts, and taping

T/F different areas of the achilles tendon respond differently to treatment

true, mid-portion responds differently than the insertional portion

T/F achilles tendon treatment should be different depending on the location of the symptoms

true, mid-substance different than insertional

What populations might the Alfredson protocol be good for?

younger and/or athletic populations