Today’s PrimalMed Prescription…Endurance!
Wonky Achilles tendon or Plantar fascia? Look NORTH to the calf!
So I got this email the other day…
Dear PrimalMD,
I usually don’t write or comment to Substack publications but I am at my wits end! My achilles tendon is ‘acting up’ and I can’t play pickleball. It’s been bugging me for 18 months. I’ve tried arch supports, stretching, and even injections but it is not improving! Any thoughts?
Sincerely,
Florida Man
Thanks Florida Man. Of course I have some thoughts and OPINIONS.
The discussion starts with WHY you have a wonky Achilles tendon in the first place. And that journey starts in the CALF.
The PrimalMed team recently returned from Disneyland, where PrimalMed Jr. ran his 9th half-marathon. We arose at 3 AM to make sure he was in his corral by 4 AM for the 5 AM start! There were about 10,000 runners who made the commitment to train for the race and get their keisters to the start line in the wee morning hours. Runners of all ages and shapes and sizes, some wearing Minnie and Mickey ears and many in costume.
Running for over 2 hours takes ENDURANCE. Mental endurance to stick to the training. Physical endurance to go the distance. Be it running, cycling, or even hiking the Dolomites, you must train to prevent injury.
Here’s my usual advice for preparing for such events:
Rule #1: Get to the start line UNINJURED.
Rule #2. Don’t trip and fall.
Rule#3. Train smart so you don’t get injured. The most common overuse injuries in runners are…you guessed it…achilles tendonitis and plantar fasciitis. How to prevent tendon overuse inuries?…muscle endurance.
MUSCULAR ENDURANCE PREVENTS TENDON INJURIES.
So, my friends, that brings us to today’s topic of endurance.
~ENDURANCE~
Here is the story of Sir Ernest Shackleton and the shipwreck of the HMS Endurance. If you think you’ve had a bad day/week/month/year, then read this link for a bit of inspiration! LINK HERE to learn more!
History lesson over. Time to move on to the science.
As a radiologist, I see MRI’s of injured ankles and feet. It’s my keen interest, probably because I have sustained, and recovered from both Achilles and Plantar issues that sidelined me in the past.
So let’s start with some Radiology.
I saw this yesterday. It’s a normal achilles tendon. It is that black line I labelled that is of uniform thickness and inserts into the top back of the heel bone (the calcaneus). It originates a bit higher in the calf muscle. You can feel your own achilles tendon just above your heel. It is that thick cord-like structure that moves up and down when you point your toes up and down.
Now look at this next image:
Do you see that the midportion or midsubstance of the tendon demonstrates fusiform thickening and has streaks of bright or white signal? Yep, that is ABNORMAL. The tendon is not torn or ruptured, but is degenerated. If you looked under a microscope at this tissue, you would see mostly disorganized cartilage and areas of fibrous and mucoid degeneration. Or, if you are not a science geek and simply looked in the mirror, the tendon would appear swollen and lumpy. It might be stiff and tender and possibly hurt when you walk. In mild cases, it aches a bit, which dissipates as you and the tendon warm up with movement and exercise. You find that you can complete your run or ride or hike. But it ain’t normal. There is no acute inflammation or ‘itis” so calling it a ‘tendonitis’ is a misnomer. We in the biz call it Achilles tendinopathy or Achilles tendonosis.
You can too.
Now the Plantar fascia is on the bottom of the heel. It too is a black line on MRI. It really is a type of connective tissue covering called an aponeurosis. It’s not really a fascia and certainly not a tendon, but it is CONNECTED to the back of the very same bone to which the achilles attaches. See below:
Now when the plantar fascia is irritated, it is sometimes called plantar fasciitis, but again, under the microscope there is no acute inflammation, just disorganized cartilage, fibrosis and areas of mucoid degeneration. Now here is an ABNORMAL plantar fascia:
See how the abnormal area is also thickened with intrinsic bright signal as it inserts on the calcaneus? LOOK FAMILIAR?
So Achilles tendinopathy and Plantar fasciopathy look and are VERY SIMILAR!
Radiology lesson over.
If you run. If you bike. If you hike. If you are over 40. If you live and breathe, I bet you or someone you know has had at one time or another an angry achilles or taken those exquisitely painful first morning steps seen with plantar ‘fasciitis.’
Now to be clear, I am NOT talking about a TEAR or rupture of the achilles tendon or plantar fascia. Achilles tears usually occur in normal tendons when an abnormal torque or force is applied. Like when you are playing basketball and you plant your foot then try to jump or pivot. It feels like someone hit you in the back of your heel and POP goes the tendon. GET THEE to a surgeon! See you in 4-6 months. A ruptured plantar fascia is painful and it is hard to put that foot down and walk. Hello boot! Those are ACUTE problems that require intervention.
We are talking today about CHRONIC issues.
WHY does it take so DARN long to recover from these injuries? Why do folks say it took 6 months or a year for their plantar fasciitis to “go away?” Or 12-18 months for the Achilles to ‘recover?’
Achy Achilles and Plantar fascia? LOOK NORTH TO THE CALF!
The best results, I believe, will come when we ADDRESS the root cause of the tendon or fascia issues.
I like to think of the achilles tendon and plantar fascia as connected cords on a pulley. Anchored respectively on the top and bottom of the posterior heel bone. Remember the above images? Now consider your calf muscles. If you stand on your toes, you will see a bulge in the calf- that’s your gastrocnemius muscle. There are two bellies so you may see a split with two halves. Do 20 calf raises where you go up and down and up and down on your toes with your leg straight! Feel the burn! That’s your gastrocs. Those are the muscles needed for propulsion. Now do that with your knees slightly bent. You will feel a deeper burn. That is the SOLEUS and TIBIALIS POSTERIOR muscles.
Running creates stress on the deep muscles of the calf as with each stride you are trying to brake and slow down. You are trying NOT to fall. The deep muscles of the calf are the unsung heroes here. The SOLEUS and the TIBIALIS POSTERIOR.
We need these muscles to be flexible and mobile so that they and NOT the achilles and plantar fascia absorb the stresses of use and overuse. We need MUSCULAR ENDURANCE. When the calf muscles fatigue, they develop trigger points and knots that interfere with optimal function. When the overlying fascia (sheet of connective tissue overlying the calf muscles) is dehydrated, it gets ‘sticky’ and knots or trigger points form. I addressed this more in the Back Attack post, but the point is, that you need healthy fascia in the calf and you need the key deep muscles of the calf to take on the load. Muscular endurance, not fatigue!
Unhappy calf muscles and fascia = unhappy achilles and plantar!
So when I say endurance in this context, I am not referring to a 4 hour marathon or 100 mile bike ride. I am talking about preventing muscular fatigue at the level of the calf, so that your tendons and fascia don’t take on an abnormal and overly stressful load.
So WHY do current therapies fail to help some folks? Now to be clear, I am not a physical therapist or orthopedic surgeon or podiatrist. I believe each case has unique features and you SHOULD be evaluated by a professional.
My opinion and observation is that current therapy is still 90% directed to the classic advice of rest, ice, ibuprofen and STRETCHING.
Here is the latest from JAMA, a review of the common painful foot and ankle conditions: LINK HERE !
Note that the therapies seem to revolve around LOCAL treatments and not only include stretching but also local injections such as steroids or PRP. These are not always successful and the literature at this point doesn’t support the use of PRP.
And here are the relevant infographics from that journal review:
My opinion? Don’t stretch an injured or compromised muscle or tendon. It needs to heal and you need to LOOSEN and MOBILIZE the muscle fibers and fascia so they become functional and strong. THEN and only then will the downstream achilles and plantar fascia heal. Aggressive stretching of the plantar fascia and achilles will aggrevate, and irritate, and prolong the injury and delay healing.
So before you stretch, you gotta loosen and mobilize the calf tissue. And that means massage, and working out those nasty knots and trigger points! Remember the analogy of your fascia being like a sponge? If the calf fascia is like a hard, dry inflexible sponge then the whole pulley system on the ankle and calf is compromised. You can stretch all you want and you may get some temporary relief, but I think you will get better, quicker and long lasting relief if you roll out and squish out the deep calf muscle first, as your FIRST line of attack!
So HOW do we go from KNOWING to DOING?
Hydrate. That’s the low hanging fruit. You want that sponge to be moist!
Do what I call “The Squeegee!” Stand up, put your wonky leg with knee bent on the chair and press your fist down on to the fleshy calf. Pound it out and focus on the deep central calf between the two bellies of the gastrocnemius. Make believe you are squeezing out a moist sponge.
Then do what I call ‘The Gripper!’ Cross your wonky leg over the good knee and grab the calf with 4 fingers over the top and your thumb behind the shin bone. You gotta go UNDER the shin bone and deep. Poke around with your thumb and feel for tender spots. Rub em out!
When your calf muscles like the Soleus and Tibialis Posterior are loosey goosey and well hydrated, then the ROOT CAUSE of your tendon dysfunction has been addressed. THEN you can focus on strengthening the calf. See the above infographic. The ECCENTRIC calf exercises have been shown to be helpful for many. They will allow your calf to develop the necessary MUSCULAR ENDURANCE that will help prevent the downstream tendon and fascia issues!
To build muscular endurance, if you are not injured, try some calf raises with toes straight, toes pointed out and toes pointed in. Do 100 over the day or until you feel the burn! Do ‘em with legs straight to work the gastrocs and do ‘em with knees slightly bent to work that unsung hero, the soleus! 100 too easy? Let me know when you’ve done 500 over the course of a day!
TL;DR: Here’s the plan Florida Man!
If the foot or ankle hurts, then a local approach with ice massage on the tendon, arch supports or a boot for a few days may help in the short term and get you out through the ‘pain dynamic.”
You gotta address the ROOT CAUSE (a common theme throughout the PrimalMed posts). FOCUS on the calf trigger points BEFORE you stretch and strengthen. Loosey goosey calf muscles = happy tendons!
Try to walk barefoot around the house! Wake up those small muscles in the feet and ankles. That will build muscular endurance. Don’t stub your toe!
Try walking BACKWARDS! It is a great way to ease into eccentric training of the calf and plantar fascia and achilles tendon. Start in your hallway under the supervision of your wife.
And listen to some Bruce (a favorite of Florida Man) while you rehab!
Ted Metzger, MD is a practicing board certified Radiologist as well as founder and owner of PrimalMed, LLC. PrimalMed educates and advocates on Metabolic Health and Wellness, as seen through the lens of a curious radiologist.
Ellen Metzger MS, RD - the other half of the PrimalMed team, is an Integrative Registered Dietitian, addressing ancestral and primal nutrition principles as drivers of metabolic health and wellness.
The information in this article is designed for educational purposes only and is not intended to be a substitute for informed medical advice or care. This information should not be used to diagnose or treat any health problems or illnesses without consulting a doctor. Consult with a health care practitioner before relying on any information in this article or on the PrimalMed website.
Thank you as always for the lesson....
Thanks Ted for another interesting and witty article!