Foot and Ankle
The Achilles tendon is the strongest tendon in the body, connecting the calf muscles to their insertion on the heel bone, or calcaneus. Achilles tendinitis is a common overuse injury in sport. It can be a killjoy – it affects walking, hiking and many sporting activities.
Pain in the rearfoot can arise from several sources – the most common site is in the mid-portion of the tendon, or at its insertion point at the heel. Classically, the tendon becomes thickened, stiff and very tender to touch. Other conditions that can cause pain in this region are bursitis, and rarely – a neuroma in the nerve that runs along the inside of the tendon.
The term “Achilles tendinitis” is somewhat misleading, “itis” meaning inflammation. Often, the tendon’s cellular make-up is degraded, and the more accurate term would be “tendonosis”, or “tendinopathy”. This is why anti-inflammatory medications often don’t work – as the underlying problem may not be inflammation.
There are several factors that predispose to Achilles tendinopathy: years of running (runners have a 30 times greater risk of tendinopathy), a recent change or poor choice of footwear, excessive calf tightness or calf weakness, and most commonly – a sudden increase in activity, such as speed, distance or volume of uphill running. Non-runners can develop Achilles pain – some have feet that pronate excessively. In over-pronators, a whipping motion of the heel is created which produces strain in the mid-portion of the Achilles tendon.
Your physiotherapist can provide several different treatment options for Achilles tendinopathy. These vary according to the location of the lesion and whether the condition is acute or chronic. A physiotherapy assessment is helpful to identify whether there are biomechanical factors that have contributed to the problem. It is important to rule out a partial tear – which may require a diagnostic ultrasound to determine.
An eccentric heel drop program works very well with chronic tendinopathy in the mid-third of the Achilles tendon. This is a graded exercise protocol. The heel is lowered over the edge of a step repeatedly, one set with the knee flexed, another with the knee straight. The volume of repetitions and speed are increased over time, generally 6-8 weeks.
Therapeutic ultrasound, and friction massage, performed by your physiotherapist, can help. Both provide an increase in the volume of collagen, an important component of tendon tissue. If tight areas in the calf muscles are found, massage, acupuncture and soft tissue release can help. Other issues in the rearfoot, such as a stiff subtalar joint (just above the heel) can be mobilized to help improve shock absorption. In some cases, a temporary slight heel lift can provide short-term relief. Kinesiotape, a one-way stretch tape applied along the tendon and margins of the calf muscle often provides immediate reduction in pain as the tendon is repairing. Relative rest and a change in training patterns for runners is critical in many cases to allow the cells in the tendon to repair and regenerate.
In cases where the tendon problems don’t respond to conservative therapy, there are other medical options available.
Sports
IT Band Syndrome
Its the time of year when its great to get back outdoors, and when many of us become more physically active again. As our bodies adjust to the increased activity, sometimes there are aches and pains that come along with it. One such problem that commonly occurs in the hip or knee is Iliotibial (or IT) Band Syndrome.
The IT band is a connective tissue that runs from the muscles in the hip, down the outer thigh to connect into the outside of the knee. When you increase your activity levels, particularly running or hiking, then the hip and thigh muscles are required to work harder and as they recover they may have that tight post-exercise feeling. Because these muscles connect directly into the IT band, more tightness in them will increase the tension of the IT band itself. As the IT Band travels down the outer thigh, it runs over two bony prominences – one on the outside of the hip, and the other on the outside of the knee. An increase in tension of the IT band can therefore cause increased friction as it rubs over the bone, which leads to inflammation and pain in the outer hip and/or knee region.
There are some common features that may predispose someone to encountering this problem. These include muscle imbalance, sudden increase in training, running or hiking up and down hills, type of foot wear, and running/ walking gait pattern.
Once the causative factors have been identified with the help of your physiotherapist, IT band syndrome can usually be managed well. Physiotherapists have an effective way of releasing the tension in the IT Band by using acupuncture needles combined with some massage techniques. As well as reducing IT Band tension and reducing the inflammation in the irritated tissue, specific strengthening of the muscles around the hip and knee is required to take some of the stress off the IT band. This will ensure that as you continue to hike or run, there is less friction on the IT Band as it moves over the underlying bone, and less friction means less pain.
So if pain in your hip or knee is stopping you from getting out there this spring, it may be a fixable case of IT Band syndrome.
Vestibular Rehabilitation (Dizziness and Vertigo)
Vertigo, Inner Ear & Dizziness
Vestibular Rehabilitation’ is an area of focus in my physiotherapy practise – I am often asked what exactly that means. The vestibular system (involving your inner ear) is responsible for sense of movement, body orientation and balance. The vestibular system (along with our eyes, muscles, and joints) send constant feedback to our brain about our body’s movement and orientation.
Dysfunctions, disorders, trauma or viruses that affect the inner ear can be a potential cause of vertigo, dizziness, decreased balance, tinnitus (ringing in the ears) or a change in hearing. As a vestibular therapist I can assess the potential causes of the mentioned symptoms and provide treatment to help decrease dizziness, vertigo and improve balance.
Dizziness is the umbrella term that refers to a sensation of abnormal, unwanted, movement – a feeling of unsteadiness, lightheaded or feeling ‘off’. Vertigo is a more specific term and implies that there is a rotational component to your dizziness – either the room is spinning around you or you are spinning in the room. Both vertigo and dizziness are symptoms, not a diagnosis, so part of my job is to figure out the possible cause and provide treatment.
One of the most common conditions within the inner ear that I treat is a condition called BPPV – benign paroxysmal positional vertigo. BPPV is caused by a crystal that is free floating within the inner ear. The signs and symptoms are pretty easy to recognize (vertigo brought on when lying flat, rolling in bed, looking up to the ceiling or bending forward). Treatment for BPPV is also quite effective.
It is also important to recognize that not all causes of vertigo or dizziness are associated with problems in the inner ear. Cardiovascular (heart) disorders, thyroid conditions, anxiety, migraines, neck disorders/injuries and neurological conditions are all potential causes.
Robina Palmer is a registered Physiotherapist and co-owner of Sun City Physiotherapy.
Robina is a graduate of University of British Columbia’s School of Rehabilitation Medicine. She has practiced in sports and orthopaedic rehabilitation in various clinical settings throughout the United States and Canada.
Physio Articles
BODY ROLLING: A new way to enhance flexibility and well being.
How often do you get a tight area in your back that you’d love to get rid of? Or a tense band in your buttock or hamstring that has plagued you for weeks?
Have you noticed that your shoulders round forward, and you’re tight across the back of your shoulders?
The nagging tight spots we feel can be the result of restricted mobility or adhesions in fascia, the elastic web of connective tissue that surrounds and connects muscles.
There is a technique to improve flexibility that is easy, inexpensive and works extremely well in conjunction with stretching to improve myofascial mobility. It’s called Body Rolling, and it’s a powerful self-treatment tool using a firm 5” diameter ball. It is similar to using foam rollers, which are popular in gyms. Because of its size and compressibility, it is useful in areas other tools can’t reach.
Body Rolling techniques combine the relaxing effects of massage with the toning effects of exercise. Working with your own body weight, the exercises ease movement by loosening the muscles and their surrounding fascia, with the benefits of a deep self-massage. It can take as little as 10 minutes to work a specific area, and you can do it at your convenience. Working an entire region or chain of muscles gives the best results, since fascia is connected in long tracts that can span more than one joint.
The techniques of Body Rolling can: free adhesions in the connective tissue sheath that wraps around muscles and lies between muscle fibres; help muscles lengthen; improve muscle flexibility and tone thereby improving range of motion and shock absorption in the joints; improve circulation; and assist in correction of faulty posture
People with an active lifestyle often come in to see a physiotherapist with unexplained pain in a muscle, tendon or joint. Physiotherapists look at posture, movement and perform selective tissue tension testing to determine the problem. As a physiotherapist, I use many tools, such as manual therapy, exercise and soft tissue releases to improve freedom of movement.
With exercise that is highly repetitive in nature such as running, cycling, rowing, racquet sports, fascia surrounding the working muscles tends to be loaded in one direction and can subsequently shorten. Movement patterns and normal posture can be altered, which can lead to injury and pain. Learning to use Body Rolling, and stretching along planes of movement, rather than spot-treating tight areas can free things up most effectively.
People working at a desk job every day tend to develop shortening in certain muscle groups– typically the pectoral muscles, the hip flexors, and the hamstring muscles. Over time, this can result in adaptive shortening. The price tag of a desk job can be poor posture, aches and pains at the end of the workday. Activity breaks and Body Rolling can help.
TMJ / Jaw
Argh! You woke up with another headache, and your teeth hurt from clenching yesterday at work, as you just met another stressful deadline. As you massage your temples and face, which actually feels relieving, your significant other tells you about your loud teeth grinding last night. As you look in the mirror while brushing your teeth, you are always intrigued by how your jaw “wiggles” side to side when you open your mouth. It’s done that for years but hasn’t created any other problems to your jaw function. Sound familiar? You are presenting with Myofascial Pain Dysfunction (MPD) of the Temporomandibular Joint, the TMJ.
The TMJ is the ball and socket joint that connects the Mandible (jaw bone) and the Temporal bone (one of the bones of your skull). It’s the small joint located in front of your ear. There is a cartilage cushion in between the ball and socket, referred to as the Disc. The disc is supported by special Ligaments, which keep the disc in place. Movement problems of the disc can be responsible for creating many symptoms in the TMJ, such as clicking, crepitations, locking, muscle spasm, and pain. There are several muscles which support and control movements of the TMJ. Symptoms can often be related to these muscles. These include temporal pain, headaches, muscle spams, tinnitus and ear pain, and even teeth pain.
TMJ Disorder/Dysfunction, or TMJD/TMD, is seen more commonly in women than men. There is a 3:1 incidence in females to males, and can include one or both jaw joints. In most instances, the dysfunction is a result of an imbalance or change in the normal function of the bones, ligaments, muscles, disc, or nerve components of the TMJ complex.
MPD can be due to various causes of increased muscle tension and spasm. In some instances, MPD can be a physical manifestation of psychological stress. Often, there is no disorder of the joint itself. There is often a history of facial pain and temporal headaches, secondary to Nocturnal (night time) jaw clenching and Bruxism (teeth grinding). Dental issues may have influenced symptoms over time. This might have lead to the use of a nighttime splint. There may also be ear pain, fullness, or tinnitus. Erratic movement patterns of the jaw during opening and closing are related to lack of neuromuscular control, which requires re-education through physical therapy.
The TMJ specific muscles involved in MPD are the Temporalis and Masseter. The temporalis is a fan-shaped muscle that fills the temporal space, and inserts onto the mandible. Its function is to raise the mandible to close your jaw. The masseter is a thick and strong muscle attached at your cheekbone and runs to the angle of the mandible. Its function is to also raise the mandible to close your jaw. Try this: clench your teeth several times and press your fingers firmly on your temples; now on your cheeks. Did you feel tenderness? Aching? Maybe even a sensation like a toothache? WHAT IS THE SIGNIFICANCE? These muscles become subjected to fatigue and overuse with prolonged and persistent clenching and bruxism, which leads to MPD symptoms. It’s like these muscles are running a marathon without rest, everyday!
Proper assessment, diagnosis, and successful treatment rely on a skilled physical therapy practitioner, with expertise in TMJ management. Treatment of MPD is focused on desensitizing muscles through hands-on mobilization, restoration of normal functional movement pattern through exercise, and providing education regarding prognosis and self applied maintenance. Treatment may also include other muscle re-education techniques such as Intramuscular Stimulation (IMS). We look at other mechanical influences such as neck disorder and posture, to assist in maximizing treatment management. At times, we often work with your oral practitioner (dentist, orthodontist, oral surgeon), and other practitioners who deal with behavioural modification, to optimize results.
Vince Cunanan is a TMJ Specialist and registered physiotherapist and associate at Sun City Physiotherapy Downtown Kelowna. He can be contacted at downtown@suncityphysiotherapy.com.
