The D-Generation: Achillies Tendinopathy on a Continuum


The achillies tendon is formed in two separate mechanisms. The first is the converging of the gastrocnemius and soleus aponeurosis 12cm above the calcaneal insertion. The Second is the with gastrocnemius aponeurosis inserting directly into the soleus aponeurosis. The achillies tendon has a round shape proximately, however flatten in the distal 4cm before insertion. The fibers of the tendon spiral approximately 90deg to allow for maximal elongation and energy storage release on propulsion.
The tendon is enveloped in a para-tendon consisting of two layers which originate from the deep fascia of the leg.
Tendons are stiff, resilient, high tensile strength incorporating anatomical structures which can stretch up to 4% before damage may occur. A number of theories resonate with the development of achillies tendon injury, the most prominent being overuse stress, however, other theories include; poor vascularity, poor flexibility, gender, genetics, metabolic factors and endocrine factors.
Achillies tendinopathy is a common degenerative injury among athletes who are involved in a lot of running. Development of the condition can occur due to a number of issues including; muscle power and tendon elasticity imbalance, a sudden increase in training intensity or duration and inadequate warm up or stretching before the completion of an explosive activity (B). Achillies tendinopathy in middle-long distance runners compared to both white collar and blue collar workers has been found to be statistically significant p <0.001 (Kujala, Sarna, & Kaprio, 2005).
The morphology of healthy tendons has been shown to be of different make-up in a normal tendon, however appears to be indistinguishable when pathology is present within the tendon.
When trying to best diagnose a suspect achillies tendinopathy, a full history should be received covering past treatment, medication, medical conditions, training patterns, past training patterns and footwear use. Palpation of the achillies tendon at insertion mid portion, origin and surrounding tissues should be complete and in many circumstances the use of US or MRI may be appropriate to confirm the diagnosis.
It is suspected that tendon degeneration begins long before symptoms begin and may even remain asymptomatic in some cases. Early diagnosis is of practical relevance particularly in high performance sport. Despite popular belief (Hirschmuller, et al., 2012)found there to be no significant link between gender and achillies tendinopathy development.
Cook and Purdam, 2010 , has described tendinopathy to be on a continuum which incorporates 3 inter-weaving stages and suggests that each may be required to be managed differently depending where on the continuum the pathology resides.
Reactive Tendinopathy: Is a non-inflammatory response to compressive or acute tensile forces which develops a thickening and therefore increased cross section of the tendon, usually due a sudden increase in activity which an individual may not be used too. There is no change in the vascularity of the tendon matrix and collagen is mostly maintained at this point.
Tendon Disrepair: Is seen as a tendon which will make an attempt to repair, as seen in the reactive tendon but suffers from increase matrix breakdown and collagen separation. The placement of this within the spectrum will generally be associated with high intensity or repetitive load over a long duration. It is still somewhat possible to reverse anatomical and physiological changes at this point.
Tendon Degeneration: Is clearly identified by changes to the matrix and cells within the tendon. The ability of the tendon to reverse any possible pathology has diminished and some cell apoptosis has occurred. Through imaging these is visualization of extensive changes around the area of concern.
When clinically managing a patient it is important to address their expectations of performance and return to sport by supplying them with a modified and sensible training plan or referring them to someone who may be able to develop a program like this for them. The activity which is believed to have instigated the problem should be ceased in the acute stages so that collagen fibers can repair and rehabilitation activities involving loading the achillies can begin to stimulate the remodeling process.
(Kader, Saxena, Movin, & Maffull, 2002) found that an eccentric loading program had a statistically significant outcome in the rehabilitation of the achillies tendon, over that of a concentric loading program. When looked at from a sport specific point of view concentric based training is the primary educated tool for most training program outside of rehabilitation and therefore the eccentric stage of movement are neglected hence we can revisit that debate of imbalance in power of the muscles vs elasticity of the tendon and ability to absorb heavy load under stress.

The achillies tendon, differentiating from other tendons, has been shown to respond to loading regimes which target the specific demands of the mid or insertional aspects of the tendon. The loads are required to be of significant stressors for the area of pathology and encourage the development of strength due to the nature of achillies tendinopathy being cause mostly via inadequate rest from repetitive load over a long duration.
The use of a 12-15mm heel raise (inclusive of heel drop of shoe) has been found to be clinically significant, however, has not been found to be evidently substantial as an offloading mechanism. The use of cryotherapy aims to reduce the metabolic rate of the achillies tendon, decreasing extravasation of blood and protein from new capillaries found in the tendon as well as producing an analgesic effect.
It is suggested that surgical intervention or opinion be sort after 6months of non-effective conservative treatment, however it should also be mentioned that poor outcomes are regularly seen for those patients with long standing issues, therefore to manage the risk of undertreating a patient it may be worth referring them for surgical opinion much earlier.
Furthermore, adequate dorsiflexion range of motion is essential during gait (both walking and running), walking stairs and as part of landing mechanics. Dorsiflexion during landing activities of specific sports is required for the absorption and dissipation of the high Ground Reaction Forces encounted upon ground contact. If dorsiflexion range of motion is inadequate, it can be inferred that increased loading of the plantarflexor complex. Ankle injuries account for approximately 20-30% of all sporting injuries, this is inclusive of any soft tissue which crosses the ankle joint ala achillies tendon. Inadequate dorsiflexion has been noted to increase the risk of ankle joint sprain, fractures or musculoskeletal injuries during sport.

Jackson McCosker
Director /Chief Editor

Bibliography
Barnes, K., McGuigan, M., & Kilding, A. (2014). Lower-Body Determinant of Running Economy in Male and Female Distance Runners. Journal of Strength and Conditioning Research, 1289 – 1297.

Cook, J., & Purdam, C. (2010). Is Tendon Pathology a Continuum? A Pathology Model to Explain the Clinical Presentation of Load- Induced Tendinopathy. British Journal of Sports Medicine, 409 – 416.

Hirschmuller, A., Frey, L., Konstantindis, H., Baur, H., Dickhuth, N., Sudkamp, P., & Helwig, P. (2012). Prognostic Valus of Achillies Tendon Doppler Sonography in Asymptomatic Runners. American College of Sports Medicine, 199 – 205.

Kader, D., Saxena, A., Movin, T., & Maffull, N. (2002). Achillies Tendinopathy: Some Aspects of Basic Science and Clinical Management. BJSportsMed, 239 – 249.

Kongsgaard, M., Aagarrd, P., Kjaer, M., & Magnusson, S. (2005). Structual Achillies Tendon Properties in Athletes Subjected to Different Exercise Modes and in Achillies Tendon Rupture Patients. American Physiological Society, 1965 – 1971.

Kujala, U., Sarna, S., & Kaprio, J. (2005). Cumulative Incidence of Achillies Tendon Rupture and Tendinopathy in Male Former Elite Runners. Clinical Journal of Sports Medicine, 133 – 134.

Kulmala, J., Avela, J., Pasanen, K., & Parkkari, J. (2013). Forefoot Strikers Exhibit Lower Running Induced Knee Loading than Rearfoot Strikers. American College of Sports Medicine, 2306 – 2313.

Maffuli, N., Kenward, M., Testa, V., Capasso, G., Regine, R., & King, J. (2001). Clinical Diagnosis of Achillies Tendinopathy with Tendinosis. Clinical Journal of Sports Medicine, 11 – 15.

Malliaras, P., & Purdam, C. (2014). Rehabilitation of Lower Limb Tendinopathiy.
Omey, M., & Micheli, L. (1999). Foot and Ankle Problems in the Young Athlete. Medicine and Science in Sports and Exercise, S470 – S486.

Patterson-Kane, J., & Rich, T. (2014). Achillies Tendon in Elite Athletes: Lessons in Pathophysiology from Their Equine Counterparts. ILAR Journal, 86 – 99.

Whitting, J., Steele, J., McGhee, E., & Munro, B. (2011). Dorsiflexion Capacity Affects Achillies Tendon Loading During Drop Landings. American College of Sports Medicine, 706 – 713.

The Evolution of Athletic Footwear: A History


It’s been almost 2500 years since Pheidippides ran from Greece to Athens in terra cotta boots to deliver his important message and sparking the Legend of Marathon. Since that time the development of athletic footwear has come a long way in design, materials, promotion, lawsuits and claims of ability. This article takes us back through the major developments of athletic footwear from the over decorated flower pot to today’s array of specialised sport equipment for the feet.

In the 300AD shoes began to be used for different reasons for the first time. Many of the different clog, boot and sandal materials which had been utilized over the years such as animal hide, reeds and woods were used as the materials to make specialized footwear. The wealthier of the time would have pairs for shopping, events and farming; while the poor may have a pair for work and a pair for inside the home (if they were lucky).

The 16th Century saw the development of the first American shoe factory with commercial quantities of shoes being manufactured as the modest cobbler became a cunning entrepreneur. At this time the primary structure of shoes were a wooden sole and leather upper until 1892 when the pre-curser shoe model for the Converse All Stars (The Keds) was released sporting the first rubber sole and canvas upper, producing a lighter, more breathable and cushioned shoe for the market.
The 1920’s were the rise of the highly cushioned, light athletic shoe. New Balance Arch Co. were the first to claim that their shoes were the answer to aching feet and Converse released their still popular and one of the first commercially placed basketball shoes the ALL STAR and followed up three years later with the equally popular edition of the CHUCK TAYLOR. From this point the association of sports footwear and high profile athletes was melded and the history of the modern athletic shoe was changed forever.

The 1936 Olympics in Berlin saw a young Jesse Owens donned in Germany’s own sporting brand ADIDAS and taking home 4 Gold medals to the United States only three years before the beginning of World War II. The victories only increased America’s obsession with track and cross country running leading to development of spiked shoes for traction.fixx_shoes

The 1960’s saw the development of the first Shod Vs Barefoot debate, but with social media still almost half a century away the debate was soon forgotten as New Balance release there next big claim in athletic footwear the “TRACKSTER” a shoe claimed to stop shin splints, weighing only 11 ounces and coming in at a retail price of $US15 it quickly became a crowd favourite. Shortly there-after with running shoes being a popular discussion point, the first running shoe review was published and Runner centred retail stores opened their doors ala The Athletes Foot (1972).

The 1970’s saw the practice of jogging come into play for health benefits and fun. With commercial quantities of shoes being produced and sold within specialty stores they quickly became affordable and accessible to almost everyone – and here begins battle of the brands!
Nike developed their waffle trainer providing cushioning and traction to a light weight shoe without the need for spikes, while Brookes produced the first ever EVA midsole and varus wedged shoe in the VANTAGE promoting what was the early brainstorm of motion control in footwear; and finally Red Onitsuka Tiger racing flats take best seller before mass production of running shoes is moved overseas allowing the space aged air cushioned Nike Tailwind to enter the market.

The 80’s and 90’s were dominated by Nike, Reebok and Adidas; with brands like Brookes, New Balance and Dunlop taking a backseat in the market. New Balance did release the first athletic shoes to retail at $100 but with the height of the American Stock Market in the early 80’s and the removal of the US dollar from the gold standard, money was no longer what money used to be. The customer was more interested in technology and cosmetics with both ADIDAS and REEBOK taking advantage of this gap in the market place with the release of the MICROPACER; the first piece of footwear with the technical insertion of a pedometer and the iconic PUMPS which could be inflated to give the feeling of walking on air.

In the mid 90’s the barefoot vs shod debate kicked off again after the World Steeplechase Championships was won by a barefoot athlete. A few magazines published articles and health professionals were asked repeatedly what their thoughts were, but the internet was still teetereebok-pump-kamikaze-ii-release-date-6ring away at 28kps and even MSN was yet to be released amongst those lucky enough to be connected.

The Naughties brought what could only be described as a continuum of footwear productions, with the release of the NIKE FREE in 2004 as a “training tool”, closely followed by the Vibram FiveFingers in 2005 (previously an amphibious clog for kayaking) and the highly promoted “Born to Run” book being published the minimalistic motion of the ideal run was in full swing. Unfortunately for Vibram this ended in a large class action for health benefits it claimed to have which were later found to be implausible.
At the other end of the scale you have the revolt of the HOKA ONE ONE a maximalist shoe which boasted more than 2cm of cushioning and very little perceptive feedback. The complete opposite end of the continuum set but those shoes known primarily as traditional athletic shoes were still the most post popular despite the surge in sales of the polar opposites.

The scale I believe looked something like this:

 

Barefoot                Traditional               Maximalist

|————————-|—————————-|

So with 3D printing already becoming a big thing in the market place and technology such as smart phones and fitbits etc. selling fast it is difficult to imagine what may come of the next big development in sports and athletic footwear.

I guess we will just have to wait and see.

Until Next Time

Jackson McCosker
Director /Chief Editor

 

REFERENCES

Brachmann, S. (2014, May 18). The Evolution of the Modern Athletic Shoe: A Patent History.

Fuehrer, D., & Douglas, S. (2014). Runners World. Retrieved from A Brief History of the Running Shoe: http://www.runnersworld.com/running-shoes/a-brief-history-of-the-running-shoe

The History of The Athletic Shoe. (2012). Retrieved from http://visual.ly/history-athletic-shoe

 

SHOE REVIEW: BROOKES GLYCERIN 13


The Glycerin 13 is Brookes premier traditionally neutral runner boasting Super DNA cushioning technology which provides up to 25% more cushioning than its predecessor, giving a soft landing under foot for even the heavier striking runners. The 3D printed seamless upper reduces shearing, minimising the possibility of blistering in a properly fitted shoe and gives a mild support as it hugs the foot with the addition of the aptly named saddle wraps.
Brookes claims the shoe to have ideal pressure zones throughout the outsole and a rounded heel which keeps the body in its ideal alignment. As discussed in; https://footnotesblogging.com/2015/01/16/foot-strike-pattern-during-running-and-athletic-performance/ and https://footnotesblogging.com/2014/09/25/90/ the body will naturally find its best striking pattern to minimise metabolic cost if said individual is not trying to specifically follow a particular type of running techniques, therefore the idea of having ideal pressure zones is very much debatable as a concept. Secondly, the rounded heel to keep the body in ideal alignment is also a questionable statement. The reasons for this is that;

  • Your hips direct where your foot lands in most cases
  • Forefoot and midfoot strikers will not utilize said technology
  • Frontal plane movement is only one aspect of a mobile foot

So how did the wear-in of the shoe go?

External Factors

Distance of runs 5km Terrain Weather My Mood Injuries/Niggles Subjective Run Score
Run One Footpath/road Very windy Good Nil 9/10
Run Two Footpath/road Windy Very good Nil 9/10
Run Three Road only Humid Very good Nil 8/10
Run Four Road only Mild Good Niggles in forefoot 8/10
Run Five Hills/ Road Mild Good Niggles in forefoot 9/10

* Each section is completed with as accurate as possible subjective information.

Intrinsic factors

Distance of runs 5km Rearfoot Cushioning Forefoot Cushioning Rearfoot Support Energy Feedback/Ride Technology Score
Run One 2.5 2.5 1 2.5 8.5
Run Two 2.5 2.5 1 2.5 8.5
Run Three 2.5 2.5 1 2 8
Run Four 2.5 2.5 1 2.5 8.5
Run Five 2.5 2.5 1 1 7

** Each section is completed with a score out of 2.5 for an overall score out of 10 per run.

Review:
Subjective review:

The Glycerin 13 was a very comfortable neutral runner, if you have read my disclaimer on the Reviews page you will notice that most shoes I generally wear offer some type of medial posting or support. The shoe has a stiff midsole and heel counter with a beautiful sock liner cushion which feels amazing when you put them on your feet.
Subjectively over the 5 x 5km runs the shoe scored an 8.6/10 for me personally, the technologies faired similarly with a score of 8.1/10. It is not believed that either the weather or my mood at the time had an influence on the score provided however, mild niggles in the forefoot during the fourth and fifth run especially on the hills revealed a less than perfect feel. Additionally, rearfoot support was rated low due to the neutral nature of the footwear not providing much more than a firm heel counter.

Who the shoe would suit best:

The Brookes Glycerin 13 would best suit active people under approximately 100kg (see DYAD for +100kg). The price point is suited to those who would prefer a runner with leisurely cushioning or an individual that takes their activity seriously. The curved last and neutral stance of the shoe indicated a less pronated foot would find this design more comfortable and width options in both male and female styles support this with standard B female and D male widths available.
Importantly it should be noted that at least a ½ size bigger than standard is required in most people due to the shape of the forefoot coming to a centre point and brushing against the medial side of the first toe.

Jackson McCosker
Director /Chief Editor