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Achilles Tendinopathy

by Caroldee Nienaber

Achilles tendinopathy (often referred to as Achilles tendonitis) is a very common injury in runners. The Achilles tendon is the thickest and strongest tendon in your body and connects the calf muscles to the back of the heel bone. A force of up to 7x your body weight is transferred through the Achilles tendon when running.

Achilles tendinopathy usually presents as a dull pain at the back of the ankle at the start of a run which gradually eases as the area warms up. The pain returns after you have finished the run and it tends to be painful first thing in the morning. This eventually can progress to a sharper pain during running eventually impeding your ability to jog lightly. The tendon is often very tender to touch when gently squeezed.

The most common cause of Achilles tendinopathy is over training, including too high mileage, too many hills and too much speed work without building up properly. Other causes include weak and/or stiff calf muscles, poor ankle range of motion, excessive pronation (“flat” feet) and incorrect footwear.

Initial self-treatment should involve icing after a run, stretching the calf muscles, decreasing training to alternate days, decreasing mileage by half and avoiding hill training and speed work for 3-4 weeks. A heel raise, which is worn in your running shoe, can help in the early stages to take the tension off the tendon and therefore ease pain. It is important to have your footwear assessed to make sure you are in the right shoe for you.

Should the problem persist your Physiotherapist can assist you with an assessment to identify any underlying biomechanical problems, manual therapy and rehabilitation. The most important component of Achilles tendon rehab is an eccentric loading program, this involves strengthening and lengthening the calf muscles to improve the tendon’s tolerance to load. The average recovery time for the injury is between 3 to 6 months.

Surgery may be considered as a last resort if there has been no response to conservative management after a period of at least 6 months.


Plantar Fasciitis

By Glen Nunes

Plantar fasciitis is an overuse condition of the plantar fascia at the calcaneal (heel) attachment. The plantar fascia connects the heel to your toes underneath your foot along the inner side and supports your foot arch. Plantar fasciitis is common in runners due to the repetitive pushing off the forefoot. Plantar fasciitis typically presents as a sharp stabbing pain underneath the foot on weight bearing with the pain generally being worse in the morning and after rest periods. This pain normally decreases with increased movement.

Risk factors include age (more common between 40-60 years), foot biomechanics (flat foot or rigid high arches), running or jumping  activities, activities involving more time spent standing on your feet, and being overweight.

Initial treatment involves reducing  milage by half, no speedwork and flatter routes. Rolling a frozen half litre coke bottle filled with water, back and forth under the foot arch for 10 minutes also helps  control the pain.

If the condition persists, it is important to address the underlying cause of the development of plantar fasciitis. A physiotherapy assessment is recommended to assess, correct  and rehabilitate  your lower limb biomechanics (hip, knee, ankle and foot). Physiotherapy treatment may also involve footwear assessment, stretching and mobilisation of the plantar fascia and calf muscles, taping, advice on wearing heel supports and/or a night splint.

In more severe cases, surgery may be required to “clean up” the fascia and even “trim” extra bone formation if a heel spur is detected.


Runners knee

By Brandon Jackson 

Runner’s knee is a general term for pain around and under the knee cap. It usually involves mal-tracking of the knee cap, resulting in pain and inflammation of the cartilage lining under the knee cap.

As with most running injuries it is caused by too-much-too-soon or over-use and all linked to poor knee and leg biomechanics. These include weak gluteal (bum) muscles, weak quads and pronated feet (flat foot arches).

Pain may be anywhere around or under the knee cap, often difficult to pinpoint. It is pronounced when running downhills or going down stairs.

Self management at first involves resting for at least 7-10 days to allow the inflammation to settle and avoiding anti-inflammatory medications.  Then try to start running flat routes, half your normal training distance, slowly and no speedwork for the next 2 weeks.  Thereafter, slowly return to normal training over another 2-3 weeks, increasing distance by about 20% per week.

It is however recommended to have a physio or biokineticist assess your lower limb mechanics and prescribe you a graded leg strengthening routine as well as assessing your feet and running shoes. Anti-pronation/motion-control running shoes are advisable and in more severe cases, in-shoe orthotics fitted by a podiatrist.

This injury usually settles in a few weeks with the above management and corrective measures.

Surgery to “clean” up the cartilage under the knee cap is rarely required and only after exhausting all of the above options. It will then post-operatively require intense rehab as above anyway.


ITB friction syndrome

By:       Brandon Jackson 

The dreaded ITB injury, medically known as IlioTibial Band friction syndrome, is one of the more common running injuries.

Symptoms are very specific, presenting as a pain on the outside of the knee, especially when running downhill or going down stairs.  The ITB is a thick strap of ‘sinewy’ tissue which runs from the hip to the outside of the knee

Where it crosses over a bony protruberance on the outside of the knee is where the trouble starts – as we run along and the band rubs back and forth across this bony protruberance, so friction develops, leading to inflammation and pain, locally over this area.

It is one of the few running injuries that virtually stops you in your tracks.  The pain is excruciating and often leads to walking the downhills and running/hobbling the uphills.

The cause is weak or severely fatigued (overtrained) gluteal (bum) muscles.  The glutes are connected directly to the ITB which extends down the outside of the thigh.  As our leg strikes the ground, the glutes contract to stabilize the hip and leg by pulling the ITB tight.  The ITB is thus a kind of shock absorber, hence the problems when running downhill. The weak/fatigued/overtrained glutes cannot control and tension the ITB properly and so it starts rubbing uncontrollably over the bony protruberance on the outside of the knee causing inflammation and “ouch”!

Self treatment involves icing the area for 15 minutes 3 x daily, resting initially for at least 7-10 days to allow the inflammation to settle, and avoiding anti-inflammatory medications.  Then try to start running flat routes, half your normal training distance, slowly and no speedwork for the next 2 weeks.  Thereafter, slowly return to normal training over another 2-3 weeks, increasing distance by about 20% per week.

If the condition persists, you need to address the weakness and tightness of the glutes and ITB by getting your physio to release these structures and starting you on a glute strengthening and hip stability programme.  This involves exercises such as lunges and one-leg-squats, but needs to be carefully integrated with your running training.

The physio should also assess your running style and foot mechanics, since a foot that falls flat (pronates) when you run may contribute to the problem, hence the need for a more supportive running shoe.

In very persistent cases and as a last resort, surgery may be indicated to ‘clean’ up the band over the bony protruberance.  This has the risk of creating more scar tissue over the area and you should thus consult with an orthopaedic surgeon experienced in treating this condition. You would then still have to do all the above-mentioned treatment and rehab, expecting about 3-6 months return to normal running.

However, prevention is always better than cure, so stretching of the glutes and ITB, strengthening of the hip and thigh muscles as well as the correct footwear when running the ‘silly’ distances we do is vital to side-step this dreaded injury.


Stress Fractures

By:  Thirona Naicker  - B.Sc Physiotherapy

Stress fractures are an overuse injury as a result of repetitive minor trauma. It may occur when muscles become fatigued and are unable to absorb added shock.  That muscle, will transfer the overload of stress onto the bone.

Stress fractures are often the result of increasing the amount of intensity of an activity too quickly.  You will have a sudden onset of pain that is localized over the fracture site.  You will experience intense pain at the start of a run, this will get worse to the point where you have to stop running.  You may also experience pain at rest or at night.

 Stress fractures may be diagnosed by your physiotherapist.  The clinical suspicion can  be confirmed with an x-ray, however an x-ray may not always show stress fractures.  In those cases, a bone scan, MRI or a CT scan may be more successful with diagnosis.

 Treatment includes rest from aggravating activity for 6 – 8 weeks, with gradual return to sport.  You may still engage in pain-free activities while healing takes place.

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