Botox for plantar fasciitis? Sounds like a bad idea to us....

image source: https://commons.wikimedia.org/wiki/File:Plantar_aponeurosis_-_axial_view.png

image source: https://commons.wikimedia.org/wiki/File:Plantar_aponeurosis_-_axial_view.png

Botox..For plantar fasciitis? Really?

We found this article (1) in one of our favorite journals, Lower Extremity Review , and were a little surprised. Let us get this straight: you are going to take one of the the most poisonous biological neurotoxins known (1) and inject it into your calf and foot?

The article in LER is well written and the results (thankfully) were inconclusive regarding its usage. They do cite 3 studies (with two by the same lead author) where it has been effective (2-4). Yes, it is better than saline (5) (but not as good as extracorporeal shock wave therapy (6)), and better than placebo (7-10) but considerably more risky.

So the premise is “if the muscle is dysfunctional, then let’s just take it out of the equation”. But this really doesn’t fix the problem, it just covers up the symptom. And what about the other potential side effects since botulinum toxin acts not only at the neuromuscular junction, blocking the release of acetylcholine, but also at the autonomic ganglia, postganglionic parasympathetic nerve endings, as well as the post ganglionic sympathetics that use acetylcholine (capillaries of skin, piloerector muscles and sweat glands) (11)?.

In our experience, most cases of plantar fasciitis are secondary to lack of forefoot rocker, lack of ankle rocker, lack of hip extension or in some cases, direct trauma. Wouldn’t it make more sense to strengthen the anterior compartment to reciprocally inhibit the posterior compartment, increasing ankle dorsiflexion and hip extension? We find, oftentimes, treating only the area of chief complaint and not what is "driving the bus" can offer temporary, symptomatic relief but not long standing pathmechanics or pathoanatomy.

Just like the road to enlightenment, there are no shortcuts in treating plantar fasciitis and if you are not going to treat the cause, then be prepared to reap what you sow.

Dr Ivo Waerlop, one of The Gait Guys

#botox #plantarfascitis #badideas #gaitproblem #thegaitguys

1. https://lermagazine.com/article/botox-injection-not-just-for-celebrities-furrows-and-wrinkles

2. Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E,
Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin A and intralesional steroids for the treatment of plantar fasciitis: A randomized, double-blinded study. Foot Ankle Int.
2013;34(1):8-14.

3. Díaz-Llopis IV, Rodríquez-Ruíz CM, Mulet-Perry S, Mondéjar-Gómez FJ., Climent-Barberá JM., Cholbi-Llobel F. Randomized controlled study of the efficacy of the injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six months. Clin Rehabil. 2012;26(7):594-606.

4. Díaz-Llopis IV, Gómez-Gallego D, Mondéjar-Gómez FJ, López-García A, Climent-Barberá JM, Rodríguez-Ruiz CM. (2013). Botulinum toxin type A in chronic plantar fasciitis: clinical effects one year after injection. Clin Rehabil. 2013;27(8):681-685.

5. Ahmad J, Ahmad SH, Jones K. Treatment of Plantar Fasciitis With Botulinum Toxin. Foot Ankle Int. 2017 Jan;38(1):1-7. doi: 10.1177/1071100716666364. Epub 2016 Oct 1.1.

6. Roca B, Mendoza MA, Roca M. Comparison of extracorporeal shock wave therapy with botulinum toxin type A in the treatment of plantar fasciitis. Disabil Rehabil. 2016 Oct;38(21):2114-21. doi: 10.3109/09638288.2015.1114036. Epub 2016 Mar 1

7. Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed by plantar fasciitis with botulinum toxin A: a short-term randomized, placebo-controlled, double blinded study. Am J Phys Med Rehabil. 2005;84(9):649-654.

8. Samant PD, Kale SY, Ahmed S, Asif A, Fefar M, Singh SD. Randomized controlled study comparing clinical outcomes after injection botulinum toxin type A versus corticosteroids in chronic plantar fasciitis. Int J Res Orthop. 2018;4(4):672-675.

9. Huang YC, Wei SH, Wang HK, Lieu FK. Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes. J Rehabil Med. 2010;42(2):136-140.

10. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int. 2017;38(1):1-7.

11. Nigam PK, Nigam A. Botulinum toxin. Indian J Dermatol. 2010;55(1):8–14. doi:10.4103/0019-5154.60343

Got hip extension?

Because she sure could use some...

we have see this gal before… yesterday in fact

  • left plantar plate lesion (yes, conformed on ultrasound)

  • left sided anatomical leg length discrepany

  • bilateral internal tibial torsion

  • incompetent L quadratus lumborum

  • adequate hip extension and ankle dorsiflexion available to her

  • lack of endurance in her abs

yep, lots more, but that is enough for now



note that she has plenty of ankle dorsiflexion, more on the right. this is due to her right leg being anatomically longer and has to travel through a greater range of motion

look at the knee and the hip articulations to assess hip extension. It should match ankle dorsiflexion, no?




Dr Ivo Waerlop, one of The Gait Guys




#gait #gaitguys #thegaitguys #hipextension #LLD #quadratuslumborum #internaltibialtorsion #anklerocker #ankledorsiflexion

Zonas vs K Tape

image source: https://commons.wikimedia.org/wiki/File:Kinesio_Taping_for_Soleus_and_Achilles_tendon.jpg

image source: https://commons.wikimedia.org/wiki/File:Kinesio_Taping_for_Soleus_and_Achilles_tendon.jpg

In this case, flexibility and an elastic component (K Tape), which adds proprioception, rather than rigid (Zonas), which takes it away, seems to work better. 

"Compared to Athletic Tape, Kinesio Tape (KT)  provides a flexible pulling force that facilitates foot eversion during early stance, while not restricting normal inversion in late stance during walking. KT may be a useful clinical tool in correcting aberrant motion while not limiting natural movement in sports."

 

 

Yen SC, Folmar E, Friend KA, Wang YC, Chui KK. Effects of kinesiotaping and athletic taping on ankle kinematics during walking in individuals with chronic ankle instability: A pilot study. Gait Posture. 2018 Aug 28;66:118-123. doi: 10.1016/j.gaitpost.2018.08.034. [Epub ahead of print]

 

 

What specific movement pattern(s) does a person with chronic ankle instability have?

image source: https://en.wikipedia.org/wiki/Ligament

image source: https://en.wikipedia.org/wiki/Ligament

...it is unique and depends on their compensation

 

"The researchers concluded that multiple distinct movement patterns were found in a high percentage of CAI subjects and each person likely incorporates unique positions and loads that contribute to the chronic nature of instability. Additionally, the data revealed distal joint stiffness was lower in those with CAI than controls generally, while proximal joint stiffness was greater than controls. These data support the theory that the hop plays a vital role in controlling lower extremity movement in CAI subjects."

 

Hopkins JT, Son SJ, Kim J, et al. Joint Stiffness Alterations, Grouped by Movement Strategy, in Chronic Ankle Instability.

http://lermagazine.com/special-section/conference-coverage/identifying-cai-through-specific-movement-patterns

 

Surgery vs casting...same results

image source: https://commons.wikimedia.org/wiki/File:Trimalleolar_Ankle_Fracture.jpg

image source: https://commons.wikimedia.org/wiki/File:Trimalleolar_Ankle_Fracture.jpg

We see many people for all types of fractures and rehab. This study looks at folks who had ankle fractures who either got mhm casted or had surgical management. Looks like conservative is just as good in this case.

"In a pre-specified, 3-year extension of a randomized clinical trial of equivalence, close-contact casting maintained equivalence in function compared to surgery in older adults with unstable ankle fracture. Furthermore, no significant differences were reported in quality of life or pain. The authors concluded that the focus of treatment for these patients should be on obtaining and maintaining reduction until union, using the most conservative means possible.

The study enrolled 461 patients; the control group (n=254) had non-diabetes-related foot complications; the study group (n=207) had diabetic foot pathology (including 61 [32%] with diabetic foot ulcer, Charcot neuropathy, foot infection, or acute neuropathic fractures and dislocations).

Researchers found no significant differences between the 2 groups related to fear of blindness, diabetic foot infection, or kidney failure needing dialysis. When compared to those without diabetic foot problems, the authors found that the 32% of the study group with identified diabetic foot disease were 136% more likely to rate LEA as their greatest fear and that 49% were less likely to rate death as their greatest fear. In their conclusion, the authors noted that the presence of a diabetic foot-related complication, having diabetes for more than 10 years, use of insulin, and having peripheral neuropathy were all variables that subjects associated with identifying LEA as the greatest fear.

 

Wukich DK, Raspovic KM, Suder NC. Patients with diabetic foot disease fear major lower extremity amputation more than death. Foot Ankle Spec. 2018;11(1):17-21."

 

source: http://lermagazine.com/issues/may/three-year-follow-up-close-contact-casting-vs-surgery

image source: https://commons.wikimedia.org/wiki/File:Trimalleolar_Ankle_Fracture.jpg

Flip Flops not so bad? We still think they suck and here's why...

journal.pone_.0193653.g001-374x500.jpg

We have talked about the dangers of open back shoes (Including flip-flops)  and loss of ankle rocker as well as changes in forefoot rocker and great toe dorsiflexion on our blog many times.

The findings of this study, with slower cadence and shortened stance are not surprising (especially since you need to fire your long flexors to keep them on!) nor are ankle joint kinematics (flip flops have no heel counter and are not torsionally rigid, so naturally there would be increseased subtalar motion), however we really question the interpretation.

 "Many have long suspected the answer, but a new study would appear to resolve the question: Are flip flops really that bad for your feet? According to Chen and colleagues from the Department of Biomedical Engineering at The Hong Kong Polytechnic University, flip flops are most likely no better than barefoot when it comes to lower-limb co-contraction and joint contact force in the ankle. The authors had hypothesized that the popular rubber footwear would increase co-contraction of the muscles between the knee and ankle joints in what they thought was a compensatory mechanism for the unstable foot–sole interface and would affect gait kinematics and kinetics.

In the study, the researchers had 10 healthy males perform 6 walking trials under 3 conditions: barefoot, sports shoes, and thong-type flip flops. Participants, who reported they were not “regular flip flop wearers,” were fitted with numerous markers that were monitored while they walked on a 10-meter pathway. The study looked at several muscle pairings that stabilize the knee, ankle, and subtalar joints, including vastus lateralis and gastrocnemius medialis; vastus lateralis and biceps femoris; and peroneus longus and tibialis anterior.

In pairwise comparisons, the walking velocity of flip flops was lower than that of sports shoes (p<0.01) but comparable to barefoot (p>0.05), findings that were consistent with the published literature. Although not significant, the minimalist footwear produced a slower cadence and shortened stance phase in walking trials compared to the other 2 types of footwear. Joint kinematics differed significantly in the ankle joint (F[2,18]=6.73, P<.05) and subtalar joint (F[2,18]=4.45; P<.05); Furthermore, ankle and subtalar range of motion was higher for flip flops than for sports shoes. However, co-contraction was not enhanced. The authors propose that walking speed does not need to be consistent for real-world activities and the slower speed could be a natural approach to avoid injury.

The authors conclude that the slowed walking speed of flip flop users could account for the comparable joint biomechanics between flip flop use and barefoot. They note, however, that, for injury prevention, the closed-toe design of the sports shoe would provide better support for joint motion and loading compared to the other 2 options."

Source:

Chen TL, Wong DW, Xu Z, Tan Q, Wang Y, Luximon A, Zhang M. Lower limb muscle co-contraction and joint loading of flip-flops walking in male wearers. PLoS One. 2018;13(3):e0193653."

image and article source: http://lermagazine.com/issues/may/flip-flops-bare-feet-or-sports-shoes-which-are-best-and-which-are-worst

Functional Ankle Instability and the Peroneals

tumblr_mgcawrDlDn1qhko2so1_400.jpg

Lots of links available here with today’s blog post. please make sure to take your time and check out each one (underlined below) 

As you remember, the peroneii (3 heads) are on the outside of the lower leg (in a nice, easy to remember order of longus, brevis and tertius, from top to bottom) and help to stabilize the lateral ankle. The peroneus brevis and tertius dorsiflex and evert the foot while the peroneus longus plantarflexes and everts the foot. We discuss the peroneii more in depth here in this post. It then is probably no surprise to you that people with ankle issues, probably have some degree of peroneal dysfunction. Over the years the literature has supported notable peroneal dysfunction following even a single inversion sprain event. 

Functional ankle instability (FAI) is defined as “ the subjective feeling of ankle instability or recurrent, symptomatic ankle sprains (or both) due to proprioceptive and neuromuscular deficits." 

Arthrogenic muscle inhibition (AMI) is a neurological phenomenon where the muscles crossing a joint become "inhibited”, sometimes due to effusion (swelling) of the joint (as seen here) and that may or may not be the case with the ankle (see here), or it could be due to nociceptive input altering spindle output or possibly higher centers causing the decreased muscle activity. 

This paper (see abstract below) merely exemplifies both the peroneals and FAI as well as AMI.

Take home message?

Keep the peroneals strong with lots of balance work!                                                             

 

 

2009 May;37(5):982-8. doi: 10.1177/0363546508330147. Epub 2009 Mar 6.

Peroneal activation deficits in persons with functional ankle instability.

Palmieri-Smith RM, Hopkins JT, Brown TN.

Source

School of Kinesiology, University of Michigan, 401 Washtenaw Avenue, Ann Arbor, MI 48109, USA. riannp@umich.edu

Abstract

BACKGROUND:

Functional ankle instability (FAI) may be prevalent in as many as 40% of patients after acute lateral ankle sprain. Altered afference resulting from damaged mechanoreceptors after an ankle sprain may lead to reflex inhibition of surrounding joint musculature. This activation deficit, referred to as arthrogenic muscle inhibition (AMI), may be the underlying cause of FAI. Incomplete activation could prevent adequate control of the ankle joint, leading to repeated episodes of instability.

HYPOTHESIS:

Arthrogenic muscle inhibition is present in the peroneal musculature of functionally unstable ankles and is related to dynamic peroneal muscle activity.

RESULTS:

The FAI patients had larger peroneal H:M ratios in their nonpathological ankle (0.399 +/- 0.185) than in their pathological ankle (0.323 +/- 0.161) (P = .036), while no differences were noted between the ankles of the controls (0.442 +/- 0.176 and 0.425 +/- 0.180). The FAI patients also exhibited lower EMG after inversion perturbation in their pathological ankle (1.7 +/- 1.3) than in their uninjured ankle (EMG, 3.3 +/- 3.1) (P < .001), while no differences between legs were noted for controls (P > .05). No significant relationship was found between the peroneal H:M ratio and peroneal EMG (P > .05).

CONCLUSION:

Arthrogenic muscle inhibition is present in the peroneal musculature of persons with FAI but is not related to dynamic muscle activation as measured by peroneal EMG amplitude. Reversing AMI may not assist in protecting the ankle from further episodes of instability; however dynamic muscle activation (as measured by peroneal EMG amplitude) should be restored to maximize ankle stabilization. Dynamic peroneal activity is impaired in functionally unstable ankles, which may contribute to recurrent joint instability and may leave the ankle vulnerable to injurious loads.

 

Try THIS at home...

Screen Shot 2018-02-07 at 11.23.24 AM.png

Cool test, results you can see and some literature to back it up. If you are interested at all in proprioception, this is an interesting read.

So, the question for us is: "Does ankle dorsiflexion actually create more stability, like is purported?"

“The point is that if I make their ankle rigid this way, then they can more effectively use the balance mechanisms at their knees, hips, and proximally, because they’re on a stable base. My proposition is that their balance is actually normal, apart from that distal segment. When their ankle is stabilized, they use their knees more effectively, and they become less dependent on their eyesight to maintain their balance.”

http://lermagazine.com/article/afos-and-balance-issues-in-peripheral-neuropathy

Your Gait Changes when you text....

GettyImages-534572749web-57a3087d3df78c3276b9fc80-2.jpg

Does texting alter your gait? It sure seems to slow you down, and according to this study, alter firing patterns of muscles about your ankle. Perhaps you are trying to preserve ankle rocker and maintain stability? It is interesting that ankle dorsiflexion actually increased and plantar flexion decreased.

"Young adults showed, overall, small gait modifications that could be mainly ascribable to gait speed reduction and a modified body posture due to phone handling. We found no significant alterations of ankle and knee kinematics and a slightly delayed activation onset of the left gastrocnemius lateralis. However, we found an increased co-contraction of tibialis anterior and gastrocnemius lateralis, especially during mid-stance. Conversely, we found a reduced co-contraction during terminal stance."

 

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579642/

Ankle Rocker Revisited....

How many times have we talked about ankle rocker and its importance? So how are YOU measuring ankle rocker? Are you looking at it on the table? On the ground? Weight bearing? Knee flexed or extended (or both?). The knee is extended at initial contact, flexes through midstance, extends at terminal stance and pre swing and flexes again during swing phase until extending at the end of terminal swing for initial contact again.

What you see on the table may not (and many times doesn't)  translate to real life. Someone with limited ankle dorsiflexion non weight bearing may have normal amounts during gait and vice versa. With gravity in place and a functioning (or malfunctioning) vestibular system, things can change rapidly. Remember that the vestibular system drives the extensors and if inhibited, you will often have flexor dominance. Talk about a tight gastroc/soleus group!


"These findings indicate that nonweightbearing and weightbearing measurements of ankle DF PROM with knee extension should not be used interchangeably and that weightbearing ankle DF PROM with the knee extended is more appropriate for estimating ankle DF during gait."

Kang MH, Oh JS. Relationship Between Weightbearing Ankle Dorsiflexion Passive Range of Motion and Ankle Kinematics During Gait. J Am Podiatr Med Assoc. 2017 Jan;107(1):39-45. doi: 10.7547/14-112.


"There is no relationship between a static diagnosis of ankle dorsiflexion at 0° with dorsiflexion during gait. On the other hand, those subjects with less than -5° of dorsiflexion during static examination did exhibit reduced ankle range of motion during gait."


Gatt A, De Giorgio S, Chockalingam N, Formosa C. A pilot investigation into the relationship between static diagnosis of ankle equinus and dynamic ankle and foot dorsiflexion during stance phase of gait: Time to revisit theory? Foot (Edinb). 2017 Mar;30:47-52. doi: 10.1016/j.foot.2017.01.002. Epub 2017 Feb 6.

 

When the ankle lies to you

When the ankle lies to you.
Yesterday I saw something I see quite often. It was a client with dorsal foot pain, nothing shocking. But, this client had plentiful ankle dorsiflexion on the table during examination but when they walked, there was barely any use of ankle dorsiflexion-ankle rocker. Heel rise was premature.

It once again proves that just because you have it, doesn't mean it is available to be used. There was adequate hip extension and glute strength so it wasn't coming from there, though that is a frequent source. The examination was detailed, but to keep it brief here today, this client, had decent strength about the ankle from what could be determined, but they failed the hop test, control was terrible, and they could tell. Once again, if you cannot control the joint under load, the body will often not give you the full range, merely out of self preservation mode to protect the joint. This client was attempting to get more ankle rocker motion via arch collapse and over pronation to get the tibia to progress forward enough for normal gait. The collapse was causing a dorsal impingement on the foot. Lots more to come on these ideas in future posts. 
None the less, it is a good lesson to all those people out there that think that everyone just needs more ankle rocker strength and range of motion. The truth is, not everyone does, and forcing it in some will cause them pain or problems or compensations . . . . and that is your fault if it is the case.

-Dr. Allen

The buck DOES NOT stop here...

The buck doesn't stop here..

image from: http://www.aofas.org/footcaremd/treatments/pages/triple-arthrodesis.aspx

image from: http://www.aofas.org/footcaremd/treatments/pages/triple-arthrodesis.aspx

One of the most pervasive problems following a ankle arthrodesis, particularly a triple arthrodesis which involves fusing the subtalar (talocalcaneal), calcaneocuboid , and talonavicular joints results in a loss of ankle rocker. The "buck" needs to be passed somewhere and this usually will mean proximally in the lower kinetic chain.

Seeing adjacent joints with osteoarthritic changes following hypomobility have another joint is nothing new; you probably see it all the time in practice. Remember that it is not always have to be a "fusion". Simple longstanding pathomechanics or longstanding hypomobility will often cause the same problems.

A nice, full text referenced review 1 of her favorite journals. Some nice side discussions as well. Enjoy : )

"Altered biomechanics after ankle arthro­desis often increase stress on the adjacent joints in the foot, which can cause or exacerbate osteoarthritic degeneration in those joints. Clinicians and researchers are working to better understand this process and how to minimize patients’ risk."

http://lermagazine.com/…/adjacent-joint-arthritis-after-ank…
#anklemobility #anklerocker #triplearthrodesis #hypomobility

 

Ankle Sprains...A nice review here

A nice FREE FULL TEXT literature review about the biomechanics, diagnosis, grading and treatment (conservative and non conservative) of acute ankle sprains. There is an interesting section at the end for prevention. Consider this a staple for your library to refer to when needed.

 "This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. "

Fong DT, Chan Y-Y, Mok K-M, Yung PS, Chan K-M. Understanding acute ankle ligamentous sprain injury in sports. Sports Medicine, Arthroscopy, Rehabilitation, Therapy, and Technology : SMARTT. 2009;1:14. doi:10.1186/1758-2555-1-14.

link to full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724472/

 

3 points to use with ankle instability

In this study they stimulated 3 points: ST41, BL60 and GB40. Take a look at their locations (above). ST41 is at the base of the long extensor tendons; gee, we never emphasize long extensor function, do we? GB 40 is at the lateral malleolus between the peroneus longus/brevis and peroneus tertius; how important are these for coronal plane stability, not to mention the ability to descend the 1st ray. BL60 is just anterior to the lateral malleolus, right by the peroneus longus and brevis (again). Could they have included K6, under the medial malleolus and near the long flexors? Sure. How about SP4 or 4, in the substance of the flexor hallucis brevis and anterior to the extensor hallucis longus. Of course. You can probably think of other points to include as well.

Do you think it was by accident that their muscle selection included dorsiflexors (excepting the peroneus longus) and everters? How about a muscle that would help descend the 1st ray and complete the medial tripod? Hmmm... There is always a reason and a rationale....

 

"CONCLUSION: Electroacupuncture can effectively improve the proprioception of athletes with FAI and achieves a superior efficacy as compared with the conventional physiotherapy."...or in this case, low level e stim to the medial and lateral malleolus.

How about adding these points, no matter how you would like to stimulate them, to your CAI toolkit?

 

Zhu Y, Qiu ML, Ding Y, Qiang Y, Qin BY. [Effects of electroacupuncture on the proprioception of athletes with functional ankle instability]. Zhongguo Zhen Jiu. 2012 Jun;32(6):503-6.

 

 

Acupuncture/Dry Needling and Proprioception. A Winning combination.

 

What a great combination of therapies for folks with chronic ankle instability, or almost any injury for that matter! Taking 2 modalities that emphasize afferent input from the peripheral mechanoreceptor system, which has such a large influence on the cerebellum as well as the segmental and descending pain inhibition pathways.

Did you notice they used the trigger points in the peroneus longs muscle to needle? Though they didn't say it, did you remember that that the point correlates to a great point: Gallbladder 34, which is an empirical point for musculoskeletal pain? Interesting how this muscle influences both frontal and saggital plan stability. 

Though the techniques of exercise could use some refinement (check out the gents posture in the photo, sure looks like he could use some gluteus medius work!), this is a good overview that provides evidence that utilizing spacial summation (combining multiple techniques that provide afferent input to more than one modality to cause an effect) has better outcomes than one alone. Put this one on your reading list : )

Salom-Moreno J, Ayuso-Casado B, Tamaral-Costa B, Sánchez-Milá Z, Fernández-de-Las-Peñas C, Alburquerque-Sendín F.Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial. Evid Based Complement Alternat Med. 2015;2015:790209. doi: 10.1155/2015/790209. Epub 2015 Apr 30.

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

Achilles Tendonitis/Tendinopathy and Needling    Achilles pain. You can’t live with it and you can’t live with it. Can needling help? The obvious answer is yes, but there is more as well.    There appears to be sufficient data to support the use of needling for achilles tendon problems . Perhaps it is the “reorganization” of collagen that makes it effective or a blood flow/vascularization phenomenon. The mechanism probably has something to do with pain and the reticular formation sending information down the cord via the lateral cell column (intermediolateral cell nucleus) or pain (nociceptive) afferents sending a collateral in the spinal cord to the dysfunctional muscle, affecting the alpha receptors and causing vasodilation.   Loss of ankle dorsiflexion is a common factor that seems to contribute to achilles tendinopathies . It would seem that improving ankle rocker would be most helpful. In at least one study, needling restored ankle function and in another it improved strength.   And don’t forget to go north of the lower leg/foot/ankle complex. The gluteus medius can many times the culprit as well. During running, the gluteus medius usually fires before heel strike, most likely to stabilize the hip and the pelvis. In runners with Achilles Tendonitis, its firing is delayed which may affect the kinematics of knee and ankle resulting in rear foot inversion. Perhaps the delayed action of the gluteus medius allows an adductory moment of the pelvis, moving the center of gravity medially. This could conceivably place additional stress on the achilles tendon (via the lateral gastroc) to create more eversion of the foot from midstance onward.   Similarly, in runners with achilles tendoinopathy, the gluteus maximus does not fire as long and activation is delayed. The glute max should be the primary hip extensor and decreased hip extension might be compensated by an increased ankle plantarflexion which could potentially increase the load on the Achilles tendon.   So, in short, yes, needling will probably help, for these reasons and probably many more. Make sure to needle all the dysfunctional muscles up the chain, beginning at the foot and moving rostrally.    Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. Cox J, Varatharajan S, Côté P, Optima Collaboration. J Orthop Sports Phys Ther. 2016 Jun;46(6):409-29. doi: 10.2519/jospt.2016.6270. Epub 2016 Apr 26    Acupuncture&rsquo;s role in tendinopathy: new possibilities. Speed C. Acupunct Med. 2015 Feb;33(1):7-8. doi: 10.1136/acupmed-2014-010746. Epub 2015 Jan 9.   The effect of electroacupuncture on tendon repair in a rat Achilles tendon rupture model.  Inoue M, Nakajima M, Oi Y, Hojo T, Itoi M, Kitakoji H. Acupunct Med. 2015 Feb;33(1):58-64. doi: 10.1136/acupmed-2014-010611. Epub 2014 Oct 21.  KIishmishian B, Selfe J, Richards J A Historical Review of Acupuncture to the Achilles Tendon and the development of a standardized protocol for its use Journal of the Acupuncture Association of Chartered Physiotherpists Spring 2012,  69-78  Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Zhang BM1, Zhong LW, Xu SW, Jiang HR, Shen J. Chin J Integr Med. 2013 Dec;19(12):900-4. doi: 10.1007/s11655-012-1218-4. Epub 2012 Dec 21.  The effect of dry needling and treadmill running on inducing pathological changes in rat Achilles tendon. Kim BS, Joo YC, Choi BH, Kim KH, Kang JS, Park SR. Connect Tissue Res. 2015 Nov;56(6):452-60. doi: 10.3109/03008207.2015.1052876. Epub 2015 Jul 29.  Tendon needling for treatment of tendinopathy: A systematic review. Krey D, Borchers J, McCamey K. Phys Sportsmed. 2015 Feb;43(1):80-6. doi: 10.1080/00913847.2015.1004296. Epub 2015 Jan 22. Review.  Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendonhealing. de Almeida Mdos S, de Freitas KM, Oliveira LP, Vieira CP, Guerra Fda R, Dolder MA, Pimentel ER. Acupunct Med. 2015 Feb;33(1):51-7. doi: 10.1136/acupmed-2014-010548. Epub 2014 Aug 19.  Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats. de Almeida Mdos S, de Aro AA, Guerra Fda R, Vieira CP, de Campos Vidal B, Rosa Pimentel E. Connect Tissue Res. 2012;53(6):542-7. doi: 10.3109/03008207.2012.710671. Epub 2012 Aug 14.  Changes in blood circulation of the contralateral Achilles tendon during and after acupunctureand heating.Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Int J Sports Med. 2011 Oct;32(10):807-13. doi: 10.1055/s-0031-1277213. Epub 2011 May 26.  Microcirculatory effects of acupuncture and hyperthermia on Achilles tendon microcirculation. Kraemer R, Vogt PM, Knobloch K. Eur J Appl Physiol. 2010 Jul;109(5):1007-8. doi: 10.1007/s00421-010-1442-6. Epub 2010 Mar 28.  Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Eur J Appl Physiol. 2010 Jun;109(3):545-50. doi: 10.1007/s00421-010-1368-z. Epub 2010 Feb 6.   Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion. Chimenti RL, Bucklin M, Kelly M, Ketz J, Flemister AS, Richards MS, Buckley MR. J Orthop Res. 2016 Jun 16. doi: 10.1002/jor.23338. [Epub ahead of print]  Forefoot and rearfoot contributions to the lunge position in individuals with and without insertionalAchilles tendinopathy. Chimenti RL, Forenza A, Previte E, Tome J, Nawoczenski DA.Clin Biomech (Bristol, Avon). 2016 Jul;36:40-5. doi: 10.1016/j.clinbiomech.2016.05.007. Epub 2016 May 11.  Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for AchillesTendinopathy. Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Foot Ankle Int. 2016 Mar 17. pii: 1071100716638128. [Epub ahead of print]   In vivo quantification of the shear modulus of the human Achilles tendon during passive loading using shear wave dispersion analysis. Helfenstein-Didier C, Andrade RJ, Brum J, Hug F, Tanter M, Nordez A, Gennisson JL. Phys Med Biol. 2016 Mar 21;61(6):2485-96. doi: 10.1088/0031-9155/61/6/2485. Epub 2016 Mar 7.  Changes of gait parameters and lower limb dynamics in recreational runners with achillestendinopathy. Kim S, Yu J. J Sports Sci Med. 2015 May 8;14(2):284-9. eCollection 2015 Jun.  Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Foot Ankle Surg. 2015 Jun;21(2):77-85. doi: 10.1016/j.fas.2015.02.001. Epub 2015 Feb 26. Review.  Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. Rabin A, Kozol Z, Finestone AS. J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.  Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack 1992.    Chan YY, Mok KM, Yung PSh, Chan KM. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1:14. doi: 10.1186/1758-2555-1-14.   Bilateral effects of 6 weeks&rsquo; unilateral acupuncture and electroacupuncture on ankle dorsiflexors muscle strength: a pilot study. Zhou S, Huang LP, Liu J, Yu JH, Tian Q, Cao LJ. Arch Phys Med Rehabil. 2012 Jan;93(1):50-5. doi: 10.1016/j.apmr.2011.08.010. Epub 2011 Nov 8.  Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.

Achilles Tendonitis/Tendinopathy and Needling


Achilles pain. You can’t live with it and you can’t live with it. Can needling help? The obvious answer is yes, but there is more as well.

There appears to be sufficient data to support the use of needling for achilles tendon problems . Perhaps it is the “reorganization” of collagen that makes it effective or a blood flow/vascularization phenomenon. The mechanism probably has something to do with pain and the reticular formation sending information down the cord via the lateral cell column (intermediolateral cell nucleus) or pain (nociceptive) afferents sending a collateral in the spinal cord to the dysfunctional muscle, affecting the alpha receptors and causing vasodilation. 

Loss of ankle dorsiflexion is a common factor that seems to contribute to achilles tendinopathies . It would seem that improving ankle rocker would be most helpful. In at least one study, needling restored ankle function and in another it improved strength. 

And don’t forget to go north of the lower leg/foot/ankle complex. The gluteus medius can many times the culprit as well. During running, the gluteus medius usually fires before heel strike, most likely to stabilize the hip and the pelvis. In runners with Achilles Tendonitis, its firing is delayed which may affect the kinematics of knee and ankle resulting in rear foot inversion. Perhaps the delayed action of the gluteus medius allows an adductory moment of the pelvis, moving the center of gravity medially. This could conceivably place additional stress on the achilles tendon (via the lateral gastroc) to create more eversion of the foot from midstance onward.

Similarly, in runners with achilles tendoinopathy, the gluteus maximus does not fire as long and activation is delayed. The glute max should be the primary hip extensor and decreased hip extension might be compensated by an increased ankle plantarflexion which could potentially increase the load on the Achilles tendon. 

So, in short, yes, needling will probably help, for these reasons and probably many more. Make sure to needle all the dysfunctional muscles up the chain, beginning at the foot and moving rostrally.

Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. Cox J, Varatharajan S, Côté P, Optima Collaboration. J Orthop Sports Phys Ther. 2016 Jun;46(6):409-29. doi: 10.2519/jospt.2016.6270. Epub 2016 Apr 26

Acupuncture’s role in tendinopathy: new possibilities. Speed C. Acupunct Med. 2015 Feb;33(1):7-8. doi: 10.1136/acupmed-2014-010746. Epub 2015 Jan 9.

The effect of electroacupuncture on tendon repair in a rat Achilles tendon rupture model.  Inoue M, Nakajima M, Oi Y, Hojo T, Itoi M, Kitakoji H. Acupunct Med. 2015 Feb;33(1):58-64. doi: 10.1136/acupmed-2014-010611. Epub 2014 Oct 21.

KIishmishian B, Selfe J, Richards J A Historical Review of Acupuncture to the Achilles Tendon and the development of a standardized protocol for its use Journal of the Acupuncture Association of Chartered Physiotherpists Spring 2012,  69-78

Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Zhang BM1, Zhong LW, Xu SW, Jiang HR, Shen J. Chin J Integr Med. 2013 Dec;19(12):900-4. doi: 10.1007/s11655-012-1218-4. Epub 2012 Dec 21.

The effect of dry needling and treadmill running on inducing pathological changes in rat Achilles tendon. Kim BS, Joo YC, Choi BH, Kim KH, Kang JS, Park SR. Connect Tissue Res. 2015 Nov;56(6):452-60. doi: 10.3109/03008207.2015.1052876. Epub 2015 Jul 29.

Tendon needling for treatment of tendinopathy: A systematic review.
Krey D, Borchers J, McCamey K. Phys Sportsmed. 2015 Feb;43(1):80-6. doi: 10.1080/00913847.2015.1004296. Epub 2015 Jan 22. Review.

Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendonhealing.
de Almeida Mdos S, de Freitas KM, Oliveira LP, Vieira CP, Guerra Fda R, Dolder MA, Pimentel ER. Acupunct Med. 2015 Feb;33(1):51-7. doi: 10.1136/acupmed-2014-010548. Epub 2014 Aug 19.

Electroacupuncture increases the concentration and organization of collagen in a tendon healing model in rats.
de Almeida Mdos S, de Aro AA, Guerra Fda R, Vieira CP, de Campos Vidal B, Rosa Pimentel E. Connect Tissue Res. 2012;53(6):542-7. doi: 10.3109/03008207.2012.710671. Epub 2012 Aug 14.

Changes in blood circulation of the contralateral Achilles tendon during and after acupunctureand heating.Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Int J Sports Med. 2011 Oct;32(10):807-13. doi: 10.1055/s-0031-1277213. Epub 2011 May 26.

Microcirculatory effects of acupuncture and hyperthermia on Achilles tendon microcirculation. Kraemer R, Vogt PM, Knobloch K.
Eur J Appl Physiol. 2010 Jul;109(5):1007-8. doi: 10.1007/s00421-010-1442-6. Epub 2010 Mar 28.

Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi H, Takakura N. Eur J Appl Physiol. 2010 Jun;109(3):545-50. doi: 10.1007/s00421-010-1368-z. Epub 2010 Feb 6.

 Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion. Chimenti RL, Bucklin M, Kelly M, Ketz J, Flemister AS, Richards MS, Buckley MR.
J Orthop Res. 2016 Jun 16. doi: 10.1002/jor.23338. [Epub ahead of print]

Forefoot and rearfoot contributions to the lunge position in individuals with and without insertionalAchilles tendinopathy. Chimenti RL, Forenza A, Previte E, Tome J, Nawoczenski DA.Clin Biomech (Bristol, Avon). 2016 Jul;36:40-5. doi: 10.1016/j.clinbiomech.2016.05.007. Epub 2016 May 11.

Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for AchillesTendinopathy. Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Foot Ankle Int. 2016 Mar 17. pii: 1071100716638128. [Epub ahead of print]

 In vivo quantification of the shear modulus of the human Achilles tendon during passive loading using shear wave dispersion analysis.
Helfenstein-Didier C, Andrade RJ, Brum J, Hug F, Tanter M, Nordez A, Gennisson JL. Phys Med Biol. 2016 Mar 21;61(6):2485-96. doi: 10.1088/0031-9155/61/6/2485. Epub 2016 Mar 7.

Changes of gait parameters and lower limb dynamics in recreational runners with achillestendinopathy. Kim S, Yu J. J Sports Sci Med. 2015 May 8;14(2):284-9. eCollection 2015 Jun.

Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Foot Ankle Surg. 2015 Jun;21(2):77-85. doi: 10.1016/j.fas.2015.02.001. Epub 2015 Feb 26. Review.

Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. Rabin A, Kozol Z, Finestone AS. J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.

Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack 1992.

Chan YY, Mok KM, Yung PSh, Chan KM. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1:14. doi: 10.1186/1758-2555-1-14.

Bilateral effects of 6 weeks’ unilateral acupuncture and electroacupuncture on ankle dorsiflexors muscle strength: a pilot study. Zhou S, Huang LP, Liu J, Yu JH, Tian Q, Cao LJ. Arch Phys Med Rehabil. 2012 Jan;93(1):50-5. doi: 10.1016/j.apmr.2011.08.010. Epub 2011 Nov 8.

Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.

and what have we been saying about loss of ankle rocker and achilles tendon problems for years now?  Here is a FREE, FULL TEXT article talking all about it  “A more limited ankle Dorsi Flexion ROM as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendinopathy among military recruits taking part in intensive physical training.”       J Foot Ankle Res.  2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study. Rabin A  1 ,  Kozol Z ,  Finestone AS .   link to full text:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243387/

and what have we been saying about loss of ankle rocker and achilles tendon problems for years now?

Here is a FREE, FULL TEXT article talking all about it

“A more limited ankle Dorsi Flexion ROM as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendinopathy among military recruits taking part in intensive physical training.”


J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study.Rabin A1, Kozol Z, Finestone AS.

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243387/