Achilles Healed???
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Re: Achilles Healed???
Postby foo on patrol » Mon Sep 08, 2014 12:14 pm
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Re: Achilles Healed???
Postby vosadrian » Mon Sep 08, 2014 2:08 pm
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Re: Achilles Healed???
Postby nescius » Mon Sep 08, 2014 2:43 pm
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Re: Achilles Healed???
Postby NeillS » Mon Sep 08, 2014 6:24 pm
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Re: Achilles Healed???
Postby Dr_Mutley » Tue Sep 09, 2014 5:05 pm
So it seems your suggesting not to compensate for a proven (on X-ray) femoral length discrepancy with asymmetrical fore-aft cleat positioning, but with cleat shims?NeillS wrote:Staggered cleat position to compensate for a femur difference is not the way to do it. 5mm is a huge differential. You will be dropping the heel differently on the affected side which has almost certainly caused the issue. I do this for a living all day, every day, and even I cannot tell when a person has a 5mm femoral length difference without a standing leg length Xray. The measurement was almost certainly erroneous, meaning you've been running a staggered cleat position for no reason - the only reason to run staggered cleat positions is if your feet are different sizes, or if there is some massive physiological assymetry such as a fused ankle or something similar, and the staggered position is the only way to make you function even remotely symmetrically. The first thing I would do is, assuming both feet are the same size, go back to symmetrical cleat positions. If you are certain that you have a proper leg length discrepancy, have a standing leg length xray performed with both knees locked into full extension and hands stretched up towards the ceiling. Then, assuming there is some discrepancy, compensate for it with a leg length shim - NOT a staggered cleat position.
There is a notion out there that cleat shimming is useful for tibial length discrepancies, and less useful for femoral asymmetry. What's your view on this?
How would u approach shimming the following:
1) rider with 10mm short tibia, symmetrical femurs
2) rider with 10mm short femur, symmetrical tibias
3) 10mm short femur, plus 10mm short tibia on same side
Assume symmetrical foot/ankle structure, size & function
Look forward to your views...
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Re: Achilles Healed???
Postby NeillS » Wed Sep 10, 2014 1:22 pm
Riders 1 and 2 I would start out with 10mm shim stacks under the short leg. If rider 2 had any issues getting over the top of the pedal stroke, and had any extraneous pelvic assymetry on the saddle, I would go down in 2mm increments until the issue resolved. Usually we end up with the full 10mm for the best results. I've done this many times and typically a full compensation is the best result. It's not "perfect" in the sense that it would be much better to physically lengthen their femur, but it's the best option without resorting to femoral lengthening.
Rider 3 I would use a 20mm shim stack, and vary it downwards if there were any issues. There rarely is. I had a bloke a few months ago with a 14mm femoral LLD. 14mm shim stack was used - near perfection and solved his issue (knee pain and quad cramps). I hardly ever have to partially shim a structural LLD.
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Re: Achilles Healed???
Postby Dr_Mutley » Wed Sep 10, 2014 5:06 pm
I do a few bike fits now again for acquaintances who have had disappointing experiences locally (hard to get any sort of decent fit in Adelaide)... If your assymetric in any way then forget it... Having said that not many fitters in Adelaide would actually work out that their subjects have structural asymmetry...
Personally, I have a large right LLD of 22mm (morphological not traumatic), with about equal discrepancies in femur/tibia. Just to make things more complex, my left foot (longer side) is 13mm shorter... Some my fit has had lots of trial n error over many years
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Re: Achilles Healed???
Postby vosadrian » Wed Sep 10, 2014 5:25 pm
I am actually wondering if my issue is more due to bursitis than the Achilles itself. The pain I mostly have is more around the heal base and is a dull burney type of pain. If I stretch the achilles I do get a higher sharper more internal feeling pain, but it is not typically that pain that is continuous. I did some swimming a couple of days ago, and the kicking did seem to aggravate it. I then got a pull buoy which enables me to swim without kicking and this seems to be fine after a swim this morning. So I do have a way to do some cardio work without aggravating it.... hopefully!
Cheers,
Adrian
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Re: Achilles Healed???
Postby Dr_Mutley » Wed Sep 10, 2014 8:23 pm
If u found the staged cleats worked for u then u can always move both cleats back the same amount and saddle down to unload your tendoachilles somewhat. As NeillS mentioned however, unilateral symptoms caused on the bike usually point to asymmetry somewhere in u or your setup.
Hope the Achilles settles quickly! I can sympathise... I've had R ITB, L Tib Ant tendinitis, L ITB, and now Left trochanteric bursitis all in the last 12 months! This riding caper can be all too frustrating at times! (I must be getting old!)
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Re: Achilles Healed???
Postby NeillS » Wed Sep 10, 2014 9:26 pm
Dr_Mutley wrote:Thanks NeillS for your thoughts... Nice to hear different opinions on what/where/how to correct for LLDs.
I do a few bike fits now again for acquaintances who have had disappointing experiences locally (hard to get any sort of decent fit in Adelaide)... If your assymetric in any way then forget it... Having said that not many fitters in Adelaide would actually work out that their subjects have structural asymmetry...
Personally, I have a large right LLD of 22mm (morphological not traumatic), with about equal discrepancies in femur/tibia. Just to make things more complex, my left foot (longer side) is 13mm shorter... Some my fit has had lots of trial n error over many years
Start with a 22mm shim stack under the short foot. Assuming a size 42 foot, start with a cleat position around 12-14mm behind the 1st metatarsal joint line, wherever that sits in your shoe. Find the joint line with your thumb nail, mark it with a pen. Take a piece of a paperclip, tape it to the mark. Put your foot in the shoe without ripping the tape off. Mark the position of the paperclip piece on the shoe. Level the sole of the shoe on a flat bench (take the cleat off to make it easy). Use a set square to create another mark straight downwards where the sole of the shoe meets the upper. The cleat's axle mark should be 12-14mm behind this point assuming a size 42 foot. Further back if size 44 etc. If you two feet are so different (a common sequelae of functioning with a large LLD as your body grows is two feet of different sizes - the differing loads on the feet that come with bearing your body's weight assymetrically during the growth phase leads to one foot that grows larger and faster than the other), you will need to find two different cleat positions in the shoes. One will be staggered further back (the shorter foot).
Now for the tricky part. A 22mm shim stack will create its own problems by moving the pivot point of the cleat/shoe complex a long way above the axle pivot. If you're a strong heel dropper or toe pointer, the effect is exaggerated and you will struggle to feel "stable" over the pedal, given the same fore/aft cleat position. Typically I would try moving the shimmed cleat BACK another 4-5mm for such a large shim stack, to improve the stability of the foot over the pedal. For a large heel dropper, it may need to be more like 6-8mm further back. You will likely need to use Speedplays with the aluminium extender plate, because your shorter foot's cleat position may end up a LONG way back on the shoe, in order to get you to function remotely symetrically. Some experimentation will be required, but try that stuff out first and see how you get on.
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Re: Achilles Healed???
Postby CKinnard » Thu Sep 11, 2014 12:24 am
thought I'd add m2cw.
the following applies to chronic inflammatory/degenerative conditions such as achilles tendinopathy, lateral epicondylitis, plantar fasciitis, and chronic rotator cuff pain.
These conditions are usually the result of repetitive low grade strain, that includes a vicious cycle of mechanical mediated microtrauma, inflammation, fibrosis, compromised blood flow and vascularization, weaker functionality.
An insightful way of looking at the dev't of such conditions, and their perpetuation, is to consider that it is not the stimulus that is the problem (repetitive strain), but compromised recovery.
Once you open your mind to poor recovery being the elephant in the room, then you can focus on improving it, thus:
- the use of ice and heat is very powerful in calming chronic inflammation and the pain it is the primary mediator of. but getting these two modalities right has to be much more aggressive than is commonly considered.
- local tissue milieu seems to be poorly understood and prioritized these days when considering recovery and rehab. Adequate hydration, optimal pH, delivery of high loads of nutrient (anti-oxidants, anti-inflammatory agents, anti-bacterial agents, pro-growth substrates, and oxygen), and the removal of metabolic waste (CO2, various acids and damaged cell debris), are all extremely important in optimizing a recovery/healing environment.
- I am not prepared to reveal my sources, but I can tell you at the highest level of sports medicine, fasting or Calorie deficits are being used to dampen inflammation and periodically facilitate recovery. The clinical rationale is based on three as yet unproven theories - 1. the body's perception of starvation leading it to preserve energy for life critical functions, at the expense of inflammation. This is mediated by higher levels of cortisol, which mediates theory 2 - the catabolization of tissue, especially less functionally critical tissue, like the fibrosis that forms in tendinopathy. breaking down such tissue facilitates capillary sprouting and appropriate remodeling of the tendon. 3 - shorter fasts and sustained Calorie deficits facilitate the removal of ageing dysfunctional cells and their recycling into new cells. There is strong evidence in the literature that this recycling improves tissue function.
- finally, the role of diet and hydration in enhancing healing and recovery, and dampening inflammation, cannot be overstated. There is no doubt the majority of Australians do not consume enough fruits and vegetables, but it is these foods that have the micronutrients critical for tissue healing.
Other considerations not mentioned yet are
- the importance of deep tissue massage into the calf muscles to reduce tension on the achilles tendon. Wherever there is a problem tendon, there are old fibrotic tears in soleus and gastro. the hams should also be stretched and massaged heavily.
- the lumbar spine should be treated as if lumbar and sciatic nerve roots are compromised, which they often are in the presence of chronic lower limb tendinopathies. irritated nerve roots do effect blood flow and muscle tone in the limbs.
- the foot should also be examined. the fascia should be stretched and massaged firmly, and all critical foot joints mobilized firmly. A stiff foot increases load through the achilles.
- biomechanically, appropriate orthotics should be used when rehabbing achilles tendons, sliding the cleats back (and associated saddle lowering) are standard adjustments. Shoes with a rocker sole such as MBTs are excellent for reducing tension through the achilles when walking/running, and have many other benefits. strapping can be helpful at critical stages during rehab, but tends to be limited by the tape's propensity to irritate skin.
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Re: Achilles Healed???
Postby Dr_Mutley » Thu Sep 11, 2014 5:44 pm
Thanks NeillS,NeillS wrote:Dr_Mutley wrote:Thanks NeillS for your thoughts... Nice to hear different opinions on what/where/how to correct for LLDs.
I do a few bike fits now again for acquaintances who have had disappointing experiences locally (hard to get any sort of decent fit in Adelaide)... If your assymetric in any way then forget it... Having said that not many fitters in Adelaide would actually work out that their subjects have structural asymmetry...
Personally, I have a large right LLD of 22mm (morphological not traumatic), with about equal discrepancies in femur/tibia. Just to make things more complex, my left foot (longer side) is 13mm shorter... Some my fit has had lots of trial n error over many years
Start with a 22mm shim stack under the short foot.
•SNIP•
You will likely need to use Speedplays with the aluminium extender plate, because your shorter foot's cleat position may end up a LONG way back on the shoe, in order to get you to function remotely symetrically. Some experimentation will be required, but try that stuff out first and see how you get on.
That's the exact process I've undertaken over 12 months or so... I started at 20mm, and reduced according to feel. I'm currently running a 11mm shim under the short leg, and a 5mm more rearward cleat on the left, to correct for the shorter foot... Along with a couple of varus wedges, much arch support, and many heel wedges, it feels pretty good. Clearly, given the recent L trochanteric bursitis, I must still not be quite tight...
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Re: Achilles Healed???
Postby NeillS » Thu Sep 11, 2014 7:51 pm
I would stay with 22mm personally, assuming you've verified the LLD via a well-taken standing xray with knees locked into full extension. The jammed SIJ will be the last source of your major assymetrical tendencies. Fix that, and your stroke will improve to the point where you'll need to increase the shim size to fully compensate for the short leg. Remember to take the cleat even further back as the shim stack increases, around 1mm further back for every 2-3mm you increase the stack generally.
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Re: Achilles Healed???
Postby CKinnard » Thu Sep 11, 2014 8:34 pm
you might also want to get your lumbar spine looked at and do some serious core work and spine stretches.Dr_Mutley wrote:Thanks NeillS,
That's the exact process I've undertaken over 12 months or so... I started at 20mm, and reduced according to feel. I'm currently running a 11mm shim under the short leg, and a 5mm more rearward cleat on the left, to correct for the shorter foot... Along with a couple of varus wedges, much arch support, and many heel wedges, it feels pretty good. Clearly, given the recent L trochanteric bursitis, I must still not be quite tight...
troch bursitis is often due to increased muscle tone in glut med and max, which hammers the bursa.
so you have to look at why the gluts are not relaxing properly.
often it is because lumbar and sacral nerve roots are irritated in the lumbar spine, by bulgey discs, stenosis, or facet jt stiffness and inflammation.
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Re: Achilles Healed???
Postby Dr_Mutley » Fri Sep 12, 2014 2:48 pm
I've corrected to 15mm in all my shoes, as this gives me a level pelvis on re-xray. This is lucky as 15mm is about the maximum u can attain in a normal shoe/runner without external build ups etc.... Your correct with my pelvis, it is quite stiff & immobile despite quite a lot of work (I was a manipulative physio in a previous life so have had good access to this). Another limiting factor in the whole lumbosacral movement/symmetry is neural tethering, which I have a large degree of...NeillS wrote:I forgot to mention; after functioning with a large LLD for so long, you will almost certainly have a posteriorly rotated and (probably) jammed SIJ on the side of the long leg. It will be stuck quite badly, and almost certainly require manipulation for a while to get it to rotate forwards. You must also use a 22mm build up in all your walking shoes otherwise your assymetric function will carry over onto the bike.
I would stay with 22mm personally, assuming you've verified the LLD via a well-taken standing xray with knees locked into full extension. The jammed SIJ will be the last source of your major assymetrical tendencies. Fix that, and your stroke will improve to the point where you'll need to increase the shim size to fully compensate for the short leg. Remember to take the cleat even further back as the shim stack increases, around 1mm further back for every 2-3mm you increase the stack generally.
As for running 22mm shim, clearly I want to run as little as possible to function symmetrically. With trial and error I've come to a figure of about 15mm which seems to get my pelvis level in standing, and any more seems to over correct it (R iliac crest up compared to left, short side). I assume the difference to some degree is taken care of in my foot/ankle complex. My shim stack reduces further again as my left cleat is some 5mm behind that of the right, further shortening the functional length of my left, longer leg. Unfortunately I find the staggered cleat setup pulls me off square on the saddle somewhat, so I have been thinking of going back to a 15mm shim stack and running a more rearward R cleat to match the L.
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Re: Achilles Healed???
Postby Dr_Mutley » Fri Sep 12, 2014 3:00 pm
Yes, your quite right. I have a large L5/S1 spondylolithesis so over the years I've had lots of lumbosacral issues. Many years of core work has attenuated any problems I've had to point where on or off the bike, I've rarely had problems. For example, last year I did well over 20000kms on the bike without any issues. My main issues have come from trying to get more symmetrical on the bike, to solve some saddle comfort issues. I suspect my L trochanteric bursitis issue has gradually developed due to increasing my orthotic heel raise from 10 to 12mm, and now to 15mm, over the last 4 months. Interesting, my trochanteric bursitis settles with riding, and flares up with walking, so I think that probably reinforces my thoughts about the cause.CKinnard wrote:you might also want to get your lumbar spine looked at and do some serious core work and spine stretches.Dr_Mutley wrote:Thanks NeillS,
That's the exact process I've undertaken over 12 months or so... I started at 20mm, and reduced according to feel. I'm currently running a 11mm shim under the short leg, and a 5mm more rearward cleat on the left, to correct for the shorter foot... Along with a couple of varus wedges, much arch support, and many heel wedges, it feels pretty good. Clearly, given the recent L trochanteric bursitis, I must still not be quite tight...
troch bursitis is often due to increased muscle tone in glut med and max, which hammers the bursa.
so you have to look at why the gluts are not relaxing properly.
often it is because lumbar and sacral nerve roots are irritated in the lumbar spine, by bulgey discs, stenosis, or facet jt stiffness and inflammation.
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Re: Achilles Healed???
Postby CKinnard » Sat Sep 13, 2014 12:13 pm
http://www.docpods.com/images/Deep-Glut ... ch-WEB.jpg" onclick="window.open(this.href);return false;
My L5S1 disc is essentially gone, (after trauma and degeneration). L5 and S1 are starting to fuse, and have advanced Modic changes at the end plates.
Nevertheless, over the last 7 years, I've gone from being able to ride 45 minutes before pain made it too uncomfortable, to riding 12+ hours for 1-2/10 pain.
Further, I've been able to slam my stem and gone from a 110mm -6 to a 140mm -17.
So never underestimate the potential for human tissue to adapt, given the right balance and progression of activities.
m2cw for your back.
- Hammer the facet joint stretches, without irritating the nerves/disc too much.
- I presume you're quite familiar with a range of core strength exercises if you have a spondy-. My go to's are dynamic planks and bicycle crunches.
- Seriously review your hydration and diet. Fluid balance, more plants, and lower body fat means less inflammation and associated pain. I have a chronic inflammatory condition and I know about it as soon as I get slack on the vege, salad, and fruit.
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Re: Achilles Healed???
Postby vosadrian » Thu Oct 16, 2014 9:59 am
IMPRESSION: Minor Achilles tendinopathy as described and minimal retrocalcaneal bursitis and Haglund’s process. No discrete tear of the tendon.
Synovitis suspected in the subtalar joint which could also be contributing to posterior pain and injection of the joint may be a useful technique under CT guidance to see if this is the source of symptoms.
Anyone got any experience with Synovitis. I am booked in for a guided Cortisone injection into the joint.
Cheers,
Adrian
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Re: Achilles Healed???
Postby vosadrian » Thu Oct 30, 2014 11:14 am
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Re: Achilles Healed???
Postby CKinnard » Thu Oct 30, 2014 2:34 pm
viewtopic.php?f=49&t=77564&start=25#p1170922" onclick="window.open(this.href);return false;
- review your diet and hydration.
- if overweight, go on a diet. the calorie deficit will help resorb calcium or sodium deposits that are very likely contributing to the ongoing pain/inflammation/poor healing.
- ice it aggressively for a week. at least 5 times a day. for chronic irritated tissue, I often prescribe 10-12x30 minute icings a day. don't use ice packs whatever you do. use crushed ice in a wet towel (1 or 2 layers between ice and skin). the ice will help a lot if the inflammation is partially within the bone (as per Haglund's Process)
- consider buying MBT shoes, with a rocker sole. these are excellent at unloading the achilles tendon. but take care in the first week of wearing them as you can fall over easily.
http://au.mbt.com/?suggest=1" onclick="window.open(this.href);return false;
- get the calf massaged heavily to 'lengthen' it and take load off the heel.
- accept your lower back may be contributing to the condition by irritating nerve roots that supply the area. adopt better posture, do core strengthening exercise, and do lower back stretches.
- forget about heel drop exercises.
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Re: Achilles Healed???
Postby sogood » Thu Oct 30, 2014 3:09 pm
RK wrote:And that is Wikipedia - I can write my own definition.
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Re: Achilles Healed???
Postby vosadrian » Fri Oct 31, 2014 10:41 am
Things to note:
* Not overweight (70kg, 175cm)
* Have done months of icing 3 times a day with ice pack
* Regular use of foam roller on calf
* Did a month of heel drops (got a bit better and then returned back in that period), but mostly not (not in last 6 weeks)
* Stretching advised by PT
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Re: Achilles Healed???
Postby sogood » Fri Oct 31, 2014 11:18 am
RK wrote:And that is Wikipedia - I can write my own definition.
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Re: Achilles Healed???
Postby CKinnard » Sat Nov 01, 2014 3:56 pm
Icing 3x a day with gel or ice enclosed in thermal insulation (plastic) is what is recommended by those who don't understand the power of cold therapy, for osis and itis.
Other interventions - shockwave therapy, sclerotherapy, GTN patches, stem cell injections.
I don't know where you live but if Sydney, try Sydney Sports Medicine Specialists.
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