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[Case Studies] 7 months to marathon: Achilles rehab case study with Jason Tuori

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In this episode with Jason Tuori, we explore an interesting case study on an elite endurance athlete who presents with Achilles tendinopathy seven months prior to competing in a marathon. We cover:

  • Key signs of Achilles tendinopathy in the subjective and objective exam
  • Calf strengthening in Achilles tendinopathy
  • Plantar flexion force production and it’s role in rehabilitation
  • Return to run algorithm 
  • Role of mental health in running and individualised rehabilitation programs

This episode is closely tied to Jason’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Jason’s case study here with our 7-day free trial: https://physio.network/casestudy-tuori

Jason Tuori is a sports physical therapist and performance coach in Atlanta, GA, currently serving as the head physical therapist for Overtime Elite. He is a Board Certified Sports Clinical Specialist with residency training from the University of Rochester and co-instructor of the continuing education course Dungeons & Dynamometers. His clinical interests include hip, ankle, and overuse injuries, and he has presented nationally on athletic injuries, strength training, footwear, and return-to-sport testing while also serving leadership roles within the American Academy of Sports Physical Therapy.

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Our host is @NoahMandelPhysio from Physio Network

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UNKNOWN:

Bye.

SPEAKER_01:

On today's episode with Jason Torrey, we discuss a case of an elite endurance athlete with an Achilles tendinopathy. We discuss the assessment and treatment of this condition and how Jason helped this runner get back on track. Jason Torrey is a sports physical therapist and performance coach based out of Rochester, New York. He is a board-certified sports clinical specialist and completed residency training at the University of Rochester Medical Center. He currently works as a performance therapist We'll be right back. PT Inquest, a show dedicated to understanding physical therapy science. He is an active peer reviewer for several physical therapy and physiology journals. Jason has done a case study with PhysioNetwork on this exact case where you could dive a lot deeper into this area than we were able to in today's episode. You can click the link in the show notes to watch Jason's case study with a 7-day free trial. You are going to love this episode as you'll become much more confident with assessing and treating Achilles tendinopathies. I'm Noah Mandel and this is Case Studies. Hey, Jason. Thank you for joining us today. Thanks for having me, Noah. It's our pleasure. So you recently created a case study for PhysioNetwork on a very interesting Achilles tendinopathy case in an elite runner. Before we dive really deep into it, can you give us just a brief overview of this case?

SPEAKER_02:

Yep. So this was, again, pretty elite, non-professional elite runner. So I think when we hear that, there's probably a wide range of what does that actually look like? Because you either talk about recreational run or you talk about professional runners. But I think sometimes when you see someone's race times, then it's like that probably contextualizes a little bit better. So this is basically a two hour and 30 minute marathon runner. So for all intents and purposes, even though he doesn't even get paid to run, he is better than all of us. So that level of elite runner initially saw him in the spring and his key marathon race for the year was Chicago. Chicago marathon is an October race. So it was about seven months before the race when I initially saw him. And he had just developed some Achilles pain after a 5K race, which is a little bit faster than some of his typical training and some of his typical races are. And so, on evaluation, and we might talk about some of this maybe a little bit more in detail, and certainly in the case study I did, deemed that it was a case of mid-portion Achilles tendinopathy. And our initial starting point from there went on through what we typically do and what we typically talk about as far as tendon rehab. But most importantly, from the initial exam standpoint, making sure that we're differentiating it and kind of being sure that this is mid portion Achilles tendinopathy versus some other things, which I bet we will and did talk about at some point.

SPEAKER_01:

Yeah. So let's dive into that actually a little bit more. So there is a lot that's going on in the posterior ankle. We sometimes jump to the Achilles very quickly, but how can we be sure that we're getting an accurate diagnosis? What are we looking for in both the subjective and the objective Yeah.

SPEAKER_02:

So to me, subjectively, what I'm trying to pick up on is, did this look like some kind of pattern of change in training or change in some kind of training variable that would have been a spike in work for the Achilles tendon? And we know that tends to be one of those patterns associated with development of Achilles tendinopathy, whether that's an increase in running speed, because that shifts more stress towards the area, an increase in elevation, so running more uphill. compared to level or downhill running. Maybe an acute change in footwear that significantly changed the loading profile of the foot or ankle. Those are some of the things that I'm usually trying to pick up on as far as the subject. In addition, of course, if somebody's had it before, some previous history of Achilles pain, Achilles tendinopathy, then it's moving pretty far up the list. I'll actually say, and this is not part of the case study because this paper just came out two weeks ago, one or two weeks ago, a new Delphi study, Peter Maliaris was the lead author on that. And it actually does a really great job of talking about all of the differential diagnoses that somebody should think about when it comes to Achilles tendinopathy. And they do really well in that paper. So, if somebody wants to read that, I would recommend. But it's not always mid-portion Achilles tendinopathy is probably the spoiler in that. In this case, it did happen to be that. But to me, I'm always thinking about differentiating at least from a tendon standpoint, mid-portion Achilles tendinopathy to insertional tendinopathy. If somebody has pain directly at the base of the calcaneus and that kind of pinching feeling, maybe some local swelling, local calcification, which would also fall under the category of like Haglund's deformity, that is going to be treated differently, at least initially, compared to a mid-portion Achilles tendinopathy. And then probably some of the other big ones I think about if we've got a lot of swelling in the tendon, pretty large amount of thickening and crepitus in the tendon, we're probably thinking about more of a peritoneanopathy, as in more swelling around the tendon sheath, rather than an actual mid-portion tendinopathy. And that also tends to be treated differently because a lot of repetitive calf raises actually doesn't make that feel very good. And as we might get into, calf raises do tend to make the mid-portion Achilles feel pretty good. In addition to some of the other, maybe further down the list from a differential standpoint, but those are probably the big three from a local tendon standpoint that folks should be aware of.

SPEAKER_01:

Perfect. And you did touch on calf raises a little bit there. And there is one clinical gem that I have taken away from case study and I feel like I've been thinking a lot about it in my own practice. And that's about the differences in the plantar flexion force production that we can get depending on different ranges of dorsiflexion that the patient is in. Can you explain the differences there in force production depending on the actual ankle angle and how that can play a role in our rehab?

SPEAKER_02:

Yeah, absolutely. I think this is one of the most fascinating parts about training the plantar flexors is that when we think back to just the basic biomechanics, you know, one-on-one training of length tension curves from a muscle. So we know that in general, this is the general length tension, maybe somewhere around mid-range position tends to be strongest. If you're too long, then it's maybe a little bit past optimal working angle. And if you're too short, you're in that kind of active insufficiency position. That in itself doesn't quite line up with the rules of the plantar flexor. where it actually seems like peak plantar flexion torque peaks in the very deep angles of dorsiflexion. So the really nice study on this demonstrated was Manal et al in 2006. And that was one where they did isometric testing at 10 degree increments. It was from 30 degrees of dorsiflexion up to 40 or 50 degrees of plantar flexion. You tend to see the peak plantar flexion torque angle is at 20 degrees of dorsiflexion. So if we're doing a calf raise, that would be probably a couple inches of deficit. So dropping the heel off the deficit by a couple inches. By the time we come up to about neutral or zero, we've probably lost about a third of our torque generating potential, which really speaks to the importance of if our goal is to improve the strength of the plantar flexors, and we're just going from flat ground up. And now when you get to 20 to 30 degrees of plantar flexion, that torque continues to drop off at a pretty exponential rate. You're looking at like five to 10% of peak torque generating potential at that point, which on one hand is probably why it doesn't hurt very much when you're going through that range and your tendon is sore. And on the other hand, why it's very hard to build calf strength if you're not going off a deficit. So this kind of informs some of the classic training that you might see in bodybuilding, actually. This is where we can borrow from the bodybuilders on this one. Heavy partials are something very common in the bodybuilding, both in practice and in research. Partials are just when you're picking a certain range of the exercise, and usually it's the longer part of the range. And you're just working in that range and you're kind of coming back to some artificial end range on the other side, not actually using the full range of movement. That tends to be how I train the plantar flexors for increasing their overall strength capacity. I'll still have them do some lighter full range kind of warmup sets, but then I'm typically taking them into heavy partial deficit calf raises where we're going to use the entire range of dorsiflexion, maybe put a stopper at the very bottom so they have some feedback that they can tap their heel to. And if they get a little bit above the deficit, maybe 10 degrees into plantar flexion, then that's the end of the range and they come back down from there. And what you'll see is if you use that as your working range, you're going to get individuals to be able to lift a lot more weight, a lot more than maybe you suspect that they can do for a calf

SPEAKER_00:

raise. Click the link in the show notes to start your free trial today.

SPEAKER_01:

Definitely. And what I found is as you're doing that, that maybe 10 degrees above the deficit point, that will feel almost like a natural stopping point when you load it up very heavy. So I've definitely been doing that in my own practice. And I'm glad that you also touched on that. That's not to say that it's never important to go all the way to the top, but I think we maybe tend to focus on that part and maybe not so much on the deeper ranges of dorsiflexion. So it's a great clinical gem. So We spoke about strength training. We spoke about the diagnosis, but this was a runner and we need him to get back to running. So can you determine how we can be either a little bit more conservative or aggressive with our return to run protocols?

SPEAKER_02:

Yeah, absolutely. Because I think that is a pretty challenging thing on the clinician side is whether this is a clinician who has a background in run coaching versus not. How do we know what a good starting point is for our individual? And And the secret is that we really don't almost ever. So the first time somebody does their first return to run, walk, run, interval, whatever distance you select, we probably base how that goes off of whether we're going to progress or regress off of that. But we do have to start with some kind of educated guess. And I think about a couple different categories. If I'm first starting off with the basic, like, what is the tissue that we're working on here? Is this a tendon? Is this muscle? Is this bone? I'm probably going to be the most conservative when it comes to bone because we have enough literature that shows that yeah if we still have some symptoms as we're pushing through this things might not go so well versus some of the literature that we have on running through tendon pain which is I guess you can push it to what four out of ten pain as long as it's not that much worse off afterwards and into the next day it's an acceptable symptom state for you that seems to not necessarily slow down the rate of rehab for most individuals so that tends to be the symptom rule that I use, and that allows us to probably push a little bit more accelerated compared to if this was something like a high-risk bone stress injury, which would be on the opposite end of the spectrum. Obviously, tissue is one thing, but what their symptom irritability is also pretty important too, because this could be quote-unquote safe tissue, but feel very bad and have a not very stable symptom state. And if that's the case, then instead of pushing it from an accelerated standpoint to start and really lighting somebody up, I might be a Now that also falls under the context of where are we from a time of season. So in this case, it was seven months to go before the Chicago marathon. We could probably be pretty conservative, at least right off the bat. This individual wanted to have at least a four month build, which is probably the minimum recommended build for a marathon. Maybe a little bit easier for an elite runner to have a shorter build just because they have so much base running volume underneath them already compared to somebody who's not running at all and then starts to train for a marathon. But let's say this is a lot closer to the end of summer, then we would have to be more accelerated to start with our return to run to meet that deadline necessary. Also within the context of, is this safe? Is this going to be, are the symptoms going to be reactive as we're getting into this? Other things like their time away from running. So in general, the longer amount of time somebody has been not running, probably the more conservative you need to be as you ramp things back up. Maybe also not necessarily because of the current symptom state or tissue that you're working on, but because you don't want to create other issues by moving too fast too soon. And outside of this case, the best example of that is probably returning to run postpartum, which is very specific amount of time that someone is probably off of running for a while and then ramping things back up while their body is just kind of in a completely different state than it was before the last time that they ran. So time away from running, probably an important category there. The other main factor that I think of working with runners is just the relationship between running and their mental health. How much running do they need to main If the answer is a lot, then I'm probably going to be a little bit more like, yeah, let's see how much you can do then and see how much this is going to be helping you versus the individual who's like, nah, I'm fine to cross train until this is feeling good again. Then I can be a little bit more conservative on that side of things. So you can see that with that many different categories and things to take into account, that's why there isn't a standard return to run protocol. Everyone runs one minute on and two minutes off for six rounds. and moves on to the next day. It's going to have to be based off of what somebody has done recently, what all these other categories are for them. And

SPEAKER_01:

if that feels like a lot of different variables to remember, you do dive into this more in the case study and you have this return to run algorithm where all of these different variables are listed out and you could consider each of them on a sliding scale. And I think it's great that we can keep our runners running potentially with an Achilles tendinopathy given that again, we deem that they're safe. So I think that's a really good point.

SPEAKER_02:

Yeah, absolutely. And that's kind of the goal of a running physical therapist or a sports physical therapist who works with a lot of endurance athletes is assuming you've passed that initial safety barrier of, is this medically acceptable? We want to keep people training as much as they can that is not going to be deleterious to their recovery. And that's the balance that you just have to try to find with every

SPEAKER_01:

individual. Absolutely. And if you want to learn more about how to strike that How to assess Achilles tendinopathies and how to continue having a runner progress through a strength training program and a return to run program. We dive into this in a lot more detail in Jason's case study, and you could access the full case study now with a seven day free trial. And the link will be in the show notes of this episode. Jason, thank you once again for joining us. I really appreciate it. Absolutely. No problem, Noah. Thanks for having me.

UNKNOWN:

Bye.