elastic tissues ready for recoil during the initiation of the concentric phase of a closed kinetic chain exercise such as heel raises.
Effective eccentric function of the triceps surae complex (TSC) results in improved muscular ‘damping’ of the high forces gen- erated by impact loading eg. those occur- ring during hopping.
The effect of impact loading has been shown to cause significantly less joint loading in athletes than those expected based on force calculations. This is because of the passive and dynamic shock-absorption capacity of the connec- tive tissues eg. the plantar fascia and achilles tendon. This is thought to explain the lower than expected incidence of joint degeneration in athletes.
For effective dynamic control of those impact forces, effective eccentric muscle function is essential. Hence this retrain- ing approach is also appropriate for joint protection strategies in the lower limb. A full eccentric-based exercise rehabilita- tion programme is outlined later in this article along with a management summary (p36).
Manual therapy ● Expert manual therapy is useful to mobilise the achilles tendon. In order to
Figure 10a: CT scan of Achilles tendinitis with no degeneration
promote resorption of static swelling by the calf and achilles, massage the area. Restore normal local tissue flexibility by Specific Soft Tissue Mobilisation (Hunter) and to reduce pain use deep friction mas- sage (Cyriax). Deep calf massage and trig- ger point therapy helps to mobilise the calf musculature and reduce myofascial pain.
● Articular manipulation that optimises joint physiological and accessory move- ment at the talocrural and subtalar joints decreases the load against which the TSC has to work and improves the shock absorption of the articular structures. This is especially relevant in a stiff, supinated foot type.
● Spinal manipulative therapy that resolves elements of somatic referred lum- bar pain and sciatic nerve irritation at a spinal level is a necessary element of reha- bilitation success.
● Gentle mobilisation of straight leg raise (SLR) and slump are indicated by symptom reproduction or movement restriction on testing.
Figure 10b: CT scan of Achilles tendinitis with mucoid degeneration
Orthoses ● Temporary foot orthoses to control
excessive pronation or supination in con- junction with improved control from lumbo-pelvic retraining are essential where these malalignments are found. Success in use of temporary orthoses, lack of ade- quate control provided by them, or the lack of sufficient correction from lumbo-pelvic retraining may result in the need for per- manent prescription.
● A supinated foot type may benefit from augmented shock absorption in the form of shock-absorbing insoles or Sorbothane heel pads.
● Taping to resupinate the foot or offload the muscles is useful in the early phase or on return to sport (Figs. 18a & 18b).
● In a case where swelling is persistent an Aircast TA brace may be useful.
Sports specificity ● Where it is felt that performance of a
The mobilisation also helps to
optimise neural mobility and supply of innervated tissues. A sural nerve bias is produced by testing with the foot in dorsal flexion and eversion, while dorsal flexion and inversion particularly biases SLR and slump tests to the branches of the tibial nerve (Fig. 17).
specific technique places the TSC at partic- ular risk, careful decisions need to be made about technique. An example is the bas- ketball player with pain on a particular type of jump who may need to adapt to a bilateral landing on running jump shots.
● Return to training and incorporation of rehabilitation strategies into future train-