Achilles Tendon Pain with Iyad Salloum

Mark: Hi there internet people, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, near Vancouver, and the outskirts of Vancouver, the soul of Vancouver in North Burnaby. And we're going to talk about Achilles tendon pain. How are you doing Iyad?

Iyad: Good. How are you doing Mark? 

Mark: Good. So what's Achilles tendon pain. I have a sore ankle. How do I know it's the Achilles tendon? 

Iyad: That's a good question. Usually one of the first things we'd want to do is talk about how it started and the history and all that kind of stuff. And that usually helps us kind of figure out if we're going to look at the Achilles tendon or not.

And with most tendon issues, it tends to happen slowly over time. It's not like a sudden trauma. Obviously there is some of this kind of where I took a step and I felt something go and those tend to be a little different. So if we think about the classic Achilles tendon pain, it's either somebody who had taken lots of time off, I'm gone away on vacation. You know, just a bit of walking and then I come back. I'm like, okay, maybe I'm going to hit the gym at the same level I used to hit before. And that big spike from a big rest. So it's a period of disuse. And then you come back to where you used to be that sense tends to look like a spike on load on our body. And then we can kind of start to develop some of these issues. 

And where the issue happens, honestly, our best bet now is to do with maybe the resilience of that area or the training history. So for example, if this person's very well-trained they might have a bit more buffer, and they can withstand that jump in activity more, or not. 

The other really important one is the pain location. So tendon pain, you know, we expect it to hurt especially in the lower limb. So like the Achilles tendon, if somebody comes in and says, well, my foot hurts. I'm not going to be looking at the Achilles. Or if they feel painted like high up in their calf, we're going to look at something else.

So we'd like it to be in and around the tendon for us to have a pretty good confidence, that it is that. And then the other one, which is really, really important is how localized the pain is. So tendon pain is very localized. It doesn't really present where it jumps up and down and moves around a lot.

So if they have that, it doesn't mean necessarily that they don't have tendon pain, but maybe it's not the only thing that's on their plate that they're dealing with. So that's where we would want to dive in and assess all the things that could contribute to sensations there. 

Example, I had somebody who said, oh, I feel it when I run. And it turns out that they have some issue with their low back and we treated the low back and their leg pain right away. So it could look like a tendon, but if it doesn't behave like it, that's where we'd want to look a little more in depth. 

Mark: So let's just dig in a little bit deeper. Is there any relationship with pain the plantar fasciitis that pain down in the middle of your foot and tendon. Is this particular Achilles tendon pain.

Iyad: Could be. They're kind of connected, the two structures and you know, the name plantar fascia makes it sound like it's not a tendon, but it kind of behaves like a tendon. It's like a flat tendon. So they could be related or it could not be related. And sometimes you don't have to have one to have the other.

So some people only have heel pain, plantar heel pain, which is pain just at the inside of their heel, and that could be related to the plantar fascia getting a bit effected. So we would treat that with a multitude of ways, including figuring out why they're just so easily triggered with certain activities and try to modify that. We could do different shoe modifications for these people just to kind of help them continue to stay active, just because, you know, you're unable to maybe exercise the way you normally do doesn't mean you should stop exercising altogether.

And that's usually what happens, is people stop for a long period of time because they try to rest it. Then they lose function in other areas, and then all of a sudden, you know, they'll tell you I gained a bit of weight and I've lost my strength and all of this stuff that happens with just prolonged rest. 

So really our job as physios is to see okay, great. So you have this injury, how can we keep you as active as possible, while also trying to treat this injury at the same time. Instead of just completely cutting them off of any activity? So yeah, they can happen together or they can happen separately. But just because they're connected structurally, they don't necessarily have to go one and two, you can just have Achilles tendon pain sometimes.

And it's because the Achilles tendon is really important. We use it through our lifetime as a spring to help us recycle the energy that we use. So for example, when we walk or when we run, we're able to kind of recapture a lot of that energy that our body puts into the system and into the floor through this nice little spring function that it has.

Mark: So how related is an ankle sprain, say like a high ankle sprain or something like that, to this Achilles tendon pain? 

Iyad: They're pretty different. They're remarkably different I would say. High ankle sprains will happen from impact. They'll happen from some kind of trauma, some fall. You know, some people say, oh, I rolled my ankle, but then it happens usually from some kind of mechanism and direct episode.

I've rarely seen it happen just from a slow buildup, an insidious onset like that. The Achilles tendon also functions very differently. It's an active structure. It's a contractile structure. Meanwhile, in the high ankle sprain, the job of that structure in the front of our ankle just the top, is to hold the two bones together. So it's literally just acting as a binding so that we don't get excessive wiggling between the two bones. Meanwhile, our Achilles tendon is constantly contracting and releasing in conjunction with our calf. 

Mark: They're opposite of each other then, really? 

Iyad: Yeah. So you could think of them as one of them is kind of like connecting bone to bone, the other one's connecting muscle to bone. So functionally very different. Structurally very different. Location very different. One's going to hurt primarily in front, the other one's going to be at the back. And one of them is primarily like, again, the key thing with Achilles tendon pain is there has to be some kind of load change that we see and it doesn't have to happen last week. It could happen weeks and weeks ago. 

But then the idea is you do is huge kind of spike in activity. And then you kind of maybe go back to normal, but your body might not have enough time to repair and adjust and it slowly builds up where you start to become symptomatic. And then in that case, what we would do is just try to see what are we actually dealing with?

Is this actually the Achilles or is this something else? We can have, for example, pain in the structure, just around the tendon tissue itself, like the sheath, which could look very different. And this is where you can get something like a cyclist saying my Achilles hurts, even though what we consider biking is not really that heavy on the Achilles tendon. Not quite like running or jumping. It's not considered a high elastic activity. It's not a high springing activity. 

Meanwhile, if you have a jumping athlete, you're kind of going to look at that a bit more or a soccer player, or even a runner where they have to constantly be using that tendon. So yeah, we would look at that first and then we would kind of figure out where their symptomology is. And then we can modify lots of things. 

Same with the plantar fascia. We can modify the load. We can put them on a different exercise routine to keep them healthy, but also do some small modifications that we can again, modify footwear. That's a temporary solution obviously, that's not going to fix the tendon, but it helps them continue staying active and training. Especially if somebody, for example is training for a marathon and their time is a little limited. So they don't have this big window of opportunity to drop six weeks off their training program.

Mark: So if we kind of narrow down to the core here, the history is really important. That's how you're going to get to the exact diagnosis and where the pain is, of course. And then you got to keep moving is basically the other message. 

Iyad: Absolutely. So the way we diagnose tendons is it's mostly functionally diagnosed. So we have a bunch of tests and the idea is you'd expect it to hurt more, as I progress the load on you, I'd expect you to be more symptomatic if it's actually a tendon that's hurting.

So progressing load is just as general term, but it means if it's heavier, if it involves maybe more pressure on the tendon, if it's faster, those are all considered higher loads, but those are the parameters that we tinker with when we're designing, for example, somebodies running program within the Achilles tendon.

We would definitely want to keep you as active as possible, but also we want to put you on a loading program for the tendon. That's how we think the tendon restores its function best. It's not an inflammation only problem. You don't just want to rub an ice cube over it and let it rest. If it's actually a tendinopathy we're dealing with, so we want to kind of put you on the best regiment and it's not necessarily just doing heel drops, because you can think about just if you're a runner, how just doing heel drops off a stair might not be enough to get you back to full function.

So we need to start restoring some of that activity. Obviously we can definitely do lots of calf strengthening and we can work on muscles of the knee and the hip to kind of help support the chain a little more because that just helps any runner. And it can definitely help people with Achilles tendon problems.

And then we could do things like gait retraining, if it's that, that we suspect caused it. Somebody's a new runner, they haven't run before. We can kind of do some modifications to how they run and that could help them continue training, but ultimately they need to load the tendon. And that's where we come in and we design a program that's appropriate for that.

Most people are quite surprised by how much they could do load wise with a tendinopathy. And that's where, you know, sometimes getting the confidence from somebody who's telling you this is safe and here's how we do it. That could be very, very useful to kind of get things started. 

Mark: There you go. If you need some help with your Achilles tendon pain, you've got pain down your heel, around your heel. Get it diagnosed, know exactly what's going on and get expert help on what to do to get it better. You got to keep moving, but you need to know what the heck's going on and how to do it properly. And the experts, they've all been trained in this extensively at Insync Physio are the people to see. You can book online at their website or you can call the Burnaby office at (604) 298-4878. They're also in Vancouver at (604) 566-9716. Get in there and get some help. Get back fully active. Thanks Iyad. 

Iyad: Thanks Mark.