A Different Way To Treat Achilles Pain - Track Athlete Case Study
Where do I start treatment for an athlete complaining of Achilles tendon issues? The same place I start every evaluation - the LTAP (locator test assessment protocol). This directs me to where the body is protecting and what the underlying driver of changing the dynamic alignment, function, and pain is. I still look at the movement and orthopedics of what was going on and likely stressed the tissue - but the story of something being “tight”, “weak”, or “inhibited” is gone. I talk about all of this and more including my entire breakdown of a recent case I had of a track athlete complaining of Achilles pain.
Resources Mentioned In This Episode:
Episode 54: A Better Way To Assess The SI Joint
The Results Cheat Code- The Missing Link FREE Course
Sign Up For LTAP in Washington D.C. (June 15-16)
Sign Up For LTAP in San Diego (Nov 2-3)
🚨FREE Course🚨
The Results Cheat Code- The Missing Link is a FREE online LIVE mini-course designed for physical therapists and athletic trainers to clearly identify where to start treatment to get the better results, even for the most difficult client cases.
Head to www.movementrev.com/results-cheat-code to sign up!
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole-body approach to care, however, it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
=================================================
Watch the podcast on YouTube and subscribe!
Join the MovementREV email list to stay up to date on the Unreal Results Podcast and MovementREV education.
Be social and follow me:
Instagram | Facebook | Twitter | YouTube
-
Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello! Welcome back to another episode of the Unreal Results Podcast. Another week. It's my last week at home for a little bit. So I'm trying to soak in all the days. Went to the beach yesterday. This is only like the third time I've been to the beach since I've been home, so definitely not enough.
Um, anyways. Here we are. Currently. Um, Doors are open for the results, cheat code, the missing link, my free mini course for PTs, athletic trainers, sports healthcare providers, basically. Um, I teach you the first test of the LTAP concepts, um, and the first test alone can get you. Some really great results. So I'm super excited to teach it.
It's one of my favorite courses to teach. It's great too because it's just like the first introduction to sort of like changing people's perspective on how the body works and um, how movement works, how injuries and pain and dysfunction are. And so that's why it's so fun is because um, for a lot of people that enroll in this course, it's like their first time.
learning from me their first time, like considering the viscera and the nervous system. And maybe, well, maybe not the first time considering it, but the first time being able to see it in practice, like in real time in their clinical practice, like make it make sense. And you know, that's the thing that you've probably heard me say on this podcast before.
And I say to my athletes all the time, like, don't ever take my word for it. Like, don't believe me just to believe me. You have to see it for yourself in order to like realize that This lens of view has such value and has such potential to be such a game changer, so um That's my favorite thing about the the the mini course It's it it's it's over an entire business week and I encourage you to be like doing the work in real time with your clients so You You can take what you're learning, but apply it and like, see for yourself, uh, how much information we can gather from a simple orthopedic test that you might already be doing.
So, I hope you'll join me. We start April 14th, so the doors close the day before, which is April 13th, which is a week from Saturday. If you are listening to this podcast on the day it drops, which is April 3rd, So yeah, if not, um, I offer it for free twice a month. And it's always available, um, as a self paced, do it yourself course, um, online as well for 197.
So, it's your chance to get it for free and get the most up to date information. Obviously, every time I teach it, I add more information, you know, more context, more stories in. So, um, even if you've taken it before, sign up again. Um, It'll be fun. So also coming up this weekend is the in person course in Arizona I cannot wait to be at exos teaching all of these professionals.
We've got a big group. We've got 26 professionals of various Professions, so we've got physical therapists athletic trainers, acupuncturists, massage therapists, Pilates instructors. Really a lot of different people. I think that's it. I might oh, so maybe some stretch therapists So just a lot of different hands on And hands off providers and it's just gonna be a great course.
I have four Teaching assistants coming. Um, the reason I have four is I wanted to represent each one of those professions and so um It's just gonna be awesome. And then on top of that, my mentor in the Barral Institute world, uh, Veronica Campbell. She's a physical therapist in Phoenix. She'll be there too, sort of being a sort of combo, a student and TA.
So, um, it's just gonna be a really great group. So, that course is full! If you're like, Oh, dying to get in, let me know. I can probably squeeze a couple more people in, but for the most part, it is full. And then the next two in person courses, June, Washington, DC. Um, I can't talk November, San Diego, filling up fast.
Love to have you there. Um, without further ado, speaking of the LTAP. So the LTAP, the Locator Test Assessment Protocol, like I said, the results cheat code missing link is the first test of the LTAP sort of as an introduction. Uh, but I wanted to, well, I want to share first, just as a reminder, like, um, what I teach, this is what I do.
my own practice. And um, so I use it on a daily basis. I use it in conjunction with the osteopathic general and local listening to sort of guide my treatment as well. But the LTAP really helps to, um, confirm everything I'm feeling with my hands, uh, which is really helpful. You know why I think it's so great.
Um, oh my gosh, little side note There's a bug on my desk and I thought it was a like I don't know. I didn't think it was a bug. I thought it was like, I don't I don't know what I thought it was like Lint or something and I just went to like wipe it off and I almost smashed it and it's kind of like a hard shell bug, so that would have been gross so Bear with me while i'm distracted by this bug bugs.
Don't really bother me too much You So, but Oh my gosh, if I was my sister or my nieces, I would be like literally flipping out. So back to the LTAP. Um, because I use it on a regular basis, this is part of the reason why I know it works so well, but then because I've been teaching it for so many years now and I've taught so many professionals and the, you know, constantly unsolicited reach out and let me know the results.
Like I just know it works. And, and it also, it's just so.
So today's podcast, I was trying to think of like, what did I want to talk about? And I, um, always get really good feedback from people when I share like case that's good cases, um, on the podcast. And so that's what I wanted to do today. I had recently worked with a track and field athlete, um, not one that I've worked with before.
So new patient, uh, and, um, I wanted to just share her. case. So she is a triple jumper. She's been having, um, kind of consistent and very limiting Achilles tendonitis type of pain. Uh, she said it's a little different than what she's normally gotten in the past was like true Achilles tendon more like. mid, mid Achilles tendon pain, and this is more insertional Achilles tendon pain.
And, um, you know, she had to take some time off training for a while and she's back training, but it's still sort of bothering her and she's doing all the things and it's really not necessarily changing a ton. So she wanted me to do a little consult on her and help guide her In like what to do on our own, right?
So this is an athlete that I don't have access to, um, helping on a regular basis. So it was really like a consult to be like, can I help you? And then how can I guide you from afar to take care of this on your own? Or is it something where you need to go see someone, uh, for some specific care? So I Um, Also, too, I will, I will preface this with, I didn't know that this was her pain or problem.
Okay, so I prefer my clients not tell me Um, and I'm going to talk a little bit about what they're coming to see me for, because I want to have the most unbiased point of view or perspective I can when I go to assess them. Because, especially because the LTAP assessment is a way to sort of ask the body, like what, where to go, what's most important.
I don't want my ego mind to be biased by like where I should go. So, um, I did not know she was having Achilles tendonitis. I did not know what leg it was. at all until after I do the initial assessment. So the way I set up a treatment is I explain to them what I m gonna do, how it s a little different from the norm, and then I say, okay, so I m gonna do the osteopathic type of assessment first, the LTAP first, figure out where the body wants me to treat.
And then once I know that area where the body wants me to treat, then we can pause and we can have a conversation about what brings you in today, like what's been bothering you, what have you been doing for it? And at that point too, we'll do all the orthopedic tests and all the movement tests to see what's going on.
Because I still sort of want an idea of like their movement and like what I would do in a non visceral and neural lens of view. So, um, that's what I did for her too. The LTAP led me to her right pelvis SI, like somewhere in her right lower extremity, um, felt pretty high up. Um, so the LTAP, the way the LTAP works is, um, the first test of the LTAP, which I teach in the results cheat code, um, it did not change with the breath hold.
So that directed me to the same side. of the lower extremity that the hypomobility was on. And then, um, then that's, that advances us to the fifth test of the LTAP. And then that helps, um, me to sort of narrow in where on the leg is it, is it down near the ankle and foot? Is it the knee? Is it the, um, hip joint?
Is it the SI joint and pelvis itself or any of the soft tissue? areas between basically the SI joint and the toes. And, um, basically, uh, it, it led me back to, uh, it was around her SI joint, uh, and around her pelvis more than anything. And so once I had that, Um, once I knew where I was gonna start in that sense, uh, then I asked her what was going on and she described what was happening and, um, she has it on both sides, but the right was ver versus the, uh, worse than the left.
And um, it's a little bit more on the inside edge of the tendon, right where it inserts on the calcaneus. And, uh, you know, she was feeling like she was a little bit limited mobility. And it is her, um, as a triple jumper. It is her takeoff leg. So it is. That whole side of her body has a lot of impact through it.
If you're familiar with triple jump, it is a lot. Um, so. I was like, okay, good to know. So then I did like orthopedic tests and, um, her ankle mobility was a little limited, felt a little bit more to me, like nerve tension limitation of dorsiflexion versus actual joint. So a little bit more soft tissue and like resistance, both of her legs had quite a lot of, um, drag on them when I lifted them into passive hip flexion.
And specifically on the right side, she wasn't folding across the front of her hip very well, so she was avoiding hip flexion on her right, but had a big, heavy, like, neural drag on both of them. Uh, she was also, on the right, lacking internal rotation, long axis internal rotation at, uh, the whole leg, hip joint.
Um, And a little bit of a deduction at her ankle. Her, if I, if I had to say something mobility wise was like a little wonky and her ankle was probably around the, um, calcaneus or the subtalar joint was a little bit different versus the left side. And, um, Then she also had, um, two sort of like positive neural tension signs, um, one on the right for the lumbar plexus and one on the left for the, um, sacral plexus.
And so, um, But you know, yeah, quite a bit of nerve tension anyway. So I did feel like there was sort of, sort of maybe a nerve thing affecting her ankle function and mobility in general. So then I looked at movement tests. So the movement tests I like to look at when, um, I'm looking at people with Achilles tendonitis is really just like, how are they loading their foot?
And so I look at closed chain dorsiflexion. And which is like the most rudimentary way to look at footloading, um, but it does give me a pretty good information. So I would look at her from the front and the back and it was very apparent on the right, on both sides. She sort of caved in quite a bit or pronated, um, Or adducted in the shin, like whatever, however you want to view it.
She caved in and her feet on both sides, but on the right, she had a little bit more of a fulcrum or like an acute angle on the Achilles at the Achilles tendon itself. And so you could see how that. Inside edge of the Achilles tendon on the right was getting overstretched every time she loaded her foot
And the more she loaded her foot, the more we saw that her calcaneus really, um, gave way into this eversion position and she collapsed a little bit more at her subtalar joint, decreased the space under the lateral malleolus on the right. And so then, I had her do calf raises, I like to look at, like, the motor control of the calf raise, and then in the, in the instance that they land their foot back down on the ground, that's another good indication of how they're loading their body.
And, sure enough, when she did calf raise, the calf raise, like, from a control standpoint, didn't look terrible. I would have liked to see a little bit more calcaneal inversion through the range of motion, you know, that like posterior tib, um, good quality strength there. But what was really apparent is when she lowered her foot back down, you could see her collapse on the inside and see that fulcrum even more on her Achilles tendon.
And then it was like more and more apparent that it was getting stretched out. And so I was like, okay, from a mechanical standpoint, This is why your Achilles is not happy and, and I, I made sure to tell her too, and this is really important to understand in this lens of view is to not discount the actual sometimes pathology that's happening to the tissue that is painful.
she has some actual tissue pathology things going on on that medial border of the lower part of the Achilles tendon because of this loading pattern. And so it's not like calling this Achilles teninopathy is not the right thing because it is exactly what's happening. The difference is understanding that the mechanics I see, this caving in of the foot, this fulcruming, um, At the calcaneus and this, this like extra lengthening of the medial side of the tendon, this lack of rear foot control and the calf raise, like all of, you know, that, the lack of dorsiflexion on the mobility test, the lack of internal rotation, all these mechanical orthopedic things are part of the clinical picture of why that tissue is being overloaded and overstretched.
And Most of the time, my Achilles tendinitis, tendinopathy people are responding to a tendon that's getting overstretched. And so all of these things are leading to that. The difference in this lens of view, considering the viscera is the nervous system, is understanding what is driving those mechanical
issues. It's not that she's lacking mobility. She's actually a very hyper mobile type of person. She even said that. She's like, I'm actually really normally super flexible. Um, kind of loosey goosey. She, um, you know, there's a lot going on in her body. That would lead me to be like, well, she's a little bit more on the hyper mobile spectrum or maybe not like spectrum, but she's more towards hyper mobility and anything.
So it's like the mobility things is not probably structural. And, um, even the posterior tibialis weakness that I see, you know, with the motor control, even, you know, in the testing, if I did, it's, it's understanding that you can see something like that, that quote unquote looks weak. And in a second it can change because that's how our body is set up.
Right? Like sometimes our motor output is limited, not because the muscles muscle cells, like the mechanics of it, the physiology of it can't create a contraction is because the neural input to that muscle to create a contraction is not adequate. And so, aka the sensory information going into that is not accurate.
And the sensory information may not be accurate because maybe the nerve that's sending that sent that information relaying that information to the motor control component of it. Maybe it's getting compressed, maybe it's getting over lengthened, right? It's altering the communication to that muscle. So, it's not up to me to instantly see these mechanics and be like, you're tight and you're weak, right?
Which is the normal labels people are given. All I do is like, interesting. I, uh, and I told her that I was like, interesting, took a video and I shared it with her and I said, interesting. Do you see how this could lead to over lengthening of your tendon? And she's like, Oh yeah, that makes sense. And she's like, and that's actually kind of what I feel too.
And I was like, great. Okay. So let, and then I'm like, well, let's see if it changes. I don't know if it's gonna change until I just start doing stuff and then rechecking it. And this requires a little patience on my end instead of just being like fixing all the mechanical things. Because fixing all the mechanical things, because I assume they are driving, the drivers of the problem, is just another way of forcing the body.
And over here, movement rev style, we don't force the body. We're not about forcing things. And so, it's like, no, go back to where the L top was leading me. So the L top was leading me to her SI joint. Right around her SI joint. She was one of those, um, few people, right? So Joe, let's link the, um, Podcast from last week about the SI joint.
She's one of those five to ten percent of people who The mobility that she was lacking in her SI joint was actually truly the SI joint ligaments itself So I did the full Gillet's test and I looked at all of the different portions of the ligaments and it was her ilial lumbar ligaments on that right side that were really stiff and indurated as well as like the top part of the sacral Iliac ligament, so they're going from like S1 to the PSIS, as well as the sacrospinous ligament was really stiff on her too.
So, um, I actually treated, did a very specific manual therapy technique to each of those iliolumbar ligaments. That, um, S1 to PSIS ligament, as well as the sacrospinous ligament. The stiffest of them were the ilial lumbar ligaments on her, um, the other ones kind of like freed up fairly easily. Um, so that was the first thing I did.
I did that and then I retested things in her ankle, in the heaviness of her leg, so the neural tension on her leg. improved. Her ankle mobility improved somewhat. It was still a little limited. Her hip internal rotation was still limited. I did not stand her up and check the movement just yet because I was like, well, if I'm not seeing big changes on passive, like I'm not just going to lift, take her up off the table.
We still have more to do. So I went back and redid the LTAP. And the second time I did the LTAP, that side of the right, that side was better, but still hypomobile. But this time it changed with the breath hold. And so now this tells me, okay, I did good work on the structural manual therapy piece. Now there's a strategic hypomobility and that directed me to the viscera or the central nervous system test, central nervous system.
And so that leads me to the second test of the LTAP, which is the central nervous system tension pattern. And sure enough, that's, uh, What was going on on her? She had a little bit of cranial tension. And so I did my neural manipulation assessment and treatment up there. We worked on her meninges and then there was a little piece, there was also like a little Um, other piece in her cranium that I, it just quickly winded the treatment up there and, um, I incorporated some leg movement into it too, just to kind of connect the two.
And, um, we rechecked things there that completely opened, not completely, but that got her almost full dorsiflexion and, um. There was still a little piece of her dorsiflexion, like the soft tissue piece was gone, but there was still a little piece of her dorsiflexion that was limited and it felt like the tibia, it was not internally rotating very well.
Like it was kind of jammed up on the medial side. And, um, after that cranial piece, she was like, Oh, my leg feels totally different. It feels so much lighter. Like, this is great. I feel it releasing, you know, without you really doing a whole lot. And I was like, yeah, that's really cool. And I was like, okay, I think we have one more piece, but let's check.
So then I did another, um, I went back to the LTAP again, and I rechecked her SI joint. And this time, Um, this time it moved. it moved much better. And so I was like, okay, like, so your body's not necessarily protecting anywhere. So now permission to clean up all the other little things that I thought mechanically was going on with her.
She was still avoiding a little bit of her groin, like anterior hip when I moved her leg into internal rotation and hip flexion. And so I was like, let's, um, and her SI joint on that side was mobile, but it was still on the stiff side. So I was like, you know what, if I treat her obturator nerve. I'm probably going to affect all of that.
So I treated, I did a quick obturator nerve neural manipulation technique right at the, um, pubic bone around the obturator, um, foramen. And, uh, real gentle technique. Did that and that cleared up her, um, hip internal rotation, the long axis internal rotation. It made her SI joint move a little bit better. I also added in a little bit of a sacral float.
So I put my hand underneath her while she's lying on supine and just floated the, um, sacrum up, uh, anteriorly. And, um, Then I rechecked her orthopedics and that totally freed up her ankle. So now her ankle was not feeling like it was jammed up anymore. So then I was like, Ooh. Let's see how you feel and let's see what your movements look like.
And we got off the table and we looked just standing on her feet. Her, her alignment was better, looked much more like the left side. She dorsiflexed and she's still, she's still relatively like caved in, but more similar to the left. And this time at her Achilles tendon, I didn't see such a big fulcrum. It was more of like a, a very.
Controlled sort of caving in of the whole leg. It wasn't just at that one little joint And then she did the calf raise and this was the coolest thing probably my favorite part of the whole thing was like Well, besides her being like amazed, but was the change in her calf raise, holy cow. It was like the best looking calf raise, totally locked in and you could see her whole heel like turn into that sort of J stroke, that really good like posterior tib.
And then when she lowered her leg down out of it, it was like rock solid, beautiful alignment. And I was like, that, that's what we need to see. And she felt better. She didn't feel the tension that she had been feeling on her Achilles. And she just felt like her, like she just, her whole body felt better.
Her whole leg felt lighter. She just felt more on top of herself. And so it was really good. Cool to see. And so I was like, isn't that interesting? Those mechanical things, the lack of ankle mobility, the length of lack of internal rotation at the lower leg and at the hip, um, you know, those things we knew was driving the Achilles problem, but had we just gone in and pushed around and manipulated all that stuff?
Yeah. We might've had some improvements today, but she would have just gone back to it. Right? It wouldn't have been so, such a big, dramatic change. And so, that was just really cool to see, and it just goes to show you. And this, this is, at the beginning of the podcast, I talked about how the Results Cheat Code is cool because you get to see it for yourself.
This is the whole thing. Like, even when teaching the LTAP course this weekend, I can't wait to see people to see it for themselves. Because it's one thing for me to tell you this. And assume you believe me, but when you see it for yourself, when you're like, holy cow, I really thought I was gonna have to do a joint mob on her ankle.
I really thought I was gonna have to like dig into her calf and then you see those changes is like so mind blowing. So, you know, and then like I said, I, I don't work with her regularly. I probably won't see her again often. So then I gave her some things to work on on her own. And the things I did have her work on was I taught her how to do a sacral float on her own to keep that side of her sacrum moving.
Now, because she has a little bit of hypermobility, she was very aware. That when we did the sacral float, she felt more motion on the left side versus the right side. So I showed her how to put her foot in her leg in a certain position on the left to force the motion on the right. And, um, I basically put her in like a force closer position on the left and then an open one on the right.
And then it was able to really target that right side ligaments better. And then the other, um, home exercise program I gave her was posterior tibialis calf raises. Well, and it was cool because she felt the difference when her leg just did it on its own. And I gave her the little cue with having a ball between her heels and sort of rolling the ball up with the inside of her heel.
And I was like, you know, continue to strengthen that because her SI joint will get jammed up again. She's a triple jumper. That's just how it works. Now I want to make that foot mechanic that was probably leading to the the tendonitis, the tendinopathy, I want to make it a little bit more resilient. So improving her posterior tibialis strength and making it stiffer is going to make her hopefully a little bit more resistant resistance to that being the weak link when her SI joint does get jammed up.
But now too, she's, she's already like a smarter athlete because she now knows if her Achilles starts to bother her first start at the SI joint and then go from there. So, um, Yeah, you know, and it was also just preemptive of like, man, like, had, had I tried to walk you through this on your own, I don't know if it would have been quite as good of a result because she did need some like very specific manual therapy at the SI joint.
But the most important thing is getting in the right spot. So anybody who would have started with that right SI joint or that right side of her hip, Versus down at her ankle or someone else, probably would have gotten pretty darn good results too. So that's sort of the um, LTAP in action. And why, you know, why when I I'm teaching people about any joint, about any injury, about any pathology, about any rehab, I'm always like, well, let's start at the LTAP because you can't assume that someone's lack of rear foot control is a true weakness or not.
In her case, it wasn't really a true weakness. As soon as her SI joint was mobile and posterior tib functioned beautifully. In fact, better on the right than the left at that point. And so, you know, it's just, this is also too, why I'm so careful of about telling athletes stories about their injury, about their body.
The story she would have been told by people is that she was weak. That's not true. That's not true at all. And in stories like that, we hold on to, and it sort of colors everything that they do after that. And so it's like, no, it's just more about less about telling a story. I'm more about being curiosity, being curious and being like, Whoa, interesting.
This is how your body is presenting. It's also protecting this other thing. So let's treat where you're protecting, get you out of protection pattern. And then see, is your body still representing that way? Or is. It's a totally different scenario. And it's very empowering, it's very empowering because so many times when people are hurt they think it's something, it's their fault, like something they did or didn't do.
And it's like, that's just not, it's not so black and white like that. Our body adapts to the environment it is living in. And that is what makes it amazing. And, and having a tool like the LTAP allows us to sort of speak to the body and be like, where do you actually need support? And it's not often where the thing is hurting.
So hope that's helpful. I need to get permission from her, but I'm hoping to turn some of those videos into a little reel. So if I do that before I post the podcast, I'll link it in the show notes. If I do it after, I'll try to remember to go back, but I can't promise anything. So, um, hope that's helpful.
Have a great day. Would love to see you in one of the LTAP courses, but definitely would love to see you in the results cheat code, the missing link. There is no reason to miss it. It's free. So hit the link in the show notes. Talk to you soon. Bye bye. .