Case Study in the Clinic

My recent practical experience with an Achilles rupture, surgery, and tendinopathy.

Seven months ago, this individual ruptured his Achilles and underwent surgery after he was jogging backward and went to change direction forward. POP! This type of injury is what we call a reactive strength injury; the tendon does not have the ability to absorb and dissipate forces during that task, resulting in the tissue yielding.

I came to assess this person a few weeks ago because I noticed his walking gait had changed significantly. I can only describe it as a double limp, whereby both knees stayed bent and couldn’t fully extend before heel striking, so I commented on it.  

After some discussion about his case, I asked him if I could assess his ankle and Achilles and if we could work on it a bit.

This was a very selfish session. I have been learning a lot about reactive strength and Achilles injuries, but it's all been theoretical up to this point. This was my chance to get hands-on experience and actually feel what we’ve all been reading, watching, and discussing.

Assessment & Findings

Obviously, with this injury and the history, there were a lot of different findings. However, the one finding that the client and I both found fascinating was the stiffness in the tendon.

This finding was especially interesting because I have been learning about tendons and how they have a stiffness and a compliant component. Meaning that a “tendon is a variable mechanical tissue”; towards the bony attachment, the tendon is stiff, compared to where the tendon blends into the muscle, where it is more flexible and compliant.

However, in this case, as I assessed the Achilles tendon in ankle dorsi flexion, we found that the ankle reached its end range of motion rapidly and didn’t have a lot of range of motion. As previously mentioned, his assessment also revealed that the tendon had a tremendous amount of stiffness, so stiff in fact that it prevented any length and tension from traveling upward into the calf and soleus muscles. The muscles were completely soft and had no tension through them.

This is a fascinating but not a shocking find: due to injury or inactivity, the muscle end of the tendon can become just as stiff as the bony end.

These findings also reveal how the bottom-up biological component of reactive strength can affect the top-down component of reactive strength, by disallowing the ability for length and force transmission to signal to the nervous system to contract muscle tissue.

Another finding is Achilles tendinosis, which is the inability of the connective tissue to transmit and dissipate forces. This leads to tissue breakdown and disorganization of the architecture, as well as loss of the behavior to stretch.

Strategy

Our strategy for treatment and training is simple: we will train multiple ecologies simultaneously. Training that will enable each ecology to affect another and create cumulative multifaceted training effects. This is a conjugate strategy in a clinical setting.

We will focus on connective tissue architecture and joint function as our ecologies. Our goal is to change the biology first, then tissue behavior. We want to create organized tissue that will allow for optimal force transmission and still behave like a tendon.

The Internal Isometric Continuum is a guide to help us constrain things like our effort and duration to ensure we funnel our work into the correct tissue (ecology), and drive adaptations that are favorable to the Achilles tendon.

We can train architecture using the Bulgarian Method multiple times daily. The stimulating intensity to drive architectural adaptation is low, the duration in positions is longer, and it can be done at a higher frequency.

In conjunction with our architectural and tendon-specific training, we will work to improve the outermost ranges of motion of the ankle joint by performing controlled articular rotations, or CARs, to improve joint function. These, too, can be done quite frequently, depending on the intensity.

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A post shared by @briangfox

This is an Instagram post showing the HIMA work being done on the slant board after our assessment and Functional Range Release work on 9/25/24. We also used the dip bar to relieve some of his body weight.

Training

His training until 10/9/24 and to be done 3x per day:

1. Ankle CARs — 3-5 each direction

2. HIMA isometrics — 15 seconds on, 1 second off for 60 seconds total. To induce Stress relaxation using isometrics. Using holding isometric muscle action, the stiffest/strongest parts of the tendon will relax the tension and allow longitudinal tensional load to occur. This will open the door for new emergent behaviors in the tendon.

3. 2-minute stretch at length

References

1. Chivers, Michael, John Quint. “Absolute Resource Guide: Fascicles of the Adult Human Tendon + Training Video.” Absolute: The Art and Science of Human Performance. Oct. 2, 2024.

2. Chivers, Michael, John Quint. “Internal Isometric Loading Continuum.” Absolute: The Art and Science of Human Performance. March 2, 2024.

3. Pacey Performance Podcast. “Training Tendons; Implications for Sprinting, Jumping, and Rehabilitation with Kieth Baar. June 16, 2021.