LP: Chronic Achilles Tendinopathy post PRP and Tenex Procedure: Phase 3 (12-26-17)

Conversation follow up concerns
- Continues to feel distal achilles soreness with walking “normally”
  - As we discussed previously, your calf and tendon are still very weak at this point and forcing yourself to walk a certain way that is painful is not ideal.
  - If this is my achilles, goal number one is to avoid any activity that aggravates it
  - If you can change your gait in a way that hurts less overall then for now…do it
  - I would still like to have a video of your version of normal walking compared to the way you have to walk for it to not hurt
    - Also did you try the tape?
      - Discussed shorter stride, taping options, self soft tissue massage for tendon
      - Rock Tape Insertional Peroneus Brevis Tendonitis
        
        This technique can also be used for the achilles, the only difference is the small piece I use in the beginning should be taken across your achilles, just above the area that is most painful
        
        Self massage tendon VIDEO
        
        This can be done lightly to work on desensitizing the tendon
        
        If an area is really sensitive work around it or be very gentle
        
        I would hit 3-4 sensitive areas for 2-3 minutes
Phase 3:
- The goal of this phase is to progress loading of the achilles tendon in a short range to improve strength without significant pain
- This will build on the strength sequence with some options that challenge the ankle along with other aspects of the trunk
- The daily sequence should be done lightly, 8-15reps for each movement
  - This can be done 2x/day on the non-strength day
  - Do 1x on the strength circuit day
- Strength circuits
  - Should be done every other day along with the daily sequence
  - Goal is a minimum of 5 reps max of 20reps
  - Focus on doing all reps slow and controlled as opposed to moving too quickly and doing a higher amount
- Daily Sequence
  - Self MFR Calf VIDEO
    - use a tennis ball or lacrosse ball
    - Hit 2-3 spots on the calf, NOT ON THE TENDON for 30to 60sec
  - Band Plantarflexion/Gastroc Activation VIDEO
    - There are a variety of band resistances
    - Try to start with something that allows you to get through as much ROM as possible
    - Go really slow on the negative 4-5 sec as you slowly load into the stretch
  - Self MFR Hamstring VIDEO
    - Same concept as above
  - Hamstring Isometric with Contralateral Leg Raise VIDEO
    - This can be done with an exercise ball of feet up on couch/chair
    - Try not to push directly onto heel as it is likely tender
    - Push more so into the calf
    - hold each 5sec
  - Hands Elevated Childs Pose Variation VIDEO
    - prop a small roll under your ankle like a yoga mat or a thick towel roll to keep excessive pressure off the ankle…I will make a video if needed if you have issues with this
  - Quadruped with Physio Ball Hip Extension VIDEO
    - Focus on keeping your low back relaxed
    - can use an exercise ball or an ottoman
  - NEW:
    - Standing Thoracic Rotation with Band Around Knees VIDEO
      - Use a mirror to maintain lower body position as you rotate
- Strength Circuit#1
  - Upper Body Assisted Squat VIDEO
    - Assist of hands should minimize excessive pressure on the achilles
    - Slow and controlled descent into the squat 4-5sec on the way down
    - NEW: PHASE 2-Progress if you are able to get 20 reps of movement above
      - Squat with Forward Reach Band Around Knees VIDEO
  - Band Around Knees Bridge Progression VIDEO
    - Keep tension in the stomach as you raise up
  - Heel Raise Isometric Hold VIDEO
    - Focus on a position that is least painful
    - Work on increasing the hold time between 30-90sec
    - If able, try to focus on more weight on the problematic leg as you are holding
    - NEW: PHASE 2- Progress once you are able to stay on your toes for 90sec
      - Feet Apart Hip Abduction Raise Small Range VIDEO
        
        30sec-2 min
- Strength Circuit #2
  - Basics of Bear with Leg Lift VIDEO
    - Start holding bear position for 30-60sec
    - Once you are able to hold 60sec…progress to part 2 with the small leg lifts holding each for 5 sec for 30-90sec
  - Lying Down Weighted Pullover Feet Elevated VIDEO
    - Start with a light weight, make sure you can do a slow and controlled descent into the overhead position
  - Standing Press in Lunge and Terminal Stance VIDEO
    - Start with the press from chest and straight out…4 positions as mentioned goal of 30-60sec each position
    - You want to feel a little unstable but not out of control
  - ICE AFTER 10-15MINUTES