LP: Chronic Achilles Tendinopathy post PRP and Tenex Procedure: Phase 4 (1-5-18)

Current issues continue to focus on tenderness in the similar area of the achilles that has been a problem even prior to procedure
- Function and tolerance for loading seems to be progressing with what sounds to be a steady amount of achilles pain
- Benefit from taping to offload then tendon while you are in the process of improving strength seems to be beneficial
- Goal for this phase is to progress loading and begin to assess/ compare the strength in the right and left leg with single leg loading progressions
- I am giving you a very specific loading exercise/test with the bench mark of minimum 30 sec and maximum of 2 minutes
  - I need to know 2 things from you
    - #1: With the progression, which phase do you need to stop it when following my instruction in the video
    - #2 Do you feel any fatigue in the calf muscle or do you just feel achilles pain
- Continue to use: Rock Tape Achilles VIDEO
Phase 4
- 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 OR 30 sec-2minutes as specified per exercise
  - 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
  - Bridge Band Around Knees Progression VIDEO
    - can do with or without band
  - 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
    - PHASE 2-Progress if you are able to get 20 reps of movement above
      - Squat with Forward Reach Band Around Knees VIDEO
    - PHASE 4 PROGRESSION
      - Goblet/Front Squat VIDEO
        
        Start with 10lbs-20lbs
        
        Goal: 8-20 reps, if you get to 20reps, increase weight and lower reps
  - Double Leg Bridge Phase 3 VIDEO
    - 8-20reps
  - 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
    - 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
    - PHASE 4 UPDATE
      - Heelraise Loading Overview Isometric to Increased Range VIDEO
        
        30SEC-2 MIN FOR EACH
        
        LET ME KNOW WHERE YOU FATIGUE
- 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
    - PHASE 4 PROGRESSION
      - Band Horizontal Abduction VIDEO
        
        8-20REPS
    - You want to feel a little unstable but not out of control
- Strength Circuit #3
  - Bear Mountain Climber Speed VIDEO
    - Start slow for 30sec to 2 minutes
    - If that goes well progress to intervals as shown
  - Sagittal Plane Stability VIDEO
    - 30SEC TO 2 MIN
  - Sidelying Leg Raise Progression to a Stretch VIDEO
    - SLOW AND CONTROLLED 5-20REPS
  - ICE AFTER 10-15MINUTES