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Achilles and Knee Pain in Youth Athletes

The Patient(s): Middle school female twins who play competitive basketball year-round. Both complained of similar symptoms of Achilles pain and slight knee pain in both knees during and after games. They had both gone through huge growth spurts over the past year.

I began with some simple strength tests and found some weakness in the hips. I then had them perform a few squats to see what this functional movement would reveal. What we observed was a whole lot of hip hinging and very little knee flexion. This is usually a good indicator that the athlete has limited dorsiflexion range of motion.

Dorsiflexion = ankle movement where the toes point up/back towards you

We wanted to test dorsiflexion further to see if this was the true reason for their limited squat. We set this test up by placing our toes one hand-width from the wall (or about 5 inches). While keeping the heel down, push your knee towards the wall. If you have full range of motion you will be able to touch your knee to the wall.

Our athletes in this case had very limited dorsiflexion and could only get their knees within about a full hand-width from the wall.

So now we know that we need to increase dorsiflexion range of motion. They are performing running, jumping, and other activities that place a big load on the Achilles tendons that are tight. This is causing the irritation and pain that they are feeling.

The treatment plan will involve stretching of the two muscles that feed into the Achilles tendon: the gastrocnemius and the soleus. we will perform each of these stretches 3x30 seconds, 3 times per day. To stretch the gastrocnemius we need to stretch into dorsiflexion with the knee straight. To stretch the soleus we need to stretch into dorsiflexion with the knee bent.

Sometimes the limiting factor is not muscle length, and is instead a tight ankle joint. You will know it is the ankle joint if you try one of these stretches and you feel pressure or pinching in the front of your ankle instead of a stretch in the Achilles. To address this, we use a banded dorsiflexion stretch. This will provide a slight glide on the ankle joint and help it move better. We can use the same stretching pattern for this: 3x30second hold, or if this is sore we can do 5-10 reps for 5-10 second hold, working up to higher reps and holds as tolerated.

Another great way to lengthen tight muscles is through eccentric loading. A lot of great research has come out about this recently. You need to make sure you are using a heavy load for this. A second reason to choose this type of exercise is due to the nice effect it has on improving tendon pain. Try 10 reps with a 5 second hold at the bottom of the stretch.

In the video I forgot to mention that I had the athletes perform some soft-tissue work with a foam roller for 2 minutes on each calf before beginning the stretching exercises. We like to do a little soft-tissue work and then follow that up with stretching. You can usually get some immediate results out of using this pattern, and it is also a great way to warm up before games and practice.

So day 1 we addressed the major limiting factor that the athletes presented with: limited dorsiflexion due to tight calves. In upcoming visits will progressively load the Achilles tendons with strengthening exercises. This will decrease inflammation and improve tendon strength so they can perform basketball activities pain-free.

I also gave them some some hip strengthening exercises since they were weak, and since the hips play such a large role in knee stability, but I will let you watch the video below if you are interested in those!

Full Vlog here explaining the patient case, assessment techniques, and treatment demonstrations:

Also, here is a short video on rolling out the calves which can be a really useful intervention:

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