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Achilles tendinosis: stopping the progression to disability.

Studies have documented that athletes who train on a daily basis are vulnerable to tendon injury, (1) most commonly in the lower extremities. (2) This is also true of ballet dancers, (3-7) who are vulnerable to multiple, chronic, and multiple-chronic injuries. (3,8-10) The field of dance medicine and science has recently made good progress with injury screening programs and increased focus on injury prevention. The goal is to keep dancers dancing and performing by addressing injuries in a timely fashion.

Why is it Important to Address Tendon Injuries?

Dancers, again like professional athletes, have higher pain thresholds than the average population. (10) An ability to tolerate high-pain levels is not advantageous if it encourages continuation of an injurious activity. This may result in ever-increasing trauma to already injured tissue. Dancers, in general, not only continue to dance while injured, they may hesitate to report an injury or delay seeking treatment until they are unable to perform. (3,6-8,10) Failure to get treatment could lead to structural weakening of tendon tissue, (11,12) thereby increasing the severity of the original injury. High pain tolerance, hesitancy to take time off from dancing, and reluctance to seek treatment could result in additional or chronic injury, which takes longer to heal and leads to more time away from dance.

What Does a Tendon Do?

A tendon connects muscle to bone, transmits force to the bone, and moves it. (3,11,13) Tendons resist tension or strain and in so doing prevent muscle damage by absorbing external forces. Human movement relies on tendon strength, flexibility, elasticity, and adaptability to accomplish dynamic control of changes in direction, level, speed, and proprioceptive control. (5,11,13)

Achilles Tendon Structure

Weightbearing movement relies on the strength of the Achilles tendon, considered to be the strongest tendon in the body. (14-16) "The Achilles tendon is subjected to the highest loads of any tendon in the body" (15); it is able to withstand forces up to approximately 6 to 12.5 times body weight. (13-15) Paradoxically, it is one of the most frequently injured tendons. (6)

Collagen and elastin, two of the important structural components of tendons, provide the strength and flexibility necessary for tolerating load and adapting to dynamic movement. (11) Collagen accounts for 30% of the tendon structure. It provides strength (11,13) but has limited elasticity and is able to elongate up to 4% of its length before structural failure. (11) Elastin, only 2% of the tendon's structural composition, is responsible for improving flexibility and can stretch up to 170% of its initial resting length before rupture. (11)

Achilles Complex

Welsch and Clodman (17) describe four zones of the Achilles tendon that can help to identify injury sites:

1. Proximal junction, where the elastic quality of the gastrocnemius and soleus muscles transition into stiffer tendon tissue and help distribute mechanical stress. Overload may lead to muscle strain.

2. Mid-portion (the area of primary concern in this report), is 2 to 4 cm above the calcaneal insertion, an area of hypovascularity (poor arterial support). Injury may lead to a mid-portion tendinitis or tendinosis.

3. Superior to the insertion of the Achilles tendon and lying between the tendon and posterior calcaneal tuberosity, the retrocalcaneal bursa (a fluid-filled sac) reduces friction in the tendon. Irritation of the bursa may lead to retrocalcaneal bursitis.

4. Tendon transitions into the calcaneus at its distal end, an area of increased concentration of stress. Repetitive stress may lead to insertional tendinitis or tendinosis.

The gastrocnemius and soleus muscles are attached to the calcaneus via the Achilles tendon. The contribution from each muscle can vary. Slightly more than half the population has a greater contribution from the soleus muscle, about one-third has equal gastrocnemius and soleus contributions, and the gastrocnemius is the dominant contributor for a small portion of the population. (16) (This information may be helpful when addressing muscle strength and flexibility imbalances.)

In addition, the soleus muscle fuses to the anterior aspect of the gastrocnemius muscle as the two muscles unite in the Achilles tendon. It appears that a more distal fusion of the muscles produces greater vulnerability to Achilles tendon injury. (18)

The fibers of the soleus muscle rotate from 30[degrees] to 150[degrees] as they join the Achilles tendon, (13,16) which rotates from medial to posterior; the left Achilles tendon rotates clockwise, and the right Achilles tendon rotates counterclockwise. (16) As tendon fibers descend and spiral toward the calcaneal insertion, torsion of the relatively broad and flat proximal tendon becomes more ropelike. This torsion concentrates the forces within the tendon. (16)

The mid-portion region of the Achilles tendon, "zone two" as identified above, has the poorest blood supply and is therefore vulnerable to poor healing and slow recovery from injury. (16,19) Vascularity is inhibited in areas of increased pressures and repetitive friction (11) and as a result may contribute to overuse syndromes.

Ultimately, the constellation of Achilles tendon rotation, concentrated stress, and inhibition of blood supply, combined with repetitive irritation, reduces the capacity of tissue healing and may lead to tissue failure.

The term tendinopathy broadly refers to injured and diseased tendons. (20) Historically, tendon injury was categorized as a "tendinitis." However, distinct names now exist for different types of tendon injury, depending on the location (as described above in the "Achilles complex" section), the timeline of injury, and the stage of healing. When is the condition a "tendinitis" versus a "tendinosis"? Identifying the tendon injury correctly will promote appropriate and effective treatment.

Types of Achilles Tendon Injury

Initial injury to the Achilles tendon can lead to an acute tendinitis, an inflammation of the tendon, or a paratenonitis, an acute inflammation of the sheath surrounding the tendon (the sheath both reduces friction and provides nutrition to the tendon). (18) During this acute injury phase (tendinitis), the swelling does not move with the tendon movement. (5) Symptoms at this stage of injury include pain, crepitus (internal noise sensation), exquisite tenderness, warmth, and dysfunction. (2,5,11,13)

Continued insult to the tendon tissue may result in a tendinosis, a chronic, non-inflammatory condition that is consistent with degenerated tissue and disorganized tendon structure. Areas of maximal pain correlate with maximal hypervascularity, a sign that healing is not complete. Cardinal symptoms include palpable nodules that move with tendon movement and focal tenderness of greater than three months duration. (5,11,21)

Distinguishing between "tendinitis" and "tendinosis" is a challenge. Identifying the mechanism of injury, combined with a careful history and palpation, should help determine the stage of injury. Diagnostic ultrasound has also been used to clarify "-itis" versus "-osis." Adding complexity to the ability to identify the condition accurately, new acute trauma and injury can occur in combination with a chronic Achilles tendon condition. (2,11,13,19) In this case, one first treats the acute inflammatory condition until it is resolved and then addresses the chronic condition.

Mechanism of Injury

It appears that a change in type, intensity, and duration of activity may result in repetitive overuse (microtraumatic) injury to the Achilles tendon. (11,16,19) Failure of the tendon to adapt to the loading of body weight may result in asymmetric stresses to the tissues. (11,15,16,22) Thus, Achilles tendon injuries are commonly a result of poor technique while running or landing from jumps. (2,5,14,19,21-23) Similarly, for dancers who pronate (feet roll inward, flattening the arch), compensatory direction of forces during dynamic movement may create increased strain and stress on the tissue. (19) With repetition of activity, the muscles and tendons undergo chronic irritation and ultimately increase tendon vulnerability to further damage, degeneration, or rupture.

Dancers, teachers, physiotherapists, and health care professionals should be aware of and address the intrinsic and extrinsic factors that contribute to or predispose one to injury. (5,9) Extrinsic factors include poor movement technique secondary to 1. improper footwear; 2. training on hard, slippery, or slanted floors; 3. working in a cold environment with lack of sufficient warm-up; 4. change in training routine, resulting in excessive fatigue, strain, or pressure; 5. repeating difficult movements; or 6. prior injuries leading to altered technique or movement pat terns. (8,9,11,13,24,25)

Intrinsic factors, including age, gender, and height, are not modifiable. Inherent tendon vascularity, ligament flexibility, and foot structure may also be difficult to modify. The most effective antidotes to such intrinsic factors involve correcting poor alignment, focusing on proper technique, and improving muscular and joint flexibility, symmetry of muscular strength, proprioception and dynamic control, and conditioning for the demands of dance activity.

Tendinopathy and Healing

The ideal goal is to prevent injury, but once injury has occurred, addressing it in a timely manner is critical to preventing an acute condition from developing into a chronic one. Restoring a degenerated Achilles tendon to healthy status is essential to avoiding continued, compensated, additional, or multiple injuries, and to preventing tissue failure or rupture.

A tendon injury heals in a multiphase progression. Initially, a tear in the tendon results in a bleed into the area, releasing cellular components that aid in an inflammatory response. (26) Inflammation is a normal part of the early healing process. (5) Inflammatory cells migrate to the injured site in order to remove the debris of injury. Deposits of collagen and other tendon matrix components attempt to repair the tendon. Ideally, during the final (remodeling) phase, inflammation is reduced, vascularity decreased, and the collagen organized. (11,26) In a chronic Achilles tendon injury, however, complete restoration of the normal histological or mechanical features does not occur without intervention. (11,23)

Treatment

A tendinitis is generally treated with relative rest (time off from activity, possibly with the use of a heel lift in a shoe, a rocker bottom shoe, or a walking boot), ice, compression, and elevation (RICE). (11-13,18,19) Treatment may also include non-steroidal anti-inflammatory medication (NSAIDs) as advised by a clinician. (22) Tendinosis is not an inflammatory condition (12); therefore, different treatment is required.

Tissue can respond to stimulation of force, load, or stress either positively (remodeling) or negatively (injury). Wolff's Law, well known in the physical therapy world, is the principle of how bone responds or remodels according to the load or stresses applied to it. Gradually, over a period of time, increased loading (such as weightbearing or resistance) will stimulate bone remodeling to handle a heavier load; an increased load demand results in an increased bone strength response. Davis' Law is the soft tissue corollary of Wolff's Law, specifically for the remodeling of muscle or tendon. Increased muscle flexibility can result from stretching; increased muscle strength can result from repetitive loaded exercise. This is the foundation for tissue remodeling. Specific exercise, such as eccentric exercise, effectively promotes tendinosis rehabilitation. (13,18,20-23,27,28)

Why Eccentric Exercise

Eccentric exercise is based on the mechanism of loaded deceleration while the muscle-tendon unit is lengthening. This type of exercise stimulates the remodeling and reorganization of tendon tissue, ultimately decreasing tendon thickness, pain, and neovascularisation. (23,27) The organization of tendon fibers normalizes. "Eccentric exercise may enhance the mechanical properties of the degenerative tendon" (12); the tendon unit stiffens and lengthens, helping to decrease strain, and the tolerance for dynamic load improves. (11,23,27,28) Eccentric exercise places more stress on the gastrocnemius-soleus-Achilles system than either isometric exercise (static muscle contraction equaling external force) or concentric exercise (muscle shortens, overcoming external force). (11,18,21,28) Performing eccentric exercise gradually over a period of time overloads the tissue, which is necessary to restore muscle strength and tendon integrity.

Physiotherapists have used adjunct therapies in conjunction with loaded eccentric exercise to achieve positive results. These include stretching of the gastrocnemius and soleus muscles; therapeutic ultrasound combined with deep tissue friction massage; use of a night splint, rocker bottom shoe, or addition of a heel lift to the shoe; and ice. (13,19,20) Addressing coexisting musculoskeletal factors--for example, symmetry of proximal muscular strength and lower extremity alignment, core support, joint flexibility or stiffness, enhanced proprioceptive response, and progressive conditioning--provides a more complete approach to rehabilitation of this injury.

Exercise Protocol for Achilles Tendinosis

The Achilles tendinosis protocol presented in this report is a modification of one used with recreational athletes with mid-portion Achilles tendinosis at the Sports Medicine Clinic at Virginia Mason Medical Center in Seattle, Washington. It is based on the Alfredson and coworkers' (21) "heavy-load" program of two types of eccentric heel raises. Each of these variations is performed with specific timing, which is important for slowing the lengthening of the muscle-tendon unit. The gastrocnemius muscle-based version is performed in an upright stance with knees straight (Fig. 1). The heels are raised relatively quickly in one count to a demi-pointe releve (Fig. 2), which is a concentric movement, and then lowered slowly with an eccentric movement in three counts to the starting position (Fig. 1), with weight bearing on the full plantar aspect of the feet. The soleus muscle-based version is performed again in standing posture, beginning with knees bent in a partial plie with full foot contact on the floor (Fig. 3), followed by a releve (maintaining the partial plie while rising into a forced arch on the metatarsal heads of the feet (Fig. 4]), and then a lowering of the heels, returning to the beginning position of knees bent and full foot contact (Fig. 3).

Each version addresses the muscle-specific strength and muscle-tendon flexibility essential for dynamic activities. "Functional" activities in dance, such as landing from a jump, include a combination of releve and plie; therefore, this author proposes adding a third version of heel raises as a part of the protocol. This would combine the gastrocnemius-based releve to demi-pointe (Figs. 1 and 2) and the soleus-based lowering into plie (Fig. 3), a movement sequence similar to performing a jump in slow motion.

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The protocol advances from one set to two sets of 15 repetitions for each of the three versions: 1. releve and lower with knees straight (gastrocnemius-based, Figs. 1 and 2 and back to 1); 2. releve and plie with knees bent throughout the entire movement (soleus-based, Figs. 3 and 4 and back to 3); and 3. a combination of releve with straight knees and lowering with bent knees into a plie (Figs. 1, 2, and 3). At first, the exercises may be performed bearing weight on both feet. When tolerated, the exercises may transition to beginning the exercises on two feet (Figs. 1 and 2 or 3 and 4), shifting weight to a single leg (Fig. 5 or 7), and lowering on a single leg (Fig. 6 or 8).

If both Achilles tendons are injured, the total number of repetitions should be doubled, in order to load each leg eccentrically. Further progression includes performing these exercises off the edge of a step, wedge, or ramp, effectively increasing the range of motion of the gastrocnemius-soleus-Achilles unit during the lowering phase of the movement (Figs. 9, 10, and 11 for the gastrocnemius version; Figs. 12, 13, and 14 for the soleus version; and Figs. 9, 10, and 14 for the combination version).

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As the exercises progress over time, either increased load may be added (this can be achieved by the use of a backpack containing weights) or a speed program may be initiated (see Tables 1 and 2). Which protocol is followed depends on the type of activity most frequently practiced or performed. That is, for those dancers involved in lifting other dancers, a load protocol may be more appropriate; on the other hand, if jumping or quick travelling movements predominate, the speed protocol may be more helpful.

The recommended duration for this protocol is 8 to 12 weeks. (19,21,23) The timeline can be extended as necessary to resolve tendon thickness and pain. Advancement from one stage to the next can be one week apart or longer. It is expected that there will be fatigue or discomfort by the last 10 repetitions of each phase. If not, one may advance to the next phase. Ultimately, pain and thickness of the nodules are expected to decrease, and exercise tolerance to improve.

"Achilles tendinopathy is an overuse injury." (14) It is ironic that an overload and overuse injury is healed by a protocol employing strenuous repetitive eccentric exercises to reverse the previous damage, stress, and strain to the Achilles tendon. Alfredson and colleagues reported pain would be experienced when performing these eccentric exercises; however, in his 1998 study, the patients were advised to discontinue the exercise "if the pain became disabling." (21) Hence, the amount of discomfort experienced should be monitored. Soreness may be acceptable as long as there is movement without compensation during gait. However, experiencing increased pain that causes abnormal weight-bearing movement patterns may indicate the need for a slower progression of the protocol. This can prevent an acute injury from compounding a chronic condition.

Summary

There are many factors affecting dance injuries. Dancers, along with teachers, choreographers, physiotherapists, and other healthcare practitioners, may reduce the risk of injury with careful attention to technique and sufficient warm-up, correction of modifiable intrinsic and extrinsic factors, and adjustment of the intensity, frequency, and duration of activity, with the goal of avoiding development from an acute injury to a more chronic and disabling condition.

Addressing injury in the early stages and avoiding progression of injury from an acute inflammatory tendinitis to a chronic degenerated tendinosis is desirable. Careful consideration of the history of activity and mechanism of injury and identification of the type and stage of injury (tendinitis versus tendinosis) help to direct appropriate treatment intervention. (16)

Eccentric exercise uses the load of body weight in a specific manner to stimulate successful remodeling of a mid-portion Achilles tendinosis. As a result, muscle strength should improve, integrity of the tendon be restored, and pain and dysfunction resolved. Three versions of an eccentric exercise protocol for Achilles tendinosis have been presented to address a progression of "load" and "speed" for restoration of function in dancers.

No rehabilitation is complete until the dancer is capable of maintaining full dynamic load and controlling directional and speed changes with confidence. This requires progressive training for a balance of strength and flexibility, as well as building endurance and proprioceptive control. Dancers, teachers, and physiotherapists can explore and enhance the repertoire of movement experiences, including eccentric exercise, required to address these needs.

Caption: Figure 1 Beginning and ending position for gastrocnemius dominant releve (or straight leg heel raise).

Caption: Figure 2 Releve.

Caption: Figure 3 Beginning and ending position for soleus dominant releve.

Caption: Figure 4 Releve from a plie position.

Caption: Figure 5 Single straight leg releve.

Caption: Figure 6 Lower to the starting straight leg position on a single leg.

Caption: Figure 7 Single bent leg releve from a plie position.

Caption: Figure 8 Lower to the starting plie position on a single leg.

Caption: Figure 9 Straight knee neutral position on the edge of a step.

Caption: Figure 10 Releve on both feet.

Caption: Figure 11 Lowering on a single leg, allowing heel to drop below level of the step.

Caption: Figure 12 Bent knee neutral position on the edge of the step.

Caption: Figure 13 Releve on both feet in bent knee position.

Caption: Figure 14 Lowering on a single leg into plie position, allowing heel to drop below edge of the step.

References

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(12.) Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A symptomatic review. J Athl Train. 2007 Jul Sep; 42(3):409-21.

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(15.) Campbell SE. MRI of sports injuries of the ankle. Clin Sports Med. 2006 Oct; 25(4):727-62.

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(19.) Myerson MS, McGarvey W. Disorders of the insertion of the Achilles tendon and Achilles tendinitis. J Bone Joint Surg. 1998;80:1814-24.

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(22.) Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42-7.

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(26.) Rosenbaum AJ, Wicker JF, Dines JS, et al. Histologic stages of healing correlate with restoration of tensile strength in a model of perimental tendon repair. HSS J. 2010. Https:// springerlink.metapress.com/content/ j64174v070611323/resourcesecur ed/?target=fulltext.pdf&sid=2sct4d u4hypz05yzc12kmx45&sh=www. springerlink.com.

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Meta Chessin, M.P.T., is at the Virginia Mason Medical Center, Sports Medicine Clinic, Seattle, Washington.

Correspondence: Meta Chessin, M.P.T., Virginia Mason Medical Center, Sports Medicine Clinic, 1201 Terry Avenue, Seattle, Washington 98104; mpchessin@ yahoo.com.
Table 1 Eccentric Exercise Load Protocol

Phase   Frequency                       Repetitions

1       1 set of 15 Gastroc             slow
        1 set of 15 Soleus
        1 set of 15 Combination =
          gastroc releve, soleus plie
2       1 set of 15 each                slow
3       1 set of 15 each                slow
4       1 set of 15 Gastroc             10#
        1 set of 15 Soleus              10#
        1 set of 15 Combination         10#
5       1 set of 15 each                20#
6       1 set of 15 each                30#
7       1 set of 15 each                40#
8-12    1 set of 15 each                50#

Phase   Frequency                       Range                Load

1       1 set of 15 Gastroc             once/day x 7 days    on floor
        1 set of 15 Soleus
        1 set of 15 Combination =
          gastroc releve, soleus plie
2       1 set of 15 each                twice/day x 7 days   on floor
3       1 set of 15 each                twice/day x 7 days   off step
4       1 set of 15 Gastroc             twice/day x 7 days   off step
        1 set of 15 Soleus
        1 set of 15 Combination
5       1 set of 15 each                twice/day x 7 days   off step
6       1 set of 15 each                twice/day x 7 days   off step
7       1 set of 15 each                twice/day x 7 days   off step
8-12    1 set of 15 each                twice/day x 7 days   off step

Note: It is expected that there will be fatigue or discomfort by the
last set. (12) If not, one may advance to the next phase per schedule.

Table 2 Eccentric Exercise Speed Protocol

Phase   Repetitions                      Speed

1       1 set of 15 Gastroc              slow
        1 set of 15 Soleus
        1 set of 15 Combination =
          gastroc releve, soleus plie
2       1 set of 15 each                 slow
3       1 set of 15 each                 slow
4       1 set of 15 each                 fast
5       1 set of 15 each                 fast/slow
6       1 set of 15 each                 fast/slow
7       1 set of 15 each                 fast/slow
8-12    1 set of 15 each                 fast/slow

Phase   Repetitions                      Frequency            Range

1       1 set of 15 Gastroc              once/day x 7 days    on floor
        1 set of 15 Soleus
        1 set of 15 Combination =
          gastroc releve, soleus plie
2       1 set of 15 each                 twice/day x 7 days   on floor
3       1 set of 15 each                 twice/day x 7 days   off step
4       1 set of 15 each                 twice/day x 7 days   off step
5       1 set of 15 each                 twice/day x 7 days   off step
6       1 set of 15 each                 twice/day x 7 days   off step
7       1 set of 15 each                 twice/day x 7 days   off step
8-12    1 set of 15 each                 twice/day x 7 days   off step

At phase 7 begin alternating days, one day with eccentric exercise,
fast and slow, then (only if pain-free) the next day initiate a walk
or jog program if desired. Note: It is expected that there will be
fatigue or discomfort by the last ten repetitions. (12) If not, one may
advance to the next phase per schedule.
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Author:Chessin, Meta
Publication:Journal of Dance Medicine & Science
Date:Jul 1, 2012
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