Hope everyone is doing well! Writing to share some of my rehab experience and get a little feedback from the crowds here.
Like many of you I’ve spent a decent amount of time trying to figure out “why” this happened and what, if anything, I can do to keep it from happening again. One hypothesis I have is that the root trigger for my rupture did not so much start with the achilles/leg but actually in my lower back. This hypothesis was primarily inspired by my experience of pre-rupture achilles pain that was temporarily alleviated after back-focused weight lifting.
While I’m not convinced that there is a “one size fits all” explanation for ruptures (so many things are involved from the back all the way down to the achilles that it’s very difficult to isolate just one cause out of the back -> glutes -> hamstrings -> calves -> achilles chain), for a number of reasons I think that starting at the relative “top” is a good place to look, which is why I’m initially focusing on the back.
After some research I narrowed down the potential “back” triggers to two primary contenders: the sciatic nerve and Psoas muscle. It turns out there’s already been a study that demonstrates a possible correlation between achilles rupture and sciatica: http://www.ncbi.nlm.nih.gov/pubmed/9631229 While this certainly won’t be scientific, I would love to poll the crowds here and see if folks can confirm the study results to any degree / have any family/personal history of sciatica / scoliosis / low back pain /if you were spending an abnormally high amount of time sitting in the days/weeks leading up to your ruptures / anything back + achilles rupture connections you would like to share.
Additionally, while probing the sciatic/achilles relationship I came across a few references to the Psoas muscle and decided to try a “Psoas release” technique I found online, which is where things got really interesting. After performing the stretch I immediately took a few steps and, to my extreme surprise, for the first time since the injury, my leg felt entirely “normal.” It’s difficult to describe, but prior to those steps I felt that there was a certain level of explosive push off power or “spring” missing from my injured leg. It wasn’t enough to notice in day to day life or to hold me back functionally– everything was progressing on schedule, normal ROM/able to walk/run/jump/do full height single legged heel raises/etc. But if I tried to do an activity that truly exposed the leg (namely running at full gallop) I could tell that there was a little something missing and a definite asymmetry between my injured and uninjured legs and the way my feet struck the ground.
I had chalked this up to power deficit/weakness, so I was completely stunned when I took a step and all of a sudden it felt like my leg was finally 100% engaged when it hadn’t been just seconds earlier. My first impulse was to cry tears of joy, and my second was to take off running down the hall in celebration. In my defense, this feeling was 6 months in the making! Fortunately I was alone so I didn’t look like a total lunatic.
Then, after a few blissful steps, almost as if a switch was flicked, the feeling of “something missing” returned. I stopped running and tried the release stretch again, and then took a few steps. No improvement. Tried the release again, nothing. Waited 10 minutes. Tried it again. Nothing. I searched for a different Psoas release technique online (there are many) and I tried that. Success! I walked around for a bit, and then sat down. When I stood up a few minutes later, the “missing” feeling was back.
This on/off between releasing the Psoas, feeling the “good feeling” and then a quick return to the “something missing” feeling continued for the rest of the day. Interestingly, after some experimenting I realized that if I walked around with my knees bent (like a t-rex — again, good thing I was alone), I could consistently produce the power feeling, but somewhere in the action of straightening the leg, the “missing feeling” would return, and it wouldn’t come back unless I performed the release, and sometimes not even then.
The next day I found the achilles significantly less stiff when I woke up in the morning (I had been experiencing tightness that required massaging/light stretching/warming up in the morning before I felt comfortable walking quickly, now it just took a few steps). I did the Psoas release and found the “good feeling” returned, and was beginning to stick for longer durations, including some seated periods and some t-rex leg to straight leg extensions.
By the third day I woke up with almost no stiffness, and after a few steps the “good feeling” engaged without me even doing any release, and then it remained for the rest of the day. Which brings me to here. I’m going to continue to experiment with this and check in with my own PT about it, but I wanted to see if anyone else has experience with the Psoas that they can share, or if their PTs can provide feedback on it. Caution: I definitely would not try any of these releases or stretches without talking to a PT first, especially if you’re in the earlier (pre week 12-16) phases of rehab. From what I can gather the muscle is fairly potent, and working on it appears to have both physical and neurological implications, so it should be manipulated carefully. Its location also makes it physically difficult to release (I’m guessing some of my “failures” may be attributed to me failing to perform the proper release technique more than anything else), so a PT will be best positioned to help in that regard as well.
Caveat that there are some other variables that I’ve been throwing into the mix, including a new (significantly firmer) mattress and lower profile shoes. I think that those may actually be contributing to the reduced morning stiffness (not the Psoas release), but jury is out on that one.
That’s all for now, but to everyone out there in rehab land, just continue to hang in there — things can truly change in a matter of days with this injury, so stay positive, keep up with the PT, and you’ll be back before you know it.
15 responses so far ↓
hillie // Oct 18th 2014 at 7:23 am
So many factors can contribute to this injury, and it was interesting to read your own experience and theories. In my case, 5 years before my atr, I started adding custom orthotics to my shoes to improve my gait and help alleviate my own back issues. This was on the advice of one of the Exeter ortho specialists.
Around 2 months before my injury I stopped wearing the inserts (don’t ask why…) and my legs and back eventually tired more easily. This warning came too late though, and after a very hard weekend of hillwalking, I bust my AT when jogging up stairs. Maybe coincidence but I take more care now.
dcoughlan // Oct 18th 2014 at 12:52 pm
Yes, definitely many factors. Need to do more research to find out whether it’s possible that the back is directly involved at the time of rupture, or whether it merely contributes to the problem (pulling causes long-term degeneration, etc.), or, most likely, some combination of the two.
Thank you for sharing your experience! Interesting to hear that you noticed your back getting tired — I also felt an unusual level of discomfort/exhaustion in my back pre-injury after sitting and working for 3 weeks straight in an uncomfortable position without exercise breaks. Tragically the achilles ruptured during my celebratory ‘finished’ run!
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Kim // Oct 18th 2014 at 5:36 pm
Hi not sure where your conversation started but wanted to say that prior to my full rupture I had eighteen months of hip bursitis in both hips I had an injection in my left hip which seemed to work but within a week i got a facet lock in my back and as in agony for weeks, was due to have the right hand hip injected and then the moment of all moments happened and i ruptured my achillies, so my back had been under strain for eighteen months. I am now 11 weeks post rupture and my back is very week again, along with trying to walk normally again. I know I need to get To Pilates but not ready yet!!!!
normofthenorth // Oct 19th 2014 at 11:15 am
Can’t strengthen this with my experience. Live long enough you probably have some back problems, whether or not you have ATRs… Mine have been pretty manageable, don’t keep me from being crazy active and competitive. I wear a back belt when I ski (single diamonds at Whistler), but not when I play 2-on-2 beach volleyball with a bunch of jocks ~40 years my junior. Can’t complain. Hanging out the side of a 15′ sailing dinghy all summer doesn’t bother my back.
I did suffer with a couple of months of sciatica recently, years after my second ATR. Miserable condition, fortunately mild and (touch wood!) temporary in my case.
heeling // Oct 19th 2014 at 12:50 pm
I have an interesting question related to this: I donate blood 5 days prior to my ATR and am wondering if there’s any correlation there? as I know the AT doesn’t have a very good blood supply. Maybe just having a bit less blood flowing to it played a part? I guess I’ll never know but I’m going to look it up and see if any connection has ever been reported because I am a bit of a nerd!
dcoughlan // Oct 19th 2014 at 1:59 pm
@norm - glad to hear you’re still getting after it! Although I will say that I don’t think associated back issues/conditions would necessarily have to rise to the level of being limiting (plenty of professional athletes have ruptured their achilles while participating in their respective high level activities seconds earlier, so it doesn’t appear their backs weren’t actively holding them down). I’d be specifically interested in you because you suffered ruptures on both legs — anything you remember about the back going into one or the other would be really illuminating! My current theory is that the rupture involves some kind of low back seizing at a time when the foot/achilles are in active traction which combines to create an unnatural pulling force on the tendon. These pulling forces progressively weaken the achilles and eventually a rupture is caused when the pulling force exceeds the available elasticity of the tendon. So it’s not so much “one move” but rather a series of them.
@heeling: Interesting theory. Non-physical elements have been associated with achilles ruptures (e.g. the use of fluoroquinolone drugs), although the exact relationship between the two is unknown. Nerding is wholeheartedly encouraged — do let us know what you find!
herewegoagain // Oct 19th 2014 at 9:10 pm
No back issues for me prior to each rupture so can’t offer any help. It would be great to be able to pick a trigger, but there are so many variables.
badmintonrupture // Oct 19th 2014 at 11:50 pm
No back issues whatsoever for me or any of my family members. I play a very high level of badminton and am totally ok suddenly reaching very low to retrieve drop shots, or stretching way backwards (sometimes mid-air) while trying to retrieve an overhead shuttle/birdie. i.e., my back is ok when I go lean way front or way back, even at rapid speeds in rapid succession in doubles badminton.
I think the single biggest reason for these achilles tendon ruptures is of course being age 30-50 and trying to move and play at levels you reached in your 20s. This seems to be true across all countries, all races etc… We tend to NOT be surprised when we have weaker hearts and eyesight as we age, but we tend to expect tendons to remain the same strength till we die!
normofthenorth // Oct 20th 2014 at 12:06 am
BR, I think you’re right BUT: We ATR folks have mostly maintained our muscle strength while our ATs developed a weak spot. It’s generally that imbalance that causes the rupture. At least the folks who ATRed in sports or dancing etc., tore their AT with their own strength and momentum. If everything got proportionally weaker, we probably wouldn’t be here…
badmintonrupture // Oct 20th 2014 at 12:11 am
normofthenorth that is true. And some people are getting more muscular in their 60s and 70s!
http://www.bbc.com/news/magazine-21151163
badmintonrupture // Oct 20th 2014 at 3:08 pm
Hi why were my last two comments not approved? Are you not allowing links?
dcoughlan // Oct 20th 2014 at 3:14 pm
Sorry @badmintonrupture, didn’t realize those comments were stuck in the holding pen when they came through. (I just saw one comment, which I have now approved.)
@BR, I don’t mean that you would experience pain per se when performing rigorous back activities (I never did when playing all kinds of back-intense sports.) It is helpful that you mention no back conditions outside of sport for you and your family, however.
There’s definitely a wear-and-tear element to the tendon, at least in the short-term, as at least two notable athlete cases ruptured mid-event while they were sufficiently warmed up and were barely moving at the time (walking) compared to what they had done earlier. Most likely that there is some kind of long term stress contribution as well.
Stuart // Oct 20th 2014 at 3:57 pm
I have had a bad back on an off for many years. It started after a muscle injury while working as a stockman (cowboy for those north) when I was a young man and then worked its way to a more structural issue. I put this down to wearing a heavy utility belt and gun for many years as a plod. They kept adding things for us to carry. I guess that is why some coppers get fat. They need more room on their belts for the gear. Although the body is surely biomechanically related from the ground up I am not sure you can correlate an AT rupture with a weak or tight psaos muscle. The psaos performs a significant function when running and could possibly be an indicator of another problem elsewhere but whether it could cause an AT rupture is questionable. It may but there are so many other factors it would be difficult to isolate it as the root cause. I don’t think humans were really designed to run long distances and the stresses that puts on every part of the body is significant. Why can some people run and never have a problem while others seem always to suffer from an injury? I can only put it down to genetics, biomechanical make up, training or other subtleties. A doctor friend of mine who is also a marathon runner about the same age as me has one leg slightly shorter than the other and I can never keep up with him. He seems never to have any problems. The psaos muscle is also a difficult muscle to access so I would be interested in how you did that yourself. Some say it is not possible to ‘release’ it which is really a term for stretch. I am just getting over another back issue which I have learned over the years to manage myself with stretching and even self manipulaton. One stretch I do may be related to the psaos and does give relief from pain and a freer walk is to lay on your stomach and get someone to hold your pelvis down while lifting your leg at the knee. I then push down with my leg against the force holding my leg up. I also do a similar thing laying on my back with the knee bent into the chest of another person and pushing up. After some time (sometimes days) stretching I am often able to free up some lower vertebrae that are locked which give me the pain. Doing these stretches does not impact on my lower leg push off power but certainly affects the upper legs ability to function. The long and short of it is running long distance is really not very good for your body but can be very addictive. I also now have an atrial fibrillation or flutter. They are not sure which one yet and that has been attributed to a thickened heart wall from long distance running. The bright side is that the older I get the more I learn about the workings of the body. Interesting discussion anyway. I know you like this sort of stuff as well and hope to hear more of it.
dcoughlan // Oct 21st 2014 at 1:25 am
Totally agree @Stuart. If only I knew the things I knew now a few years ago, I may have been able to avoid this whole mess! At the same time very grateful for this injury as I can already tell it is going to impact my running positively.
With respect to why some get hurt and others don’t, I think you’re on the right track — great genetics and a little bit of luck. I was actually relatively injury free for the first 2 years of my competitive career, and then one injury that I attempted to train through caused a series of cascading injuries and I haven’t been fully healthy since. Have been fortunate to see some great PTs this time around who really taught me how to fix everything from the ground up (literally, turns out even my toes on the right foot are out of whack!) It will probably be a year of re-training my body and de-learning all my bad habits. Cannot recommend time with a qualified PT enough.
Am sorry to hear about the heart diagnosis. I often tell people that discovering running is both the best and worst thing that has ever happened to me. Not sure who or where I would be without it, and I don’t really care to know. Hopefully the wheels keep turning but if they come to a stop, well, I can’t really say I regret it.
You are right that the Psoas is quite difficult to release. I have had the most success laying flat on my stomach and using a trigger point massage ball in the area. I prop myself up on my forearms and the slip the ball into the groove where it essentially acts as a hand (it has a cone/dome shape to it which allows for a more focused pressure) . Can be quite painful but the relief is worth it! Have a look at the trigger point products (and mainly just the various points themselves), I’ve actually found them to be quite useful, although the prices leave a lot to be desired.
badmintonrupture // Oct 21st 2014 at 3:05 am
I forgot to add that my MRI results suggested some pre-existing tendinosis on the ruptured tendon. No idea how they could tell from the images.
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