Learn how the Achilles tendon truly can bring down the whole structure with renowned shockwave therapist, Uran Berisha. Today he explains how the Achilles tendon is a unique complex that is also intricately connected to several others. When it is injured, find out how radial and extracorporeal shockwaves work on multiple cellular processes to speed healing and get you pain-free faster. If you have suffered from foot, ankle and/or calf pain that won’t go away, shockwave could be the option that sticks.
Hi, welcome to another episode of the Unpain Clinic Podcast. This is episode number four, and today we are going to talk about the Achilles Tendon. So if you actually think about the origin of the Achilles and how it got its name, it was because in Ancient Greek culture there was a superhuman that nobody could fight but he had a weak spot. And that was his Achilles Tendon. As soon as the tendon was cut he was brought to the ground, he was weak. That’s how you would probably feel if you have Achilles tendon pain or tendonitis. The first couple steps in the morning, when you’re walking or running when you are doing pretty much any activities. If you already have tried other therapies, like physiotherapy, massage, stretching for Achilles Tendonitis, and other forms but are still in pain. It is a stubborn tendon because it is one of the thickest tendons in the body, and it’s in your foot so you pretty much cannot walk if you have pain. So what typically happens with chronic Achilles Tendonitis or Tendinopathies. These are all the fancy names, but I don’t like to use the names of the conditions at Unpain Clinic. We would rather focus more on trying to figure out the cause and if you just listened to the previous episode, episode number three, where we talk about Plantar Fasciitis, the Achilles Tendon is similar to the plantar fascia. Actually, they go together. But now I want to provide more information about Achilles Tendinopathies that are chronic and have been for a minimum of three months. So the first thing that we need to understand is that tendons are the bridges that anchor between a muscle and a bone. So the reason we have tendons wherever we have muscles is because it is helping this muscle to anchor on the bone so that the muscles can actually pull more. The body has designed the tendons do not have good blood circulation because they’re not really designed to get injured. But in the case of injury, it still has the mechanism where it can repair itself. What happens when it can’t? That means there is a dysfunction in the muscle. From my personal experience, I have learned that every time when we are dealing with Tendinopathies or Tendonitis, like inflammation of the tendons of the body, regardless of where they are we first have muscle dysfunction. Because of the muscle dysfunction, it affects the joints. So then it forces you to walk, function, exercise differently. Now, this tendon is not functioning properly, those fibres are getting overworked and the body is sensing more mechanical forces impacting the tendon. Those cells are thinking they need to make the tendon even stronger because they are getting more load. And then the tendon starts thickening up and loses its elasticity. Then it starts hurting, it even blocks the fluid flow inside the tendon. There’s actually fluid even inside the tendon, at a microscopic level every tissue in the body, every muscle fibre, every tendon fibre has facial layers in between those that help them glide against each other. So it’s almost like lubrication of the tendon, so once you’re running that tendon becomes an elastic structure. After about 40 minutes of running it almost becomes your muscle, the muscle starts tightening up because it’s producing more force. Now the tendon starts heating up and becoming more elastic, offering you more elasticity in your body. But when it gets injured it loses that ability and therefore started hurting after you have stopped running. Because when you’re running you gave the task to your nervous system to finish the 5K, 10K, 20K, 40Ks. And now your body is going through an adrenaline rush, different types of adrenaline can push you, and therefore you don’t feel the pain. [Your body] is going to start using other things, so it can get you through that. But then, after the activity, you start feeling the Achilles pain and it really hurts that’s when you realize you have a problem. What I have found personally is the dysfunction of the Gluteal muscles, the biggest muscles of your bum/hip area. When these muscles become dysfunctional they don’t produce enough power. When you are running or walking, you are talking shorts steps instead of long strides, or really extending your hip and you are not engaging your gluteal muscles. You are overusing your hamstring muscles which pull on the calve muscles, and then the calve muscles pull on the Achilles Tendon and the Plantar Fascia. So this is the typical chain, so now we have to reset the chain. You can even try this at home, my suggestion is always to start stretching from the intrinsic muscles in your feet, on the bottom of your feet. Focussing the stretches there actually hits multiple reflexology points and relaxes the fascia of the whole leg. Then you can start doing some passive stretching for the Achilles Tendon, the calve muscle and the hamstrings. But I do not recommend stretching the Glute muscles, like the Glute max. If you’re really precise and can isolate the Glute med you can do that. I recommend taking a small fascia ball, tennis ball, or lacrosse ball and putting it a little bit lower than where your hip sits, so if you place your hands on the side of your hips, about 45 degrees. The crest of your hip will mainly hit Glute max, so I don’t want you stretching that much. If you put your hands on your Iliac crest, wherever your fingers end about 45 degrees back. That’s where you can actually stretch and relax and that might help you more. The other type of stretching that you get from the search on YouTube is the eccentric stretching of the Achilles Tendon. So they help revive the aggravating factors of the Achilles Tendon problem. What we do or what we recommend, again, because we specialize in shockwave therapy. We have personal experience with it, and it works amazing for tendon issues pretty much anywhere in the body, especially shockwave for Achilles Tendinopathies. So what we would do is actually start breaking down the scar tissue adhesions that are restricting the gliding of the tendon fibres and then it would literally force the muscle to relax. So when we do the treatment we have to treat everything from the calve muscles, hamstrings, and then treat the plantar fascia, and then focus the whole treatment on the Achilles Tendon. So after it breaks down scar tissues and adhesions, because it’s a mechanical sound wave it actually triggers false injury in that area so it can repair whatever has been injured, and that is the main effect of the shockwave. In this case, it is used to stimulate new blood vessel growth. So we improve the blood circulation to the muscle, especially in the junction where the muscle turns to the tendon. So because of the increase in blood circulation in the area, the muscle gets more oxygenated and the tendons and muscles become more elastic so they can actually start working properly. Then about eight to nine weeks after the third session of shockwave, typically there is the highest amount of stem cell activation in the area where the body can go and start repairing the injured tendon. Shockwave stimulates all the growth factors in the body including collagen. Collagen is a very important element when it comes to tendon repair. I explained this a little bit when I talked about the Plantar Fascia because it’s the same mechanism, but it’s even more important for the Achilles Tendon because the tendon fibres are very solid. They need to be very tiring to support your whole body. All tendons are actually built from collagen material, and those fibres can actually snap or tear. Then there’s microscopic space between the fibres, your nervous system senses this space and thinks “ okay, I have an area in the body where I’m not actually feeding with nutrients, I’m not supplying it with blood” and then you start creating blood vessels to supply that area with blood circulation. But what happens, in reality, is it makes things more complicated, and worse because your tendons need new collagen fibres to be built not new blood vessels. If we needed more blood supply whoever created us or through evolution, we would have that blood supply in the tendon already. The question is why. Why doesn’t it heal? Because we don’t live that natural lifestyle anymore. It’s like if you were living 10, 000 years ago, you didn’t have a computer to sit in front of, you didn’t drive, you didn’t sit for eight or nine hours. If you got injured you got up and walked, you created mechanical forces, you went through the pain, and that helped you rebuild. You had the proper food, sleep, and all the factors that that earth has provided for you to injure yourself and heal yourself. But nowadays because we have changed the situation and we have evolved, even the aggravating factors have evolved. The healing modalities have also evolved. Therefore we as humans have created shockwave, lasers, PRP stem cell techniques, and injections to help recover even faster. We even have supplements, like collagen which help your body to rebuild those tendons faster.
So anybody that has ended up with a chronic tendon injury, and it’s not healing for a minimum of three months even after trying everything. The first problem that I have learned recently in this virtual conference in Berlin is the biggest fascia research conference. And this is exactly what they explained this is what they have learned and found out about. I actually learned this in Salzburg for the first time at the shockwave conference and International Society for Medical Shockwave Treatments. They were monitoring, tennis and golfer’s elbow tendinitis and they said it’s like they call them, those “bad blood vessels”. They said you have to do shockwave to re-injure the area to get rid of those bad blood vessels, because they were supposing that there are actually supplying inflammation and that’s why the tenders are not getting better, even after using, you know, stem cells, PRP, shockwave and there’s still a problem. Now, at the recent conference, they found out that they’re actually good blood vessels, they’re just bringing the regular blood but instead of the body re-creating the collagen fibers, it is creating those blood vessels, which is making the tendon weaker because the other remaining fibers that are already working, they’re overworking now, they’re getting thicker and you have ended up in this vicious cycle.
So, wherever you are in the world, (I’m talking about our personal experience here), the best modality that has worked in our experience is shockwave therapy. One thing that you have to look for is True Shockwave Therapy. There are two types of shockwaves on the market: you have radial pressure wave and then you have what we call true shockwave which is the same technology as the one that breaks down kidney stones. If you’re in a place that there is no access to true shockwave and it’s only radial pressure wave available (which sounds a jackhammer), even that one is still good. Even that, the research shows really good results for Achilles tendonitis. So, you can go and get that treatment and, typically, you need about three to five sessions. If that doesn’t make any difference over three to five sessions plus about three months later for healing, your cause is not in the Achilles tendon. So, you must focus the whole rehab towards more of the lower back, or the glute muscles or more on the core muscles to strengthen those big muscles so you can actually offload the pressure on the Achilles tendon. The main goal, at this point, is re-injuring the area with shockwave, stimulating new blood vessel growth, stimulating more collagen production, while you are still trying to be active.
Because not doing, is the same as overdoing. So you cannot go on to completely stop walking or completely stop your activity, because then there’s no stimulation and we’re designed to move. I learned this when I went to university for physical therapists in school they learned a saying: “A door handle that keeps moving never gets rusted.”
So, even when you have an injury and when you do an activity, a gauge to see how much you have done is: the next day, you don’t want to be sore. You just do it enough to get things going and it’s totally fine if it hurts that day, but the next day, you don’t want to be feeling sore with pain at 6-7 out of 10. It’s normal, even the next day, if the pain is below 3. So, you’re kind of doing the right level of activity for that injury, and you just add a little bit more. So, keep up with stretching, strengthening exercises help too; however, not strengthening the calf muscles. (Again, I’m talking from my personal experience). These muscles are already over working, they’re in overwork mode, you don’t want to strengthen them more. What you want to strengthen is the muscle that is above it which is usually the quadriceps muscle group and the glute muscles. And when you strengthen those, that offloads the whole leg.
There are other modalities that definitely provide benefits. Another modality that I have found that helps (I don’t personally do it myself) is dry needling, or IMS. BUT one thing with it: have to be careful because IMS is really good. If you use it on an overworking muscle, it kind of helps the muscle to take a break. But if there’s a muscle that is what we call “weak and tight”, so there’s a muscle that is trying to create tightness to support the area, and then you go and treat that you’re gonna literally just kill that muscle (in neurological terms), you’re gonna kill that muscle. So, your nervous system is trying to actually add support to the area. You go and use dry needles, and then you fully relax it and now something else has to take over and that’s where you get IMS for probably 10 or more sessions, and nothing is changing or helping.
So, I have had cases where I’ve seen an Achilles chronic tendinitis problem, recently I had a triathlon guy. Took me, honestly, seven sessions to rehab him. The reason is that he had a lot of IMS dry needling on the calf muscles, and then it over-relaxed the muscle, which removed support for the tendon. So, everything that he was doing, was loading directly on the tendon. So then the plantar fascia took over.
So I treated and the tendon was so thick that I tried the shockwave and it was very painful during the treatment. I wasn’t able to use the right energy so then I had to start treating the what we call the ‘collateral tissue’, (tissues that are around the injury) to start helping the tendon so it can actually handle the load of the body more as a region, rather than as a specific structure which is the tendon. So, I had to go in with Flashwave which is a electrohydraulic shockwave which, in our experience, helps more with muscle activation because it has a bigger focal point. So I had to go and treat the calf muscles with it, and then go in with shockwave and the radial pressure wave trying to loosen the area and then do the electromagnetic shockwave which is more concentrated, to stimulate healing of those fibers. Then I had to treat also the plantar fascia to relax it and once we started treating the surrounding tissues the body felt safe.
The nervous system felt safe to start offloading the tendon, because you have to remember: your nervous system does whatever it takes to keep you staright and against gravity (we challenge gravity, daily) and we’re pretty much one of few animals that are only walking on 2 legs. So it’s very challenging for our whole system if one leg is not working because now the other leg is taking everything. So, our weight distribution is 50/50. We don’t walk on our legs and hands, so at least we have the weight distribution is 25% each, like quarters, right? So, if one is injured at least you have still 75% of the system taking care of you and you can still function and go while you allow the healing. If one leg gets injured for us, that’s it. Like, the other side is going to be loaded 75% or more. So that’s why it’s very hard for the body to feel safe and to go into repair mode, and it’s constantly just trying to keep you upright and to support you, whenever you have given a task. It’s a task just to get up and go in the morning to work and do your errands and do your things. It’s like all this mechanism has to to is first, keep you alive. Support the breathing, support the blood circulation, support your mind… like they’re all those mechanisms inside. It doesn’t matter where it is in the body. It has a reason – it’s supporting you during the day. If something actually breaks down and becomes dysfunctional, something else is gonna take over.
So, let’s say if you’re an era that there’s no modalities whatsoever, like, you’re now in the middle of the forest. How do you heal your Achilles tendon So, what you do is firstly focus on the breathing, because without oxygen, nothing functions.
Take a deep breath. Probably practice. If you heard about Wim Hof breathing (the Iceman), that’s a really good type of breathing, or any type of breathing where just take a deep breath, send it in through your nose into your abdomen, relax, focus on that. So, if you provide the body with oxygen, you’re providing the body with fuel and energy that is going to help everything to work properly. That’s the first thing. The second thing is just do a self assessment. Just go and stand on one leg and see like how your body’s handling this gravity. Okay? Try to pay attention to what you’re using when you’re walking. When you walk, try to feel your glute muscles, are they engaging? Are your hamstring engaging? Are your quads working?
Okay, so then start kind of teaching your body when you walk, you don’t have to contract the muscle, I call it artificially, with your consciousness, because everything in the body inside should be working, automatically, but extend your leg. Try to use your, your glute muscles more, try to use your core muscles. Okay?
If you have any abdominal surgery, that can make your, your core muscles dysfunctional and your glute muscles dysfunctional. Take a kinesiotape just put it over the scar. And while you have that tape, it will make your nervous system communicate better with that area. Honestly, try this just as a trick, like you can do a self-test on this. You go in one leg and try your balance first. Then take the tape, put it if you have the C-section or appendectomy, put the tape on on that scar and check your balance.
These are all fine things, but you have to remember that we are these bunch of cells that has created this big structure. You have to think at the cellular level; then you can actually think of the structure because, even today, daily, although, my clients pretty much most of them are open minded and understand that the body function as a whole unit but I still have people that come in and say “how is my big toe is affecting my neck, how can it be connected?”. And I say, “Okay, if you think that it’s not connected, let me take a hammer and hit you on your toes, and if it doesn’t hurt, it’s not connected. If it hurts, it’s connected.”
Yes, it affects your neck, because if you’re walking and you’re not pushing off with that toe, you’re not doing a good extension. Imagine, your toe is the root of the tree, and your head is the tip of the tree. So, if the root is not good, that the tip is going to be unstable, so it will affect everything up.
Anyway, I just started to go kind of off topic here but I just I’m trying to help you in any way that I can, any way possible. If you’re lucky to be from Edmonton, or areas that you can easily find a shockwave treatment, then that’s where we would suggest that to go and try it because it’s amazing. But even if shockwave doesn’t help you within 3-5 sessions, it doesn’t matter like your Achilles is hurting. That’s not where the cause is you have to change the approach, you have to change your habits. Check what you’re doing, check how much sitting you’re doing, check how much running you’re doing because, again, even too much activity is not good either.
Life, it’s all about balance. It’s between breathing, oxygen, nutrition, your mindset, THEN it comes to activity. Without these all being in a good condition, if you just try to be active and to be ‘tough’, you know, you’re actually almost doing more harm. Because even when you ask your body to lift weight and to run, you’re still stressing the system you’re just changing the type of stress. So, in those cases we recommend more meditation, or more loosening up the system rather than just trying to push more work. And you have to remember, you have enough time. It’s better to allow proper healing, so you can get going, than trying to overdo things and then you get injured, you have to deal with, with pain. At Unpain Clinic, even our name (and I love our name!) my goal is for any every human to live their life without pain. As long as you’re active and healthy and there’s no pain, that’s all that matters. But without medication.
So, thank you for your time, that you have dedicated to listening to this crazy guy here. I hope I helped you in any way possible. If you’re from Edmonton then you’re lucky you have unpain Clinic. Hopefully soon we’ll have Unpain Clinic all over Canada and United States. So, that’s our goal. So, thank you for listening and have a great time till the next episode. Thank you.