Athletes Treating Athletes

In the last post, we talked about how to manage the common symptoms of tendon injuries. This included using Rest, Ice, Compression, and Elevation (aka R.I.C.E.) to reduce pain and swelling. We also reviewed what A-T-A techniques are best for treating this type of injury.

To review, typical treatment for a tendon injury looks like this:

1) R.I.C.E. + gentle stretching. There should be no pain with stretching.

2) Begin using the foam roller to work on the muscles first (in other words above the tendon). The tendon is what attaches the muscle to bone. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscle above the tendon -> stretch -> RICE.

3) Begin using the foam roller over the tendon to tolerance. The order should be foam roll the muscle above the tendon-> over the tendon -> stretch -> RICE.

4) Begin using the tennis ball for cross friction. Remember, you will want to work perpendicular to the the tendon. Start with light pressure at one end of the tendon and work your way all the way down it. Repeat as needed (and as tolerated) with increased pressure. If it’s too painful- wait and try again the next day. The order should be foam roll the muscle above the tendon -> over the tendon-> cross friction -> stretch -> RICE.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

The toughest part of the above treatment plan is using the cross friction technique. This is a deep muscle release technique that works against the muscle and tendon fibers to break up restrictions and adhesions. The movement relies on sinking deep into the muscle. Due to this pressure, there is actually very little side to side movement (1-2 inches at the most!). This prevents sliding over the skin as you want the skin and muscle to move together. To perform this technique you can use a tennis ball or your first two fingers depending on the size of the tendon. 1) Relax the muscle and let the tennis ball/you fingers sink in, 2) apply pressure (this is key!). 3) you always want to work perpendicular to the direction of the tendon. This prevents you from damaging it! apply pressure and then work in this direction (remember 1-2 inches max!). When done correctly, you should be able to feel uneven, hard, or even “crunchy” spots. Shoot for 2-3 minutes. Here is a video of how it is performed, click here.

In this post, I want to help give you a visual for the CF technique. Remember- the goal is to always to work perpendicular to the direction the tendon runs in. In the pictures below you will find all of the common tendon areas in the lower body. The tendons are shown in green. To use the cross friction technique, you will want to work in the same direction as the red line.

Outside of the leg:

#1 The lower end of the IT band. As you can see by the green line, the ITB runs vertically from the hip down the leg to the fibular head. The lower tendon is a common area for tendonitis/inflammation. To use cross friction on the lower area where it inserts onto the fibular head, you will want to work in the direction of the red line.

#2 The Peroneal tendons. The two peroneal tendons both wrap around the outside of the ankle and continue to wrap under the arch of the foot. As you work on the tendon, the upper part runs vertically and then changes direction as it moves below the ankle. In the case of tendonitis, you will want to work on both parts.

Front of the leg:

#1 The Quadricep tendon. As the quad muscles move down the thigh they join together just above the knee cap (small black square in the picture above). While tendonitis is more common in the patellar tendon, it is important to also focus on the quad tendon itself above the knee cap.

#2 The Patellar tendon. The common quad tendon holds the knee cap and becomes the patellar tendon as it inserts onto the front of the tibia. Both run vertically down the front of the knee and are easy to work on with cross friction.

#3 The Anterior Tibialis tendon. This tendon runs down from the shin bone over to the inside of the arch. As a result, the tendon runs more in a diagonal direction than vertical. By pulling your foot up and twisting it in, the AT tendon will be visible.

#4 The Toe Extensors. These tendons run down the top of the foot, one to each toe. By pulling your toes back you will be able to see them.

Back of the Leg:

#1 Upper Hamstring Tendon. The upper insertion point of the hamstring tendons is a common area for tendonitis. To find it, simply sit on your hands and feel for your sit bones. Directly below that (approx 1-2”) is the hamstring tendon. For this area, you can use the tennis ball.

#2 Lower Hamstring Tendons. As the hamstrings move down the back of the thigh, they split and move down behind either side of the knee (one tendon goes to the outside and the other moves to the inside). Both tendons can be easily traced as they run diagonally behind the knee. As you bend and straighten your knee you will feel the two “rope like” tendons.

#3 Achilles Tendon. The gastroc and soleus muscles combine to become the achilles tendon and insert on the heel. This tendon is visible and runs in a vertical direction.

Inside of the Leg:

#1 Posterior Tibialis Tendon. Like the peroneal on the outside of the ankle, the post tib wraps around the ankle bone and continues on to wrap under the arch of the foot. This means that the tendon changes directions as it moves towards its insertion point. In the case of tendinitis, be sure to work the tendon as it wraps around the ankle bone and again as it wraps under the arch.