Ankle impingement and patellar tendinopathy rehabilitation log

[MattS]

Hi Kit, Olivia, and all other forum members.

too long; didn't read: this log is documenting my bodyweight squat progression and rehabilitation of bilateral anterior ankle impingement and patellar tendinopathy using Stretch Therapy principles along with other techniques (joint distractions etc.) that i've found beneficial.

"The What"

I have never achieved a full bodyweight squat. I believe this will assist greatly in my rehabilitation of the following injuries:

Left leg:
- Patellar tendinopathy (24 months - in the disrepair stage on the tendinopathy continuum)
- Anterior ankle impingement (24 months; occurs very quickly - and painfully - into dorsiflexion)

Right leg:
- Patellar tendinopathy (1 month - hopefully still in the reactive stage)
- Plantar fasciitis (2 months - right foot loses structural integrity when loaded; this isn't my greatest concern as it's minor and manageable)
- Anterior ankle impingement (cannot put a time on this. It is a gradual compression sensation in the front of my ankle which in contrast to the acute pain experienced in my left ankle).

The injuries to my left occurred around the same time - I was playing indoor soccer and rolled my ankle. I remember hearing a distinct crack and this sidelined me for about 6-8 weeks - I haven't played sport since. I knew nothing of proper rehabilitation and I didn't get it checked out at the time; coming from a military background, ankle sprains are like hot dinners. I would estimate 4 decent sprains to each ankle in my lifetime. At the same time as the sprain, I began to develop fat pad impingement and patellar tendinopathy. I had a cortisone injection and this provided some relief. My left ankle impingement hadn't really been a noticeable concern until 6 months ago, where the restriction in movement and pain really started to kick in. Even bearing weight causes pain at the front/outside of the ankle. I've managed to progress well with my tendinopathy rehab through a progressive loading protocol - the injury is still there, but I can walk up stairs now without limping.

The injuries to my right, other than plantar fasciitis, seem to have occurred recently as part of my attempt to rehab the left patellar tendinopathy. What rehabbed my left patellar tendon appeared to aggravate my right.

"The Who"

I am a stretching novice and I have never put any serious time into stretching other than 'holding for 30 seconds' after a run or lifting weights. I never thought there would be a reason to take my flexibility and mobility seriously because, up until 2 years ago, I have been able to play sports and perform all activities pain free (even without being able to bodyweight squat - I got by). I'm 26 years old and I've played footy, cricket and social sports all my life; I also served 5 years as a full-time infantry soldier.

"The Why"

My intention in creating this log is threefold:

1. Personal accountability and a journal to document my progress and learning
2. Assistance from other forum members
3. Provide assistance to others in my current position, whether they be other forum members or someone searching keywords on Google.

"The How"

Ankles/Calves

I will be using the Master the Squat series and modifying the exercises accordingly - not that I believe I know better - but, for example, I currently impinge too quickly for any posterior tension to occur in my left leg when performing Master the Squat E1A-E1D (calf exercises) - except the single leg down dog, where the tension is all in my hamstrings. Conversely, I can get a good contraction on my right gastroc from performing the calf exercises - so a bit of experimentation will go a long way. I am excited to get in and progress with the other stretches in the routine, however, my main focus lies in my ankles/calves.

So far, in attempts to stretch my soleus, I have learnt (specifically for my left): 
a) 2 minutes of joint distraction is the minimum - 3 yields better results - and from different angles (foot facing in/out/straight); 
b). Once some posterior tension can be achieved in any bent knee stretch, generally through using a kettlebell on my knee as leverage, it's critical to spend time (10 minutes-ish) holding that tension. I also find it difficult to contract into the tension, so i'm still experimenting with ways to achieve this; I know ST principles don't suggest a sets/reps/time set up, but I currently have difficulty in performing a contract > relax > go deeper.
c) Using my shins to pull myself into dorsiflexion seems to assist the stretch

In my toolbox I have a voodoo floss band, resistance band, and a seat belt type band that I am using for really distracting the ankle joint (the resistance band doesn't provide traction to my left ankle). Photo of seat belt type band below.

Patellar Tendinopathy

I have yielded best results by training legs every day - preferably loaded - using box squats, lunges, bw squats, back squats, front squats, squats with lifting shoes, split squats.

For anyone reading that is currently unable to perform leg movements without pain, I was also in that position at one stage. I started with isometric loads (45 second holds of wall sits, Spanish squats etc), moved onto squatting patterns (lunges, box squats) and then next will be plyos/energy storage movements. I used feedback on how I felt immediately post workout and also the next morning - if I felt good, then I would progress that previous workout. Discomfort while training is okay - pain is not. I found load to be the biggest driver so far. The amount of weight I put through my tendon is yielding better results than the number of reps i'm performing.

I have slipped up and jumped the gun when I thought I was completely rehabilitated (eg. I went out to football training after I had been sprinting/jumping in my rehab without pain only to push the tendon further than it could handle as a result of the acceleration/deceleration/change of direction). I have done something similar on 3 separate occasions which has provided me with a good learning experience.

By freeing up my ankles, my knees will improve. When I hit end range dorsiflexion (the impingement), I can feel my patellar tendon compensating for the lack of ROM.

Plantar Fasciitis

Heavy, slow loading of the windlass mechanism seems to be doing the trick. When progress stops here, there is plenty of good information on this website on pronating ankles/plantar fasciitis.

Current Stats:

Knee to wall tests:
Left (cold, and taken to full impingement): 51mm

Right (cold, and taken to full impingement): 70mm

Squat (cold, from the front - left leg is on the right side of the photo):

Squat (cold, from the side - right leg is closest to camera):

 

I welcome both discussion and criticism.

Thanks.

 

[MattS]

4/5/18

Managed to come down with a cold overnight due to the shocking weather in Adelaide.

Morning session:

Banded distractions
- mins 1-4: right ankle; mins 4-11: left ankle

Bent knee soleus stretch (left)
- i left the timer running from my banded distractions and it read 45 mins by the time I had finished. I tried several positions with my hips and feet but was unable to clear the impingment and get a stretch. A little disappointing on two fronts: I wasted the majority of the session with no results which could have been spent stretching elsewhere; and 6 mins of distracting the ankle joint was unable to create enough space in the joint

Bent knee soleus stretch (right)
- the lack of structural integrity in this foot sent the stretch into my achilles tendon. I played around with the sensations for a bit but when I tried to go deeper I impinged at the front. Continuing trying to stretch the soleus wasn't getting me anywhere so I tried stretching the gastroc off a step

Straight leg calf stretch off a 'step'
- By step, i mean i folded up my ankle weights and used that as a step. I managed some contractions in the gastroc in both legs which felt good. Keeping my hips straight and even putting my non-stretched leg in front of the other seemed to intensify the stretch. 3 rounds of C/R for 10 second contractions, lasting approximately 4 minutes each leg, and by the end of it I felt my knee was going to hyper extend so I stopped. There is possibly a form issue here.

Inversion stretch (left foot only):
- this was painful because of my old inversion ankle sprain from 2 years ago. I am really unsure why it's still painful? Scar tissue around the injured area? Either way, I did small pulses into the stretch for 5 minutes or so. Coming out of the stretch was painful, but when pulsing into dorsiflexion immediately after, things felt slightly "looser" and I achieved some nice cracks and pops (on every rotation in both directions my ankle clicks anyway). Hopefully stretching that side of my ankle can stretch the injured ligaments and free up some space in the joint capsule.

I finished the session holding a squat position, pushing all my weight to one side for 1 minute 30 and then switching legs for another 1 minute 30. My goal is build up to 3 minutes by next weekend, and then ultimately 5 minutes per side.

Tonight's session (tendon rehab):

Warm up: squat mobs
Back squat: i'll work up to 3 heavy sets of 5. I expect this to be near 100kg
Rear foot sliding barbell lunge: 10 reps each leg @ 40kg or 50kg (tendon rehab)
Reverse nordic curls: 10 reps to complete failure (tendon rehab)
3 rounds: 100 bw squats; 50 KB swings @ 24kg
Stretches: bent knee calf stretch; straight leg calf stretch; frog stretch; relaxed lunge stretch; pigeon stretch

In front of the TV tonight watching the footy i'll do my calf stretches and experiment with more hip stretches, sitting piriformis etc and generally stretch what feels tight.

[MattS]

5/5/18

The tissues at the front of my ankle were angry at me all day, regardless of whether they were warm or not. Bearing weight hurt. I'd imagine this is a result of too long doing the banded distractions the day prior, so I think 6 minutes was over doing it (even though it didn't clear the impingement anyway). I opted to do daily CARs for each joint and rest up.

Later that night I massaged the painful ligaments around my ankle and this provided some relief and my ankle felt 'looser'.

6/5/18

Woke up and massaged the ligaments around my ankle again, and this provided (what felt like) additional ROM. Upon reflection, it was likely reduced pain at the front of the ankle. I still wasn't able to get a stretch in the bent knee soleus position unfortunately.

After spending the last few days frustrated with my lack of ankle progress (possibly even regression), it felt good to find some relief in self massage. Using this window, I decided to go for a run this morning to get some movement through the joint. Only pain in the ankle came from running up hill (until the joint cooled down) and a little tenderness in the knee tendons.

If i'm unable to mobilise and joint and stretch the surrounding muscles because of a structural issue (forcing the joint to mobilise using a band just increases pain at the moment), i'm going to start reducing the tightness in my hips and lower back, which, i hope, provides a bit of slack in the ankle. I've also read a little on Andreo Spina's work on closing angle joint pain, and he recommends rotational force to clear the impingement. I'll experiment with this, self massage, and continuing stretching.

Gym - Pull session:
3 x 5 @ 120kg box squats (tendon rehab)
2 x 5 @ 150kg deadlift
3 sets AMRAP @ bodyweight chin ups
3 x 12 @ 20kg meadows rows
5 x 12 @ 10kg rear delt flyes/super set with 20 rep band pull aparts
4 x 12 @ 20kg barbell curls
4 x 12 @ 12kg hammer curls

**20m lunges between sets as rest

[Kit_L]

@MattS: I am teaching in Adelaide this weekend—I am surprised you're not in the room!

You ankles are loose enough to squat deep (your images show you just below the sticking point—that is the point that requires maximum ankle flexibility); your fascia and your quads are tight, and your calves and hamstrings not soft enough to flow out of the way; hence your current depth. 

No problem here: you are like about a quarter of the room yesterday. You need to sit on your heels, with a stick in between, RollStretch style:

https://www.youtube.com/watch?v=X1nxYoWA0GI&t=3s

There's much more; start here. Yours is a common limitation—everyone in the room yesterday was able to get a deeper squat after rolling calves and hamstrings, and stretching quads, and that was after only doing the exercises once.