DO NOT STRETCH CALF (TENDO ACHILLES TENDON) TIGHTNESS If IT DON’T HAVE GOOD STRENGTH IN PLANTAR FLEXORS


DO NOT STRETCH CALF (TENDO ACHILLES TENDON) TIGHTNESS If IT DON’T HAVE GOOD STRENGTH
Most of the neurological cases presents with calf (Tendo Achilles tendon) tightness i.e hemiplegic, paraplegic, cerebral palsy & Parkinsonism. On routine examination we come across mild to moderate TA tightness. And common line of treatment is TA stretching. But very few people take strength of plantar flexors in account. If we stretch a muscle which is already weak & unable to hold the body against gravity then this will lead to crouch. The person who was able to maintain the ankle in 90 degree and stabilize the body in standing due to tightness of TA, will not be able to maintain ankle in 90  degree  and this will lead to relative dorsiflexion ankle and knee flexion which caused as crouch. More the crouch lead to more flexion of hip knee and ankle this causes postural instability.

21 responses to “DO NOT STRETCH CALF (TENDO ACHILLES TENDON) TIGHTNESS If IT DON’T HAVE GOOD STRENGTH IN PLANTAR FLEXORS

  1. Sir.. so the optimal stretching can be provided by using a Posterior leaf splint in standing?
    According to your post sir excessive should not be done.. sir so a mid range stretch can be given ? and sir how can we strengthen the muscle without treating the tightness sir?
    What i mean to say sir..
    normally we proceed by treating the tightness initially and then strengthening the muscle.. How can we do it both simultaneously?

    Thank you ,
    Rohan Sawant

    • dear Rohan, optimal stretching can not be provided by using a Posterior leaf splint in standing because it doesn’t have so much stiffness to provide a good stretch. i will write a new blog for your query on how to give a stretch the severely tight TA.

      please remember before deciding how to stretch any muscle you need to find out is there need to stretch it. if TA tightness is limiting the effective walking pattern or sit to stand and stair climbing or limiting any other functional activity, then only you need to stretch it. we should’t plan our treatment goals based on impairments. we should plan based on activity limitation. i will write a separate blog on “your goals shouldn’t be based on impairments”

      there is no question of excessive or minimum stretch. the point is ” is there any need to stretch the muscle, especially if it is weak and may lead to crouch. we have to give optimum stretch depending on the activity limitation.

      dear Rohan your every question is a new thought for my blog. i promice soon you will see. answer for your each question as a blog.
      still in short i will tell you the answer for your query now and will explain in details in the next blogs. is that ok with you?

      sir how can we strengthen the muscle without treating the tightness sir?
      What i mean to say sir..
      normally we proceed by treating the tightness initially and then strengthening the muscle.. How can we do it both simultaneously?

      Ans —yes we strethen the muscle while stretching or lengthening it. strengthening doesn’t means concentric contractions of muscle even if you work on eccentric contraction of the muscle you still get the lengthening effect as well as the stretch ( new length of muscle}.
      spastic muscle can’t eccentrically lengthen. so we have to teach the eccentric lengthening.

      if you just stretch and get a new length of muscle then the change in new length will never last longer after sometime of stretching muscle goes to more shorter range than the before, specially if it is a spastic muscle. you changed the length of muscle temporarily but not the MUSCLE SET POINT. YOU NEED TO CHANGE BOTH LENGTH & SET POINT ALONG WITH THE STRENGTH.

  2. Yes, impending crouch is a more difficult problem to manage than just a distal problem…. But… NDT says ‘first lengthen and then activate’ and even the normal development course of events is elongation followed by activation. e.g…. the extensor tone is the first to develop in babies as these muscles are already in elongated position due to neonatal physiological flexion. What we must be cautious about is not to over-lengthen the short muscle before activating it… What say, Gajju?? This has a lot of implication for kids post intervention.. like Botox or muscle lengthening surgeries…

  3. DEAR MADHAVI,
    i appreciate your comment. thank you very much for taking this point. (this is a new thought for new blog}

    i do agree with you that NDT says ‘first lengthen and then activate’ and even the normal development course of events is elongation followed by activation.

    But i didn’t said ” don’t lengthen the muscle”. but i said don’t stretch the muscle if not needed.

    i want to say that , There is a big difference in stretching and lengthening.

    In lengthening we just take the muscle to the normal length of the muscle which is the elongated state of muscle. i.e. extrafusal msucle fibers are put in the lengthen state from the lax state{ we just take the slag out} so that the intrafusal muscle fiber are elongated and the muscle spindle also under some degree of tension.
    This is the optimum length of the muscle which helps in effective facilitation of muscle. this is what the Frank Starling law stated ” The length of muscle is directly proportional the strength of the muscle.” in this optimum length there are maximum number of cross bridges are available on actin and myosin filament for contraction ( walk along theory }.

    where as in stretching we are not bothered about the optimum length of muscle but we ant get the normal range of the joint and length of the muscle even if the muscle has strength or not to maintain and work in that new length.

    during this kind of stretching specially the spastic muscle we don’t get the change in the length of the contractile element of the muscle, instead we stretch the non contractile muscle. this will over lengthen the muscle and put under mechanical disadvantage and sometime changes the angle of pull of muscle.
    all these abnormal stretching and mechanical disadvantage of muscle will reduce the strength of muscle make it permanent weak.
    example over stretching of quadriceps or long flexors of hand put them in inefficient length or position. and what we call this condition as EXTENSION LAG in quadriceps. i will explain this in more details with diagram in new blog.
    For long flexors of hand i will explain it in the blog on “PATHO-MECHANICS OF SPASTIC HAND”

    • Sorry for the delay in replying, Gajanan… Your answer is justifiable. As therapists we need to be extra cautious while preparing the spastic muscles for strengthening.. They are always short and what we need the most is eccentric strengthening. Not to forget, whenever we want to get eccentric work of that muscle, we are getting lengthening… So, what I am trying to point out is there is a very thin line of demarcation between the two and we always want to work for both… One more point worth mentioning here is hypertonia versus spasticity. We can easily get length by targeting the non reflexive elements causing hypertonia (therefore decreased length and tightness).One need not always stretch the spastic muscle for it… Why don’t you write one more blog on spasticity versus hypertonia versus tightness. Just a suggestion:)

      • thank you very much Madhavi,

        i am planning to write my next blog on these guidelines.

        1. spastic muscles cant do eccentric lengthening
        2. myofascial tightness reduces the strength of muscle.
        3. spactic muscle have both components, dynamic ( reflexive components} and static { non contractile element, muscle tightness/ myofascial tightness.
        4. spasticity vs hypertonia and tightness.
        5. how to treat the dynamic ( reflexive components} and static { non contractile element, muscle tightness/ myofascial tightness?
        6. we should start eccentric/isometric training followed by concentric training.

  4. My patient is a 58 yr M,wid a 11mnth old L hemiplegia. VC is 0 fr UL & LL. tks minimal wt. on d affected side(almost negligible) has calf tightness along wid hip flexor tightness. while mkin him tk wt on d L leg,d calf gets stretched.d hip flexor tightness causes sm crouching. can dis lead to lengthening of d calves?hw to avoid it. he also walks a stick but only sideways,keeping d right leg ahead n dragging d left leg frm behind.

    • dear Manish,
      thanks for your query. but first of all i want to request you one thing.
      please do not write the SMS language type word (short words i.e. wt, tk, d,mking}.

      because you are not just writing me but whole world will read your comments or questions. they should understand your question properly. everybody should want to read your comments. you should frame your questions so creatively that whole world should appreciate your level of thinking.

      please note, i am not criticizing you. i know, what is your level of thinking and clinical hand. let the world also know who you are…!

    • First thing you should note is that, your patient is a old11 month old case, but still there is zero voluntary control in upper & lower limb. that means he has adaptive musculoskelatal tightness along with either spasticity or hypotonia. in old case they get the adaptive changes in the muscle. this is body’s response to immobility and weakness. these muscle try to maintain the length of muscle by tightness.

      Second thing you should check that – check if the hip flexors & plantar flexors tightness is changing the body’s alignment during standing, sit to stand and walking.
      most of the case with hip flexors tightness changes the alignment of trunk and hip which in turn causes flexion of knee in standing and this gets added with platar flexors tightness. if in sitting and standing you cant maintain the ankle in neutral position then you need to stretch but if it is in neutral and you cant gt the further degree of relative doriflexion then please do not stretch the muscle. because the tightness of TA is providing you with ankle stability in spite of zero control in ankle.

      When you have multiple joint tightness problem. tackle the hip flexors if it is causing too much flexion of trunk in standing. try to use eccentric lengthening of hip flexors.
      usually we fix the trunk and use distal limb for stretching. But sometime it is very painful for the patient and either he doesn’t cooperate or goes in more flexion due to pain.

      so you should do other way around fix the the distal segment and let move away the proximal segment. this is less painful, the body weight is used for eccentric lengthening and stretching of the muscle. these movements are under the control of patient and he can stop anywhere he gets pain. This relative ability to control the stretch movement gives him confidence and he will participates well in the stretching.

      “More the participation of patient in the active lengthening less is the pain”

      Method- make the patient sit bedside with legs hanging down. you press your both hands on the anterior aspect of thigh and stabilize it. firmly and now let the patient slowly go/fall backward. and slowly let him lye down flat on bed. in the end patient will be having full hip extension along with eccentric lengthening of muscle.

      to maintain the ankle alignment in neutral and knee in extension you can use a Floor reaction orthosis {FRO} or high AFO.

      TO solve your problem of walking- only able walk sideways & dragging the left leg.
      we have analyse that :-
      he is not able to maintain the trunk symmetry.
      his antero posterior stability is poor in the dynamic activity of walking
      so he prefer to walk side ways.
      he drags the foot because he cant clear the foot during swing phase.
      he can’t clear because of
      poor hip knee, flexion,
      increased postural or
      extensor tone in standing
      slow speed of walking
      poor dynamic stability & fear of fall
      unable to reduce the length of leg due to TA tightness & poor control o hip and knee flexion

      what is the solution:
      solution is simple
      1. give him AFO or FRO get good stability and good alignment at ankle and knee.

      2. give raise eon normal side. this will lengthen the normal side and will help reducing the length during swing

      3. by this even without zero control of lower limb he can step forward by just forward trunk rotation of that side.

      4. you cann’t change his strength in few days but you can make him walk with present level of impairments.

      5. don’t work on strength per-se of the muscle work on restoring the pattern of walking.
      how to work on pattern of walking ?????

      don’t ask me…! ask yourself a RIGHT QUESTION…..!

      till today you were working on tightness or strength of muscles and asking a question to your self how to change the tightness or strength of muscle.

      now please change the question and ask your self the right question

      ” HOW TO MAKE HIM WALK?’
      ” WHAT IS LIMITING THE PATTERN OF WALKING”
      “WHAT I SHOULD DO TO CHANGE THE ABNORMAL STEPPING / WALKING PATTERN / INABILITY TO STEP?”

      IF YOU ASK THESE KIND OR SPECIFIC AND FUNCTIONAL ORIENTED QUESTION YOU WILL BE ABLE TO FIND THE MULTIPLE WAYS TO CHANGE THE ACTIVITY LIMITATION OF PATIENTS..

      • hi gajju sir, gr888 revision for all th epractical difficulties and questions!! gr88 work, keep it up.

  5. Hello Sir,
    This is Neha kelkar.Sir , we had a 4 year old child diagnosed as erb,s palsy.He has now been botoxed in order to achieve muscle balance.Sir , What is the outcome of botox in erb,s palsy?

    • I cant directly comment on outcome of botox in Erb’s palsy. but first we have find out what the objective of botox. which muscles were having imbalance and which muscles were botox.

      Botox is good in correcting imbalance as it temporarily paralyses the muscle. but we we have find out what was the need of botox and after botox that objective is solved or not. we don’t get functional improvement and results by just doing botox but we get a platform to work {with reduction in muscle imbalance}.

      BOTOX itself is not good or bad but the success of botox leis in the selection of objective and selection of right muscle and follow up management post botox.

  6. Hello Sir, Im a 3rd year BPTh student. I read your blog today and got inspired, will use it in practice and think more on it. Thankyou.
    -Manisha Kaurani

  7. Please Let me know your objective. then i can help you better.
    Are you using in CP?
    The best test is Tardieu scale. It helps to differential tightness and spasticity.
    sending you different references see if this can help you.

    References
    1: Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity
    whereas the Ashworth Scale is confounded by it. Clin Rehabil. 2006
    Feb;20(2):173-82. PubMed PMID: 16541938.

    URL- http://www.ncbi.nlm.nih.gov/pubmed/16541938

    The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it.
    URL of Full text-

    http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/noajc/10-11/March/The%20Tardieu%20Scale%20Differentiates%20ContractureFromSpasticity%20whereas%20the%20Ashworth%20Scaleis%20Confoundedby%20it.pdf

    2: Alhusaini AA, Dean CM, Crosbie J, Shepherd RB, Lewis J. Evaluation of
    spasticity in children with cerebral palsy using Ashworth and Tardieu Scales
    compared with laboratory measures. J Child Neurol. 2010 Oct;25(10):1242-7. doi:
    10.1177/0883073810362266. Epub 2010 Mar 10. PubMed PMID: 20223745.

    3: Pandyan AD, Price CI, Rodgers H, Barnes MP, Johnson GR. Biomechanical
    examination of a commonly used measure of spasticity. Clin Biomech (Bristol,
    Avon). 2001 Dec;16(10):859-65. PubMed PMID: 11733123.

    4: Ada L, O’Dwyer N, O’Neill E. Relation between spasticity, weakness and
    contracture of the elbow flexors and upper limb activity after stroke: an
    observational study. Disabil Rehabil. 2006 Jul 15-30;28(13-14):891-7. PubMed
    PMID: 16777777.

    5: Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R, Pohl M.
    Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in
    adult patients with severe brain injury: a comparison study. Clin Rehabil. 2005
    Oct;19(7):751-9. PubMed PMID: 16250194.

    6: Fleuren JF, Voerman GE, Erren-Wolters CV, Snoek GJ, Rietman JS, Hermens HJ,
    Nene AV. Stop using the Ashworth Scale for the assessment of spasticity. J Neurol
    Neurosurg Psychiatry. 2010 Jan;81(1):46-52. doi: 10.1136/jnnp.2009.177071. Epub
    2009 Sep 21. PubMed PMID: 19770162.

    7: Ansari NN, Naghdi S, Hasson S, Mousakhani A, Nouriyan A, Omidvar Z.
    Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical
    tool in measurements of post-stroke elbow flexor spasticity. NeuroRehabilitation.
    2009;24(3):225-9. doi: 10.3233/NRE-2009-0472. PubMed PMID: 19458429.

    8: Ansari NN, Naghdi S, Hasson S, Azarsa MH, Azarnia S. The Modified Tardieu
    Scale for the measurement of elbow flexor spasticity in adult patients with
    hemiplegia. Brain Inj. 2008 Dec;22(13-14):1007-12. doi:
    10.1080/02699050802530557. PubMed PMID: 19117179.

    9: Takeuchi N, Kuwabara T, Usuda S. Development and evaluation of a new measure
    for muscle tone of ankle plantar flexors: the ankle plantar flexors tone scale.
    Arch Phys Med Rehabil. 2009 Dec;90(12):2054-61. doi: 10.1016/j.apmr.2009.08.141.
    PubMed PMID: 19969168.

    10: Chung SG, van Rey E, Bai Z, Rymer WZ, Roth EJ, Zhang LQ. Separate
    quantification of reflex and nonreflex components of spastic hypertonia in
    chronic hemiparesis. Arch Phys Med Rehabil. 2008 Apr;89(4):700-10. doi:
    10.1016/j.apmr.2007.09.051. PubMed PMID: 18374001.

    11: Haugh AB, Pandyan AD, Johnson GR. A systematic review of the Tardieu Scale
    for the measurement of spasticity. Disabil Rehabil. 2006 Aug 15;28(15):899-907.
    Review. PubMed PMID: 16861197.

    12: Gracies JM, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D, Matthews D,
    Tilton A, Delgado MR. Reliability of the Tardieu Scale for assessing spasticity
    in children with cerebral palsy. Arch Phys Med Rehabil. 2010 Mar;91(3):421-8.
    doi: 10.1016/j.apmr.2009.11.017. PubMed PMID: 20298834.

    13: Vattanasilp W, Ada L, Crosbie J. Contribution of thixotropy, spasticity, and
    contracture to ankle stiffness after stroke. J Neurol Neurosurg Psychiatry. 2000
    Jul;69(1):34-9. PubMed PMID: 10864601; PubMed Central PMCID: PMC1737004.

    14: Allison SC, Abraham LD, Petersen CL. Reliability of the Modified Ashworth
    Scale in the assessment of plantarflexor muscle spasticity in patients with
    traumatic brain injury. Int J Rehabil Res. 1996 Mar;19(1):67-78. PubMed PMID:
    8730545.

  8. Passive knee extension test to measure hamstring muscle tightness.

    H Fredriksen, H Dagfinrud, V Jacobsen, S Maehlum
    National Sport Center, Oslo, Norway.
    Scandinavian Journal of Medicine and Science in Sports (Impact Factor: 3.21). 11/1997; 7(5):279-82. DOI:10.1111/j.1600-0838.1997.tb00153.x
    Source: PubMed
    ABSTRACT The purpose of this study was twofold: (a) to examine the reliability of a test designed to measure tightness of the hamstring muscles, and (b) to assess the pelvic motion during this test. The knee was passively extended by a standardized force, while the hip was stabilized in 120 degrees of flexion. The knee angle was measured with a goniometer and represents the hamstring tightness. Twenty-eight test-retests were performed. The correlation coefficient was found to be 0.99, and the CV was found to be 1%. We used a MacReflex measurement system to assess the associated pelvic motion. Eight measurements were taken, and the median of associated pelvic motion was 4.1 degrees. It is concluded that the passive knee extension test is a simple and reliable method, and the associated pelvic motion is minimal.

  9. Hamstring Muscle Tightness Reliability of an Active-Knee-Extension Test .
    Phys Ther. 1983 Jul;63(7):1085-90.
    Hamstring muscle tightness. Reliability of an active-knee-extension test.
    Gajdosik R, Lusin G.
    Abstract
    The purpose of this study was to examine intratester reliability of a test designed to measure tightness in the hamstring muscles. The test measures the angle of knee flexion with a pendulum goniometer after active knee extension with the hip stabilized at 90 degrees flexion. The angle of knee flexion represents hamstring tightness. After an instruction session for the subjects, the hamstring muscle tightness of both extremities of 15 men was measured during test and retest sessions. The reliability coefficients for test and retest measurements were .99 for the left extremity and .99 for the right extremity. High reliability resulted from strict body stabilization methods, a well-defined end point of motion, and accurate instrument placement. If conducted properly, the test should provide therapists with an objective and reliable tool for measuring hamstring muscle tightness.

    http://www.ncbi.nlm.nih.gov/pubmed/6867117
    http://physther.org/content/63/7/1085.full.pdf

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