Jan 29, 2015Olympic Effort
Following the 2008 Olympics, Wallace Spearmon struggled with an Achilles injury for two years. A team approach to his diagnosis, rehab, and strength training now has him primed for the 2012 Games.
By Dr. Joel Kary, Darrell Barnes, & Brandon Johnson
Joel Kary, MD, is a Sports Performance Physician at St. Vincent Sports Performance (SVSP) in Indianapolis. Darrell Barnes, MS, LAT, ATC, CSCS, is the Performance Medical Coordinator at SVSP. And Brandon Johnson, CSCS, USAW, PES, is a Performance Specialist at SVSP. They can be reached through the SVSP Web site at: www.definingsportsperformance.com.
Winning an Olympic gold medal is a runner’s ultimate dream. A lofty goal even under perfect circumstances, it becomes nearly impossible when your training is affected by an Achilles injury–which is exactly what Wallace Spearmon has been dealing with for the past three years.
A member of the 2008 Olympic team, Wallace is one of the fastest men in the world. He excels in the 200-meter dash and is a two-time national outdoor champion and two-time bronze medalist at the World Championships. He is on the short list to win a medal in London this summer–if he can finally overcome an injury to his left Achilles that he sustained back in 2009.
Over the past two years, Wallace was able to continue racing as he received treatment from various healthcare providers across the country, but his Achilles pain never fully resolved. In fact, his condition continued to worsen until the pain forced him to stop running early in the 2011 season.
Wallace began searching for new treatment options, and learned that USA Track and Field had recently formed a medical partnership with St. Vincent Sports Performance (SVSP) in Indianapolis. SVSP incorporates a multi-discipline approach to treating athletes’ injuries. In our system, physicians diagnose and treat injuries, certified athletic trainers and physical therapists provide additional treatment and rehabilitation services, and certified strength and conditioning coaches help train athletes to perform at a higher level than before their injury.
In this article, we share how our team approach helped Wallace return to the track in time for the fast-approaching 2012 Olympics. Rather than just diagnose Wallace’s injury, put him through a rehab program, and then send him into the weightroom, the three of us worked together–merging our specific skill sets and knowledge–to make the transitions seamless.
DIAGNOSIS
The fundamental first step in evaluating an injured athlete is making an accurate and definitive diagnosis. Obtaining the proper diagnosis, or multiple diagnoses in some cases, allows us to direct our treatment plan in a targeted manner. Based on the information we uncover, we are able to layer multiple modalities, treatments and rehabilitation methods, and coaching techniques into a comprehensive treatment plan.
Physician evaluation of an injured athlete starts with a careful intake history. This process often begins with communication prior to the athlete’s arrival at our location. Getting background information about the injury and a thorough medical history, including any surgeries, is extremely important.
Athletes often gloss over minor injuries in their history because they assume they have little correlation with their current injury. But even small details can provide critical clues to an underlying or root cause of an injury. We have found that prior “lesser” injuries often cause subtle changes in biomechanics and movement patterns, ultimately resulting in an injury that negatively affects the athlete’s performance.
Comprehensive injury evaluation includes asking about their current nutritional plan, psychological issues, and family medical history. Like the pieces of a puzzle, these small details can be assembled to form a picture of how the athlete has developed their current injury, and help guide our diagnosis and treatment plan.
For example, identifying and correcting a vitamin D deficiency in an athlete with recurring stress fractures is one piece of the puzzle in finding resolution for the root causes of their injury. The vitamin deficiency, along with training modifications, correction of abnormal movement patterns, and rehabilitation of strength/flexibility asymmetries must all be addressed.
In Wallace’s case, a previous right knee injury and subsequent surgery in 2008 was an important part of his history. It’s clear his Achilles pain began after this surgery and likely played a role in forcing him to overuse his left leg. Although the surgery was successful at relieving his right knee pain, subtle changes in Wallace’s functional movement patterns and strength may have led to increased load on his left Achilles and ultimately the development of his current injury.
The next step in evaluation is a physical examination. This includes the usual evaluation of joint range of motion, strength, palpation, and flexibility. Attention is paid to the entire kinetic chain, including joints and muscles proximal and distal to the injured area.
When Wallace came in for his physical exam in July 2011, we looked closely at his injured Achilles tendon and the ankle and foot joints. Our primary findings were that Wallace felt tenderness with palpation along the midportion of his Achilles tendon and the sheath overlying the tendon.
We utilized x-ray and MRI of the ankle and Achilles to aid us in further defining the extent of any pathology. Wallace’s x-rays revealed normal bony anatomy of the ankle and foot, but the MRI of his Achilles tendon showed mild thickening on the midportion of the tendon without evidence of partial tears. This is frequently seen in mild tendinopathy of the Achilles tendon.
We then used diagnostic ultrasound, which has become an excellent way to image soft tissues such as tendons, muscles, and ligaments. Musculoskeletal ultrasound is now our preferred method over MRI for tendon imaging due to the high spatial resolution, dynamic imaging component, and utilization of power doppler.
Dynamic imaging refers to the ability to look at soft tissue structures during movement, something MRI does not allow. We were able to observe movement of Wallace’s Achilles tendon with ankle plantarflexion and dorsiflexion and see if any tears were visible during these movements.
Doppler ultrasound helps us recognize any neovascularizaton in tendons. Research has shown that tendons with chronic changes of tendinopathy have new small blood vessels infiltrating the tendon along with new small nerve branches. It is hypothesized that these nerves grow along with the blood vessels and contribute to the pain associated with tendinopathy. Doppler ultrasound can identify these changes if present. With the ultrasound, we were able to identify some mild thickening of the midportion of Wallace’s Achilles tendon, in addition to mild neovascularity, but no evidence of any tearing.
After seeing the thickening and neovascularity, we diagnosed Wallace with mild Achilles tendinopathy. We decided to perform a single treatment of platelet-rich plasma (PRP) therapy to his Achilles tendon in order to promote a regenerative healing response. This was performed just two days after diagnosis and under ultrasound guidance to enhance accuracy of the injection.
We managed Wallace by placing him in a boot for approximately one week and followed a gradually progressive rehab program over the next six weeks. When the program was over, he still had sensitivity of the tendon sheath and skin overlying the midportion of his Achilles tendon. To help with this remaining pain, we injected dextrose solution between the tendon and the skin to sclerose (harden) any painful nerves that might have been causing his pain. Again, this was done under ultrasound guidance for accuracy and effectiveness.
TREATMENT
After diagnosis and establishing his plan of care, our focus shifted to Wallace’s rehabilitation. Our goals were to:
– Decrease pain and inflammation and provide an environment where the PRP treatment would be effective – Increase mobility, flexibility, and strength of the foot, ankle, and entire lower extremity – Identify neuromuscular imbalances and faulty movement patterns that may have been contributing to his injury.
Wallace was given a post-PRP home exercise program that focused on pain management, increasing range of motion, and gradually strengthening the foot and ankle. An eight-week active rest period allowed the tendon to heal and Wallace’s pain level to decrease.
When he returned to Indianapolis in late August, Wallace settled into a hotel and we began an intensive rehabilitation and strength training regimen. The first focus was to improve mobility, flexibility, and strength in the foot and ankle, and to identify if there were any underlying imbalances that would continue to stress his Achilles.
Assessment of Wallace’s lower extremity at this time showed poor dorsiflexion, poor great toe extension and pes planus (flat feet) bilaterally. His strength levels were poor in left ankle inversion, dorsiflexion, and great toe flexion. A calf raise test showed poor concentric and eccentric control of plantar flexion/supination and a significant dominance of the peroneals. His first toe mobility was also poor, and finally, his talocrural joint had limited anterior/posterior glide.
The good news was that Wallace felt minimal Achilles pain with ambulation. The bad news was that the tendon was still tender to palpation on the medial side and had significant mobility and myofascial restrictions.
We initially focused treatment on regaining normal function of the left lower extremity. Modalities, soft tissue techniques, taping techniques, and joint mobilizations were used to decrease pain, improve flexibility, and regain normal Achilles and foot and ankle joint mobility.
Over the two months Wallace was in Indianapolis, his pain steadily decreased and we were able to focus less and less on decreasing pain and more on improving strength and function. Soft tissue work and modalities were still used to help Wallace maintain proper mobility and manage any soreness secondary to the workouts. This continued right through his last day at SVSP.
A progression from running shoes to racing flats and eventually to spikes was needed to gradually load the tendon. Wallace did most of his rehab and strength and conditioning work in running shoes, which tend to have a heel lift and therefore place less stress on the Achilles. Very close to the end of his two months at SVSP, he transitioned to a racing flat. Spikes were not worn until March–long after he was back on his own training schedule.
Strengthening exercises were introduced at the same time his rehabilitation treatment started in August. We focused on retraining the foot to control pronation and supination more efficiently during the stages of gait. This was accomplished by working on arch-controlled balance and proprioception exercises in mid-stance and maintaining the arch-controlled position with calf raises during the “toe off” phase. Calf raises progressed from double- to single-leg, but always focused on eccentric control and an even dispersal of pressure among all five toes. We did this by placing a tennis ball between Wallace’s ankles as he performed the calf raises, which decreased his tendency to push off the lateral aspect of his foot (peroneal over-dominance).
In addition to treating his Achilles, we spent considerable time trying to identify other physical imbalances that may have contributed to Wallace’s injury. When he gave his medical history at the diagnosis stage, Wallace stated that prior to his Achilles injury he had sustained a right knee injury at the 2008 Olympic trials and struggled with it through the Olympics.
During our initial evaluation, we also discovered that Wallace had an up-slip to his right illium and mild neural tension in his right lower extremity. His right knee range of motion and strength were within normal limits, but both hips were tight in extension and abduction, and he had considerable illiotibial band tightness. Hip extension and abduction were significantly weak and lumbar stabilization was poor.
Wallace performed a functional movement screen (FMS), which showed poor movement patterns during his squat, lunge, and rotary stability. We believe that each of these findings affected Wallace’s ability to run efficiently and ultimately contributed to overstressing his left Achilles, which resulted in the injury and an inability to fully recover. So in addition to the rehabilitation of his Achilles, rehab and performance exercises to address these underlying issues were added.
PERFORMANCE
Wallace’s treatment continued with performance training. In addition to the screens and tests Wallace had already done, we took Wallace through another assessment to determine if any compensatory patterns may have been adding to his Achilles issues.
Testing revealed that Wallace had poor hip mobility and lacked proper thoracic extension. He also didn’t have very good neuromuscular control.
With his results in front of us, we put together a performance plan that would optimize mobility, flexibility, and pliability, and increase neuromuscular control. In the end, our goal was to develop Wallace’s dynamic strength and power–necessities in his arena as an elite sprinter.
When Wallace arrived at the training center, he had the frame of a Lamborghini, but with a very leaky suspension. So for the first four weeks of his training program, the focus was on improving his foundational strength. Wallace came in five days a week. Three days a week the focus was on total-body strengthening and two days a week the focus was on corrective work and core strengthening.
Every workout started on the turf, where we prepared his body for the day’s work. On Wallace’s total-body days, he prepped with a corrective series that addressed his imbalances. We’ve found that a high percentage of the track athletes who come in to SVSP have issues in the foot and ankle complex as well as the glute/hip region, and Wallace was no different. To help strengthen his glutes, he performed the glute bridge series, loop band series, and quadruped series.
Next, he progressed to neuromuscular activation. These exercises educate the neuromuscular system and prepare the body to maintain pelvic-postural position.
We began our progressions with isometric holds and then progressed to holds with movements. Some of the holds included the plank series with variations and different pushup hold positions that challenged his core control. Different devices were used to aid in these activation techniques, including loop bands, tennis balls, and different pads to challenge his stability. The exercises were crucial in teaching Wallace how to control his body as well as improve his body’s ability to fire in sequence.
After neuromuscular activation, Wallace performed a dynamic warmup that included exercises that didn’t put a lot of stress on his Achilles and foot, but allowed him to accomplish two things: Get warm for his workout and allow us to see how his Achilles was progressing from treatment. Some of the movements included the capital-T walk, knee-hug walk, quad stretch walk, elbow-instep lunge, and squat cradle.
During the majority of the first four weeks, Wallace performed a significant amount of bodyweight exercises on his three total-body days. During the two corrective and core work days, he would prep with foam rolling and then address his hip mobility and thoracic extension issues, followed by addressing his core from shoulders to hips front side and back side.
We also had Wallace try some light running on the AlterG treadmill. The anti-gravity treadmill allowed us to take a significant amount of Wallace’s bodyweight off his lower body, which in turn allowed him to focus on his running form. The AlterG, along with the treatment he was receiving from Darrell, helped Wallace transition to running on the turf.
During the second four-week phase of Wallace’s training, the two days dedicated to core work and corrective training shifted to movement training. On the three strength training days, Wallace started doing low-level plyometrics using the trampoline and a jump rope. We would vary the intensity depending on how his Achilles responded to the stress. External resistance was also incorporated into his lower body exercises, including squat and lunge progressions with external resistance, and eventually a lot of single-leg work.
During our movement sessions, we started to incorporate light A-series movements. This was mostly to work on Wallace’s range of motion, but also to see how his Achilles and foot responded when it contacted the ground in a more dynamic fashion. His warmup on these days began to include dynamic warmup exercises, including inside/outside thrusts, inside/outside mountain climbers, and donkey kicks. These ground-based exercises allowed us to see what kind of force Wallace could put into the ground without pain and helped us judge how to progress his movement program.
As Wallace continued to progress in his rehab and enter the final phase of his performance training, we started to incorporate movement improvement exercises for linear acceleration, including the wall drill series: power line stance, power line ready position, acceleration non-alternate march, and acceleration alternate leg march. From there, he progressed to performing acceleration 1-2-3 count series on the wall. At this point, we added external resistance with a band around his waist during acceleration march, skip, and sprinting drills. This allowed us to actively evaluate how much strength he had gained in his glutes and lower body, which would take stress off his Achilles. By the time Wallace left our facility at the end of November, he was working on his three-point start and had advanced to doing six explosive starts in one training session.
During the final stage of his rehab, Wallace’s movement mechanics were filmed and analyzed using Dartfish software. This allowed us to show Wallace his start movements and see how he was progressing in his rehab.
A sprinter’s ability to apply greater force to the ground is one major part of being able to run faster. When Wallace started working on his performance here at SVSP, he wasn’t able to apply the force needed to obtain his world-class speed without pain. By the time he left SVSP, he was continuing to progressively load his Achilles without pain, which allowed him to use the ground force necessary for his performance on the track.
Once Wallace left our facility, he started his normal training again. In March, he ran the fastest time in the 200 so far this year. If Wallace runs three more sub-20s, he’ll have the most in the world.
