September 17, 2025 • 29 mins
Describe the pathomechanics of insertional achilles tendonopathy, identify altered motor patterns and tendon structure as a consequence of achilles tendonopathy, and discuss updated evidence on rehabilitation concepts for insertional and midportion achilles tendonopathy
Timestamps
(3:09) Anatomy Review
(4:12) Pathomechanics of Achilles tendonopathy
(9:26) Deficits associated with Achilles tendonopathy
(14:08) Rehabilitation concepts for Achilles tendonopathy
--
ARTICLE CITATIONS used for this episode: https://atcornerds.wixsite.com/home/blog
AT CORNER FACEBOOK GROUP: https://www.facebook.com/groups/atcornerpodcast
Instagram, Website, YouTube, and other links: atcornerds.wixsite.com/home/links
EMAIL US: atcornerds@gmail.com
SAVE on Medbridge: Use code ATCORNER to get $101 off your subscription
Music: Jahzzar (betterwithmusic.com) CC BY-SA
—
TO GET CATEGORY A CEUs for listening to this episode, enroll in this course: https://clinicallypressed.org/courses-home/
Take the quiz and course evaluation and your certificate will be generated for you!
We have no financial disclosures or conflict of interests.
--
-Sandy & Randy
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Hey, this is Sandy. And Randy?
And we're here on AT Corner. Being an Ath Eye trainer comes
with ups and downs and we're here to showcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of AT Corner.
For this week's episode, we haveour first CU episode of the
(00:22):
season. Yes, we do, and we are doing a
familiar topic if you travel back in time and go back to
Season 1. Which actually, this was our
first education episode we've ever done.
I actually didn't know that fun.Fact, yes, it was Achilles
tendinopathy. So what's really exciting about
(00:42):
this is we've had, it's been so long since we've had it that we
can actually kind of do an update episode.
So it's been about five years ish.
So look at five years worth of updated research.
How cool. So like we said, this is ACEU
episode and it is a category ACEU episode which all of our CE
US are currently category A Thank you so much to Athletic
(01:04):
training Chat and Clinically pressed.
If you go down to the show notes, there's the website
ofclinicallypressed.org/courses I believe and you can check out
all of our courses on there. The latest 5 episodes will
always be free and then past episodes are really affordably
priced like 3 dollars $5.00. So then you can help support the
(01:27):
show as well. If you would like a video
tutorial on our Instagram, we have a pinned post that says how
to get to your C us and it literally has us going through
and enrolling in the cart and itshows you the whole thing.
So check that out. So what are objectives for today
Mandy? Yes.
So we're going to try and expandon kind of what we talked about
(01:47):
in that very old episode that wedid on Achilles tendonopathy.
So we're going to describe the path of mechanics of insertional
Achilles tendonopathy. Our last episode was really
geared towards more mid portion.So we're going to try and expand
a little bit more and talk aboutanother type of Achilles
tendonopathy. And we'll identify altered motor
patterns and tendon structure asa consequence of Achilles
(02:08):
tendonopathy. And then we'll discuss updated
evidence on rehab concepts for insertional and mid portion
Achilles tendonopathy. I'm.
Going to be honest, when I, I don't think I when I was newly
certified, I don't think I really paid attention to the
difference between midpoint or insertional Achilles
(02:29):
tendonopathy. And it wasn't until I was
referring an athlete who had just chronic Achilles
tendonopathy. We did everything we could and
it wasn't until one of my docs asked as overtext if it was
insertional or mid substance. And that like simple question
(02:50):
like completely changed like oh this actually does matter the
difference between the two. And we'll talk about how it
makes such a huge difference in how treatment for one could
actually be not great for the other.
So as with any of these type type of episodes, we got to
start with some anatomy. But again, we went, we did a
pretty in depth anatomy of the Achilles tendon in that older
(03:14):
episode. So this is going to be just
quick review. So like we said before, the
Achilles tendon really looks like more like a braided rope.
It's not just this like flat sheet of tendon that just comes
down what kind of looks like in textbooks, right?
So it actually has like a spiralcomponent to it.
And what's really unique about this is each tendon of the
tricep Surrey. So that's the lateral gastroc,
(03:35):
medial gastroc and soleus. All can be individually
separated. So you can actually find the
different components like, oh, this tendon goes to the medial
gastroc, this one goes to the soleus.
And what this is referred to as in the literature is like sub
tendons. And these sub tendons do
actually have the ability to slide and glide against each
other. So if you think about it, there
(03:55):
could be some maybe issues between maybe them not gliding
as well between each other. So that's really kind of the
quick kind of anatomy to just kind of set the table for what
this episode is going to kind ofbe about and understanding how
the Achilles just kind of functions.
OK. So you just talked about the
anatomy and how the tendon looksmore braided and so we have this
(04:18):
slide glide. How does that translate into
mechanics and path of mechanics?Yeah, absolutely.
So really how Achilles tendonopathy happens and just
probably any tendon in general is there's just an overload of
the tendon. And one concept that we brought
about in the first episode on Achilles tendon was this idea of
(04:41):
like force sharing. So basically the different
muscles basically contributing all together to absorb and
produce force. So if one's lacking on that,
right, another part of the tendon's going to have to take
over. So that's kind of that idea of
each tendon working individually.
So basically the tendon gets overloaded, tendon's not able to
repair itself before you do the next bout of exercise.
(05:03):
And this just if this just keepshappening, keeps happening,
tendon becomes damaged and weakened.
And there's some characteristic signs of Achilles tendinopathy,
right? You can see what's referred to
as increased neo vasculization, which is basically like new
blood vessels forming within thetendon.
And that's to get the inflammatory mediators there to
help kind of the repair process.You can see more fluid in the
(05:26):
tendon. So there's a lot more liquid,
more water in the area cause again, some swelling, but also
trying to get fluids basically getting trapped there.
And this causes that increased cross-sectional area.
So if you read about it, you always talk about, oh, the
tendon looks thicker, the one that's the involved side and
what? It is.
Because it is exactly. It has more things happening to
(05:49):
it. And another one that I thought
was really interesting is you see a lot of decreased tendon
stiffness, right? And a lot of times when you
think of that, you would think, oh, shouldn't that be good?
Decreased stiffness, But the tendon has to be stiff because
that's what tendons do. They absorb and then recoil,
right? They're supposed to help us with
(06:10):
the, the efficiency of movement,efficiency of producing force.
So what reading that, I was kindof thinking like, well, if we're
starting to see a breakdown of collagen, that collagen is
what's usually pretty rigid. Well if that's starting to
weaken and get damaged, you could see tendon becoming less
stiff. Which makes sense.
Yeah. So can you go back to the what
(06:30):
you were talking about between how midpoint and social can be
so different? Yeah.
So how it's defined in in research is mid portion Achilles
tendonopathy is pain on the Achilles tendon that's two to
seven centimeters proximal to the insertion of the Achilles,
which I mean, I don't know how many people are starting to pull
out rulers and stuff to be like,oh, oh, wait a minute, that's a
(06:52):
centimeter or a centimeter and ahalf.
But just know it's just a littlebit of ways, just not over that
calcaneus and then the insertionalso.
Just to give you perspective andinches, I think a centimeter is
2.5 ish. Oh, I think you're right, 2.5
ish centimeters mix an inch justa little bit over 2.5.
(07:15):
So we're talking about just an inch beyond the insertion point
is what we call mid. Portion, yes and again like I
think most people are pretty familiar with it probably closer
to that 7:00-ish centimeters when they think of mid portion.
But yeah, it's a little bit of arange and then insertional of
course is just within that 2cm. So basically it's where you feel
(07:37):
the tendon joined the bone. That's it.
The one thing that's a little bit unique with insertional
because mid portion tendonopathy, again, it's just
the idea of oh, it's just, you know, tendon's just overloaded
and that's kind of the same for insertional.
But the way it happens with where the Achilles tendon
inserts is quite unique. And that area isn't just exposed
(08:00):
to like the tension from like plantar flexion being forced to
stretch, ecentric load, like allthat.
It's also exposed to compression.
And this compression is basically the calcaneus
compressing the anterior side ofthat Achilles.
So something a little bit different, a little bit more
unique. And it is actually a
(08:23):
consideration too, when we starttalking about how do we treat
this, how do we kind of do our rehab, because that compression
is noted when you're in full dorsiflexion.
So if you bring your ankle into full dorsiflexion, that
compression is really at its maximum against the anterior
side of the Achilles. It's giving like plantar fascia
(08:44):
vibes. Kind of, yeah.
And the bummer is, is like, again, I don't want to spoil it
for the rehab part, but like onething you always tell people,
not always, but like one treatment of Achilles tendon
issues could be, oh, we'll stretch.
Well, if you force yourself intofull dorsiflexion, all you're
doing is recreating the compression for insertion.
(09:04):
So that's why knowing insertional Achilles tendonopy
could make a huge difference. So then it would probably be
better to work manual therapy ofthe calf to get length rather
than a true dorsiflexion stretch.
Yeah, for sure. Noted.
Duly noted. So regarding deficits associated
(09:27):
with Achilles tendinopathy, would you say that those are
kind of the same generally between no matter where it is in
the tendon or are those going tolook different depending on
where it is? That's a that's a great point.
I didn't see a ton that actuallycompared the two.
A lot of times it's either they just looked at insertional
Achilles tendinopathy and what'sgoing on or mid portion or they
(09:48):
kind of grouped them all together in the thing and just
called it Achilles tendinopathy.So it was really kind of hard to
pull them out, but I think a lotof them do kind of align with
each other depending on what thestudy kind of looked like.
Because with any injury, right, there's going to be deficits,
right? We know that the motor system
changes, the muscle tissue changes.
(10:09):
So this is basically what we're going to try and target with our
rehab. And what you see with Achilles
tendonopathy is again decreased stiffness of the Achilles
tendon. Because of breakdown of
collagen. Yeah.
And but as we look deeper into that, what else could be driving
that decreased stiffness? And some of this could be driven
by the lateral gastroc because some studies have looked at each
(10:31):
individual tendon they've noticed out of all the three sub
tendons, the lateral gastroc hasless stiffness compared to the
medial and the soleus. What do you mean by that?
So like if they were to like look at like how stiff the
tendon is, like each sub tendon,the lateral gastroc has a lot
less tension compared to the soleus and the medial gastroc
(10:54):
tendons. What does that mean clinically?
Clinically, it's it's a way of looking at the tendon isn't
going to be able to absorb the force.
That's where the weak point is and that's what's starting to
break down now. Can we necessarily see it
clinically? I haven't seen that necessarily.
But what that could also translate into is decreases in
(11:18):
strength or force production. You do see an Achilles
tendinopathy that there's especially insertional is
there's actually a decrease in the rate of torque development.
So just how fast your muscles can produce force.
So that could be where you're seeing that.
And from a clinical standpoint is more through those functional
things unless you had like ultrasound and you're like
(11:41):
you're doing all that measurements and stuff.
So yeah, clinically it would be more from the ability, the
muscles ability to produce force.
Got it. The only reason I ask is because
I feel like when I'm doing manual therapy on a gastroc I
feel like I find more tender points and trigger points in
(12:03):
medial head rather than lateral.Like a lot of people have more
pain and and I guess you could say tightness in the medial
side. So what that could be
contributed to is there is altered motor control of lateral
gastroc. So basically what was seen in a
few of the studies is there's this increased discharge rate
(12:26):
from the motor system. So basically it's like really
trying to discharge the lateral gastroc to try and possibly
accommodate or like accommodate this lack of stiffness because
it's now the muscle has to work harder and there's a decreased
de recruitment threshold, which basically just means the muscle
has a hard time or turns off a lot faster.
(12:47):
So your muscles basically getting on off on, off, on off
on off on off on off like repeatedly, right.
And I think what this could see is you could start to see it
just start to fatigue over time.So possibly in that case where
you're like, oh, we're getting alot of trigger ports, trigger
points elsewhere. Those muscles are probably
having to take over because lateral gastroc's going nuts
over here. He doesn't know what he's doing.
(13:09):
Right. So that's what I would almost
say to that point, like, Oh yeah, there's a lot of tightness
there because that could be taking over the duties that
lateral gastroc to dog, you're all over the place.
So that it makes sense that we can treat the medial gastroc,
but it's still going to continueto occur unless you actually get
to the source of what the altered motor control is
(13:31):
happening in the lateral gas truck.
For sure. And then I could see that also
adding to more decreased stiffness because now if your
muscles fatigue, it doesn't havereally good tone to maintain
contractions. And now it may be stiffness is
even dropping more. And I said, so you'll see that
again, rated torque development starts to decrease.
And as with any study over time,literature's always mixed.
(13:55):
But in general, you kind of see a pretty good like there is
evidence out there that's showing decreased strength and
decreased endurance of the plantar flexors in those with
Achilles tendon issues. OK.
So how do we address this in rehab?
So most of the literature that is looked at rehab tends to kind
of gravitate towards eccentric exercises.
(14:18):
And I think most people, even without not knowing the name of
it, are pretty familiar with thewhat I believe it's the
Alfredson protocol. That's where they just said do a
ton of eccentric calf raises even if it hurts and then just
keep doing more and more as timegoes on.
That one's like pretty common inthe research and it's been shown
(14:39):
to be effective. There are some issues with it
because one issue is compliance,right?
It kind of hurts. So people aren't going to be
like yippee I. Can't wait to do my rehab.
Normally that doesn't hurt. I really can't wait to do the
rehab that actually. Hurts.
So what do? You mean I don't get to sit here
(14:59):
and just get a massage? Yeah, exactly.
So it's now kind of thinking, OK, is that just the only way or
what else can we do about this? And there is actually some
alternatives that can be slightly better or even have the
same effects as like that eccentric protocol.
And a really cool study and you're kind of seeing this a
(15:20):
little bit more with other tendinopathies is just doing
high loading on the tendon, justapplying a high load.
And the study looked at 12 weeksof high load isometric exercise.
So literally just it's just, I think it was like 90% of their
Max voluntary contraction. Like it was a fairly high load
and the results were pretty comparable to doing that
(15:41):
eccentric protocol, if not superior in some things.
So I. Feel like isometric exercise is
so underrated for tendons because I feel like people just
jumped. Everyone here is like eccentric.
We need to do eccentric, but I feel like you need to at least
minimum start with isometric. Yeah.
(16:02):
And I was actually just going tosay that like if you have
someone who's like pretty tenderand like eccentric exercise is
like kicking their butt and likeif their pain's really high,
maybe going starting with the isometric and just doing a high
load could be super beneficial for them.
I mean, how I explain it to my athletes is your tendons need
load, So what we're going to do in rehab is provide them
(16:25):
progressive load. And an and, yeah, and an optimal
load, right? Because if you don't have enough
load, the tendon's not going to adjust like you said, right?
It needs load. And then obviously too much is
probably why we were in this position.
So it's that, yeah, it's that progressive optimal load to just
kind of, I mean, too much. Load and not enough of the
(16:47):
others other muscles doing their.
Jobs. Yes, exactly.
Another reason for that too is just again, you're going to do
it more right. That probably feels a lot better
than just blowing up your calf with eccentric eccentric work.
To emphasize that high load thing.
Again, they've even shown that just a slow high load eccentric
(17:07):
exercise is better than doing low load eccentric exercise.
So actually having more load on that eccentric exercise is more
beneficial than if you didn't have enough.
So clearly load is going to be what the tendon's responding to
and that's how it changes. And really where you see a lot
of this benefit from again the high loading, the ecentrics, the
(17:30):
isometrics is the tendon will start to get more stiff.
So the collagen is starting to repair itself.
And that really is pretty like consistent to see that in like
the short term of your rehab. But over time as this is going,
you'll actually start to see thecross-sectional area will get
better. So less fluids going to be
(17:51):
accumulated there. The neo vascularity is going to
be gone, right? The body's like, hey, I don't
need these new small blood vessels delivering things.
Get on out. I'm healing.
I don't need more healing cells.Yeah.
Exactly. And again, that's another sign
of just good progression. But with insertional
(18:12):
tendinopathy, this kind of adds a whole new wrinkle how you
treat it, because most people when they think of those
exercises outside of the isometric, like the eccentric,
we're going like full dorsiflexion.
You're on a ledge going into a stretch.
But like we said, that could actually make insertional
Achilles tendinopathy worse. So what has been advocated for
that is basically you can still do your calf raises, you can
(18:35):
even still do eccentric, but you're staying neutral.
So basically instead of going dropping down, you're basically
just on the ground flat. Or to add more load, you could
do it where your toes are on thestep still and your heel is off,
but you're just not going into that dorsiflexion.
You just don't drop it into dorsiflexion, you keep it
(18:57):
neutral. That that has worked really
well. And then once that's getting
better, you can progress them tomore different ranges of motion.
Again, stretching at the with insertional is really not great
because of that dorsiflexion. Another thing that's been
advocated for is heel lifts. You can put them in a heel lift
(19:18):
and that'll help when they're walking, right?
Because you do get into dorsiflexion when you walk.
That can help alleviate just theday-to-day of just constantly
irritating it or even rehab withthe heel lifts you could do too.
Can you explain that a little bit?
Because I feel like doesn't thatcontradict you adding load on
(19:42):
them not? Necessarily because it would be
passive, right? So if you put the heel lifts in
the shoe, right, it keeps them in slight plantar flexion.
So when they're walking, they'renot necessarily going into that
full dorsiflexion. So getting that compression.
Does that make sense? So you're still doing the same
exercises. Just more of it.
(20:03):
I mean, like you could do like you can have them in the weight
room doing like squats, like stuff like that.
I think you're still doing the calf raises to neutral.
Got it. Yeah, you're not doing.
Oh, we have a heel lift now. We can go lower.
Got it. It's not like that.
Yeah, Yeah. It's just to prevent that, to
truly keep them away from getting into dorsiflexion.
The heel lifts would be able to do that day-to-day stuff.
(20:23):
We've started adding a lot of like Eric's pad toes on the
Eric's pad heel lift off and then doing movements with that
like lumberjacks or taking a kettlebell and going around your
like we call it around the world, but like around your
shin, kind of like passing it orpassing it back and forth,
especially like basketball back and forth mimicking like that
(20:46):
functional. We also will do like monster
walks with their heels lifted oryou could even do split squats
with it heel raise too. Yeah.
I like doing that with like likeadvanced like as they're getting
better and in that especially cause for soleus cause the bent
knee. You know, I was going to ask
(21:07):
actually if you saw anything, any benefit of training the
soleus like separately than the gastroc because like if, like if
you're doing like seated weighted calf raises versus like
a standing calf raise. Yeah, we talked about some of
that or some of the contributionfrom the Soleus in the that
(21:27):
first episode. And and really what you see is
you're seeing, I believe it was the soleus like during gait
activate sooner than it normallywould without Achilles
tendonopathy again, probably forcount for lateral grass rock.
Who knows what the hell he's doing.
That could be why. So I could see again kind of
(21:49):
that starting to fatigue a little bit sooner.
So yeah, definitely I would try to train soleus as well.
And also too, what people forgetis I think I feel like when we
talk about like the calf musclesand the triceps are everyone
thinks like gastroc, everyone thinks medial lateral.
But honestly, the soleus is actually a really big muscle and
it actually contributes a lot toour force, like our forward
(22:11):
propulsion and just like a lot of load through the ankle.
So the soleus is actually very important to how the Achilles
functions and just how we produce and absorb force.
So yeah, I would definitely. And I, and I do too in my rehab,
attack the soleus a lot through stuff like that.
I'll even when they do calf raises, I'll even have them do
(22:33):
them bent like bent need to. But yeah, then I'll also, I also
like pairing in like the split squats and then do a calf raise
or have them hold the split squat and then just bust out
calf raises there. Oh, I love.
Yeah, I'll do like, oh, that's what I was thinking of, of we'll
have them do like a squat hold and then like a 32nd like straw
(22:56):
hold and then they'll do heel lifts at that.
I mean, it's concentric. It's not, it's not isometric or
eccentric, which we talked about.
But it's kind of getting that like it's getting the endurance
portion. For sure.
Yeah, it would get the enduranceportion for sure.
And then also just working full body, 'cause, you know, we could
go on and on about how it's how important it is to work the
(23:17):
glutes in this and the core glutes.
Especially if you go back to that first episode when we talk
about all that arch work and howthe arch plays a role,
especially in that rated role. Rated Rope.
Yeah, absolutely. And I think in that one too, we
talked about the connection fromthe Achilles to the plantar
fasher moves, plantar fasher UPS, I can't remember, but there
(23:37):
is some connection that does actually fun fact go away as you
get older. Oh, really?
Yeah. It's crazy.
That's in. That's like how?
Like when? I can't remember.
I I know it's like definitely like older adult.
So you're talking someone over 40 / 50 is when they really
(23:59):
don't have that connection as much between the Achilles and
the plantar fascia anymore. Interesting.
Yeah, there is another thing youcould do with your rehab as well
is because again we're talking lateral gas rocks, a disaster
just at what's happening. You can actually tailor your
calf raises to start targeting lateral gastroc and I believe
(24:21):
it's toes out. We'll kind of focus more on
lateral gastroc. OK, I I always see this of like
the heels out toe like heels outor heels in like I don't
understand how it targets the calf, one sided calf more more
(24:45):
because I feel like because the hip is the one internally or
externally rotating, I don't understand how that is coming
from the calf. For sure.
I actually, I saw studies reference it.
I didn't actually read those ones, so I don't know why that
happens. I do need to look at that, but I
(25:07):
do remember seeing that, yeah, that was one way that you can
actually get more activation outof your lateral gastroc compared
to the rest. So if you're really like, I'm
going to teach lateral gastroc who's boss and get it back on
schedule, that would be a way you could do that.
Could you do Russian stem with the lateral gastroc while they
(25:29):
do calf raises? Yes, but I haven't seen anything
that that did it. But theoretically, yes, that
would be the same idea. OK, I feel like this this could
be the action item. Oh, I was going to say for
action item, just really be like, know what you're dealing
with right then whether it's midportion or insertional, because
(25:50):
it does really change. Yeah, what you're going to do
with them. And then don't be afraid to load
them when you're rehabbing them.And obviously, I mean, I tend to
be a little more conservative with my like ecentrics, right?
Like I think research says like,oh, they could be up to A7 out
of 10 of pain. I'm like that's brutal.
Like I'd like to keep mine. Like hey I tell them if it feels
(26:14):
uncomfortable that's OK, but if it's excruciating pain let me
know. I just got a form.
That's a good one too, right? Like if it like because of pain
or just like if it looks not great, it definitely isn't
great. Right.
I tell them that tendon rehab isthe worst rehab that they're
(26:34):
going to do. It's fair that usually I'm not
OK with pain in rehab, but I'm OK with pain in tendon rehab.
Yeah, that's why I give the wiggle room of uncomfortable
hey, like it's not going to feelgreat, but I also don't want
them like this is like excruciating pain like OK, well,
yeah, if it's. Going to make if it's going to
make it worse. Yeah, we're not trying to do
that. Did it say anything about
(27:00):
activity modifications? You're OK to stay in daily
activity up to 5 out of 10 Pain.What about like sport?
5 out of 10 pain like they could.
They could still participate in whatever they're doing.
So we're not making it worse if they're if they're staying under
(27:23):
like 5 out of. 10, That was kindof the barometer of like, hey,
if you're staying around or under 5 out of 10, you could
still do those activities, but if an activity increases that,
then that's what you want to avoid.
So it's a total rest isn't necessarily beneficial.
I mean, I guess if it's like your tendon's super blown up,
you can't do anything without intense pain, then yeah,
(27:45):
probably. Yeah.
Don't rupture these guys, Yeah. Some rest will probably be
needed, but yeah, as long as they're 5 out of 10 pain, they
can do those activities. And again, same thing like the
heel lift for the insertional might be able to help keep them
active while they're rehabbing and treating it.
Heel lift or and or Achilles tendon tape.
(28:07):
Yeah, as long as it's restricting the dorsiflexion.
Well, cool. Yeah, that was our first update
episode. I was really excited about that
and really thinking like how cool that it's been that long
that I could act, that we could act.
Half a decade, yeah. That we could actually look at
what literature has come out since our last episode and how
does that like, I don't know, that's really nerdy, but I
(28:30):
thought it was really cool that.Was really cool.
So if you are interested in claiming this as a category ACU
again, go down to the show notes, click on that clinically
pressed link. It will take you to the course.
You can enroll in it if it's within our latest 5 episodes, it
will be free if it is not withinour latest 5, it will still be
(28:51):
really affordable and again you you will help support the show.
So once you're enrolled in the course, it will you can watch
the episode and claim your certificate.
So if you guys have any questions, just reach out to us
or go to our Instagram. We have a whole tutorial online.
And if you are new, we actually have different types of episodes
(29:13):
other than CE us. We have a lot of interviews this
season. We've actually recorded a ton
already. So we're super excited to share
those throughout the season. And we also have story episodes
where we take stories from real life athletic trainers and we
bring them to you about a special highlight topic, which
is just fun to hear other people's experiences.
(29:34):
And we're super excited to bringyou so much in Season 6.
So thanks for tuning in. Do you have anything else,
Randy? Nope.
Thank you for helping us showcase athletic training
behind the tape. Bye.
Hey, this is Sandy. And Randy?
And we're here on AT Corner. Being an Ath Eye trainer comes
with ups and downs and we're here to showcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of AT Corner.
For this week's episode, we haveour first CU episode of the
(00:22):
season. Yes, we do, and we are doing a
familiar topic if you travel back in time and go back to
Season 1. Which actually, this was our
first education episode we've ever done.
I actually didn't know that fun.Fact, yes, it was Achilles
tendinopathy. So what's really exciting about
(00:42):
this is we've had, it's been so long since we've had it that we
can actually kind of do an update episode.
So it's been about five years ish.
So look at five years worth of updated research.
How cool. So like we said, this is ACEU
episode and it is a category ACEU episode which all of our CE
US are currently category A Thank you so much to Athletic
(01:04):
training Chat and Clinically pressed.
If you go down to the show notes, there's the website
ofclinicallypressed.org/courses I believe and you can check out
all of our courses on there. The latest 5 episodes will
always be free and then past episodes are really affordably
priced like 3 dollars $5.00. So then you can help support the
(01:27):
show as well. If you would like a video
tutorial on our Instagram, we have a pinned post that says how
to get to your C us and it literally has us going through
and enrolling in the cart and itshows you the whole thing.
So check that out. So what are objectives for today
Mandy? Yes.
So we're going to try and expandon kind of what we talked about
(01:47):
in that very old episode that wedid on Achilles tendonopathy.
So we're going to describe the path of mechanics of insertional
Achilles tendonopathy. Our last episode was really
geared towards more mid portion.So we're going to try and expand
a little bit more and talk aboutanother type of Achilles
tendonopathy. And we'll identify altered motor
patterns and tendon structure asa consequence of Achilles
(02:08):
tendonopathy. And then we'll discuss updated
evidence on rehab concepts for insertional and mid portion
Achilles tendonopathy. I'm.
Going to be honest, when I, I don't think I when I was newly
certified, I don't think I really paid attention to the
difference between midpoint or insertional Achilles
(02:29):
tendonopathy. And it wasn't until I was
referring an athlete who had just chronic Achilles
tendonopathy. We did everything we could and
it wasn't until one of my docs asked as overtext if it was
insertional or mid substance. And that like simple question
(02:50):
like completely changed like oh this actually does matter the
difference between the two. And we'll talk about how it
makes such a huge difference in how treatment for one could
actually be not great for the other.
So as with any of these type type of episodes, we got to
start with some anatomy. But again, we went, we did a
pretty in depth anatomy of the Achilles tendon in that older
(03:14):
episode. So this is going to be just
quick review. So like we said before, the
Achilles tendon really looks like more like a braided rope.
It's not just this like flat sheet of tendon that just comes
down what kind of looks like in textbooks, right?
So it actually has like a spiralcomponent to it.
And what's really unique about this is each tendon of the
tricep Surrey. So that's the lateral gastroc,
(03:35):
medial gastroc and soleus. All can be individually
separated. So you can actually find the
different components like, oh, this tendon goes to the medial
gastroc, this one goes to the soleus.
And what this is referred to as in the literature is like sub
tendons. And these sub tendons do
actually have the ability to slide and glide against each
other. So if you think about it, there
(03:55):
could be some maybe issues between maybe them not gliding
as well between each other. So that's really kind of the
quick kind of anatomy to just kind of set the table for what
this episode is going to kind ofbe about and understanding how
the Achilles just kind of functions.
OK. So you just talked about the
anatomy and how the tendon looksmore braided and so we have this
(04:18):
slide glide. How does that translate into
mechanics and path of mechanics?Yeah, absolutely.
So really how Achilles tendonopathy happens and just
probably any tendon in general is there's just an overload of
the tendon. And one concept that we brought
about in the first episode on Achilles tendon was this idea of
(04:41):
like force sharing. So basically the different
muscles basically contributing all together to absorb and
produce force. So if one's lacking on that,
right, another part of the tendon's going to have to take
over. So that's kind of that idea of
each tendon working individually.
So basically the tendon gets overloaded, tendon's not able to
repair itself before you do the next bout of exercise.
(05:03):
And this just if this just keepshappening, keeps happening,
tendon becomes damaged and weakened.
And there's some characteristic signs of Achilles tendinopathy,
right? You can see what's referred to
as increased neo vasculization, which is basically like new
blood vessels forming within thetendon.
And that's to get the inflammatory mediators there to
help kind of the repair process.You can see more fluid in the
(05:26):
tendon. So there's a lot more liquid,
more water in the area cause again, some swelling, but also
trying to get fluids basically getting trapped there.
And this causes that increased cross-sectional area.
So if you read about it, you always talk about, oh, the
tendon looks thicker, the one that's the involved side and
what? It is.
Because it is exactly. It has more things happening to
(05:49):
it. And another one that I thought
was really interesting is you see a lot of decreased tendon
stiffness, right? And a lot of times when you
think of that, you would think, oh, shouldn't that be good?
Decreased stiffness, But the tendon has to be stiff because
that's what tendons do. They absorb and then recoil,
right? They're supposed to help us with
(06:10):
the, the efficiency of movement,efficiency of producing force.
So what reading that, I was kindof thinking like, well, if we're
starting to see a breakdown of collagen, that collagen is
what's usually pretty rigid. Well if that's starting to
weaken and get damaged, you could see tendon becoming less
stiff. Which makes sense.
Yeah. So can you go back to the what
(06:30):
you were talking about between how midpoint and social can be
so different? Yeah.
So how it's defined in in research is mid portion Achilles
tendonopathy is pain on the Achilles tendon that's two to
seven centimeters proximal to the insertion of the Achilles,
which I mean, I don't know how many people are starting to pull
out rulers and stuff to be like,oh, oh, wait a minute, that's a
(06:52):
centimeter or a centimeter and ahalf.
But just know it's just a littlebit of ways, just not over that
calcaneus and then the insertionalso.
Just to give you perspective andinches, I think a centimeter is
2.5 ish. Oh, I think you're right, 2.5
ish centimeters mix an inch justa little bit over 2.5.
(07:15):
So we're talking about just an inch beyond the insertion point
is what we call mid. Portion, yes and again like I
think most people are pretty familiar with it probably closer
to that 7:00-ish centimeters when they think of mid portion.
But yeah, it's a little bit of arange and then insertional of
course is just within that 2cm. So basically it's where you feel
(07:37):
the tendon joined the bone. That's it.
The one thing that's a little bit unique with insertional
because mid portion tendonopathy, again, it's just
the idea of oh, it's just, you know, tendon's just overloaded
and that's kind of the same for insertional.
But the way it happens with where the Achilles tendon
inserts is quite unique. And that area isn't just exposed
(08:00):
to like the tension from like plantar flexion being forced to
stretch, ecentric load, like allthat.
It's also exposed to compression.
And this compression is basically the calcaneus
compressing the anterior side ofthat Achilles.
So something a little bit different, a little bit more
unique. And it is actually a
(08:23):
consideration too, when we starttalking about how do we treat
this, how do we kind of do our rehab, because that compression
is noted when you're in full dorsiflexion.
So if you bring your ankle into full dorsiflexion, that
compression is really at its maximum against the anterior
side of the Achilles. It's giving like plantar fascia
(08:44):
vibes. Kind of, yeah.
And the bummer is, is like, again, I don't want to spoil it
for the rehab part, but like onething you always tell people,
not always, but like one treatment of Achilles tendon
issues could be, oh, we'll stretch.
Well, if you force yourself intofull dorsiflexion, all you're
doing is recreating the compression for insertion.
(09:04):
So that's why knowing insertional Achilles tendonopy
could make a huge difference. So then it would probably be
better to work manual therapy ofthe calf to get length rather
than a true dorsiflexion stretch.
Yeah, for sure. Noted.
Duly noted. So regarding deficits associated
(09:27):
with Achilles tendinopathy, would you say that those are
kind of the same generally between no matter where it is in
the tendon or are those going tolook different depending on
where it is? That's a that's a great point.
I didn't see a ton that actuallycompared the two.
A lot of times it's either they just looked at insertional
Achilles tendinopathy and what'sgoing on or mid portion or they
(09:48):
kind of grouped them all together in the thing and just
called it Achilles tendinopathy.So it was really kind of hard to
pull them out, but I think a lotof them do kind of align with
each other depending on what thestudy kind of looked like.
Because with any injury, right, there's going to be deficits,
right? We know that the motor system
changes, the muscle tissue changes.
(10:09):
So this is basically what we're going to try and target with our
rehab. And what you see with Achilles
tendonopathy is again decreased stiffness of the Achilles
tendon. Because of breakdown of
collagen. Yeah.
And but as we look deeper into that, what else could be driving
that decreased stiffness? And some of this could be driven
by the lateral gastroc because some studies have looked at each
(10:31):
individual tendon they've noticed out of all the three sub
tendons, the lateral gastroc hasless stiffness compared to the
medial and the soleus. What do you mean by that?
So like if they were to like look at like how stiff the
tendon is, like each sub tendon,the lateral gastroc has a lot
less tension compared to the soleus and the medial gastroc
(10:54):
tendons. What does that mean clinically?
Clinically, it's it's a way of looking at the tendon isn't
going to be able to absorb the force.
That's where the weak point is and that's what's starting to
break down now. Can we necessarily see it
clinically? I haven't seen that necessarily.
But what that could also translate into is decreases in
(11:18):
strength or force production. You do see an Achilles
tendinopathy that there's especially insertional is
there's actually a decrease in the rate of torque development.
So just how fast your muscles can produce force.
So that could be where you're seeing that.
And from a clinical standpoint is more through those functional
things unless you had like ultrasound and you're like
(11:41):
you're doing all that measurements and stuff.
So yeah, clinically it would be more from the ability, the
muscles ability to produce force.
Got it. The only reason I ask is because
I feel like when I'm doing manual therapy on a gastroc I
feel like I find more tender points and trigger points in
(12:03):
medial head rather than lateral.Like a lot of people have more
pain and and I guess you could say tightness in the medial
side. So what that could be
contributed to is there is altered motor control of lateral
gastroc. So basically what was seen in a
few of the studies is there's this increased discharge rate
(12:26):
from the motor system. So basically it's like really
trying to discharge the lateral gastroc to try and possibly
accommodate or like accommodate this lack of stiffness because
it's now the muscle has to work harder and there's a decreased
de recruitment threshold, which basically just means the muscle
has a hard time or turns off a lot faster.
(12:47):
So your muscles basically getting on off on, off, on off
on off on off on off like repeatedly, right.
And I think what this could see is you could start to see it
just start to fatigue over time.So possibly in that case where
you're like, oh, we're getting alot of trigger ports, trigger
points elsewhere. Those muscles are probably
having to take over because lateral gastroc's going nuts
over here. He doesn't know what he's doing.
(13:09):
Right. So that's what I would almost
say to that point, like, Oh yeah, there's a lot of tightness
there because that could be taking over the duties that
lateral gastroc to dog, you're all over the place.
So that it makes sense that we can treat the medial gastroc,
but it's still going to continueto occur unless you actually get
to the source of what the altered motor control is
(13:31):
happening in the lateral gas truck.
For sure. And then I could see that also
adding to more decreased stiffness because now if your
muscles fatigue, it doesn't havereally good tone to maintain
contractions. And now it may be stiffness is
even dropping more. And I said, so you'll see that
again, rated torque development starts to decrease.
And as with any study over time,literature's always mixed.
(13:55):
But in general, you kind of see a pretty good like there is
evidence out there that's showing decreased strength and
decreased endurance of the plantar flexors in those with
Achilles tendon issues. OK.
So how do we address this in rehab?
So most of the literature that is looked at rehab tends to kind
of gravitate towards eccentric exercises.
(14:18):
And I think most people, even without not knowing the name of
it, are pretty familiar with thewhat I believe it's the
Alfredson protocol. That's where they just said do a
ton of eccentric calf raises even if it hurts and then just
keep doing more and more as timegoes on.
That one's like pretty common inthe research and it's been shown
(14:39):
to be effective. There are some issues with it
because one issue is compliance,right?
It kind of hurts. So people aren't going to be
like yippee I. Can't wait to do my rehab.
Normally that doesn't hurt. I really can't wait to do the
rehab that actually. Hurts.
So what do? You mean I don't get to sit here
(14:59):
and just get a massage? Yeah, exactly.
So it's now kind of thinking, OK, is that just the only way or
what else can we do about this? And there is actually some
alternatives that can be slightly better or even have the
same effects as like that eccentric protocol.
And a really cool study and you're kind of seeing this a
(15:20):
little bit more with other tendinopathies is just doing
high loading on the tendon, justapplying a high load.
And the study looked at 12 weeksof high load isometric exercise.
So literally just it's just, I think it was like 90% of their
Max voluntary contraction. Like it was a fairly high load
and the results were pretty comparable to doing that
(15:41):
eccentric protocol, if not superior in some things.
So I. Feel like isometric exercise is
so underrated for tendons because I feel like people just
jumped. Everyone here is like eccentric.
We need to do eccentric, but I feel like you need to at least
minimum start with isometric. Yeah.
(16:02):
And I was actually just going tosay that like if you have
someone who's like pretty tenderand like eccentric exercise is
like kicking their butt and likeif their pain's really high,
maybe going starting with the isometric and just doing a high
load could be super beneficial for them.
I mean, how I explain it to my athletes is your tendons need
load, So what we're going to do in rehab is provide them
(16:25):
progressive load. And an and, yeah, and an optimal
load, right? Because if you don't have enough
load, the tendon's not going to adjust like you said, right?
It needs load. And then obviously too much is
probably why we were in this position.
So it's that, yeah, it's that progressive optimal load to just
kind of, I mean, too much. Load and not enough of the
(16:47):
others other muscles doing their.
Jobs. Yes, exactly.
Another reason for that too is just again, you're going to do
it more right. That probably feels a lot better
than just blowing up your calf with eccentric eccentric work.
To emphasize that high load thing.
Again, they've even shown that just a slow high load eccentric
(17:07):
exercise is better than doing low load eccentric exercise.
So actually having more load on that eccentric exercise is more
beneficial than if you didn't have enough.
So clearly load is going to be what the tendon's responding to
and that's how it changes. And really where you see a lot
of this benefit from again the high loading, the ecentrics, the
(17:30):
isometrics is the tendon will start to get more stiff.
So the collagen is starting to repair itself.
And that really is pretty like consistent to see that in like
the short term of your rehab. But over time as this is going,
you'll actually start to see thecross-sectional area will get
better. So less fluids going to be
(17:51):
accumulated there. The neo vascularity is going to
be gone, right? The body's like, hey, I don't
need these new small blood vessels delivering things.
Get on out. I'm healing.
I don't need more healing cells.Yeah.
Exactly. And again, that's another sign
of just good progression. But with insertional
(18:12):
tendinopathy, this kind of adds a whole new wrinkle how you
treat it, because most people when they think of those
exercises outside of the isometric, like the eccentric,
we're going like full dorsiflexion.
You're on a ledge going into a stretch.
But like we said, that could actually make insertional
Achilles tendinopathy worse. So what has been advocated for
that is basically you can still do your calf raises, you can
(18:35):
even still do eccentric, but you're staying neutral.
So basically instead of going dropping down, you're basically
just on the ground flat. Or to add more load, you could
do it where your toes are on thestep still and your heel is off,
but you're just not going into that dorsiflexion.
You just don't drop it into dorsiflexion, you keep it
(18:57):
neutral. That that has worked really
well. And then once that's getting
better, you can progress them tomore different ranges of motion.
Again, stretching at the with insertional is really not great
because of that dorsiflexion. Another thing that's been
advocated for is heel lifts. You can put them in a heel lift
(19:18):
and that'll help when they're walking, right?
Because you do get into dorsiflexion when you walk.
That can help alleviate just theday-to-day of just constantly
irritating it or even rehab withthe heel lifts you could do too.
Can you explain that a little bit?
Because I feel like doesn't thatcontradict you adding load on
(19:42):
them not? Necessarily because it would be
passive, right? So if you put the heel lifts in
the shoe, right, it keeps them in slight plantar flexion.
So when they're walking, they'renot necessarily going into that
full dorsiflexion. So getting that compression.
Does that make sense? So you're still doing the same
exercises. Just more of it.
(20:03):
I mean, like you could do like you can have them in the weight
room doing like squats, like stuff like that.
I think you're still doing the calf raises to neutral.
Got it. Yeah, you're not doing.
Oh, we have a heel lift now. We can go lower.
Got it. It's not like that.
Yeah, Yeah. It's just to prevent that, to
truly keep them away from getting into dorsiflexion.
The heel lifts would be able to do that day-to-day stuff.
(20:23):
We've started adding a lot of like Eric's pad toes on the
Eric's pad heel lift off and then doing movements with that
like lumberjacks or taking a kettlebell and going around your
like we call it around the world, but like around your
shin, kind of like passing it orpassing it back and forth,
especially like basketball back and forth mimicking like that
(20:46):
functional. We also will do like monster
walks with their heels lifted oryou could even do split squats
with it heel raise too. Yeah.
I like doing that with like likeadvanced like as they're getting
better and in that especially cause for soleus cause the bent
knee. You know, I was going to ask
(21:07):
actually if you saw anything, any benefit of training the
soleus like separately than the gastroc because like if, like if
you're doing like seated weighted calf raises versus like
a standing calf raise. Yeah, we talked about some of
that or some of the contributionfrom the Soleus in the that
(21:27):
first episode. And and really what you see is
you're seeing, I believe it was the soleus like during gait
activate sooner than it normallywould without Achilles
tendonopathy again, probably forcount for lateral grass rock.
Who knows what the hell he's doing.
That could be why. So I could see again kind of
(21:49):
that starting to fatigue a little bit sooner.
So yeah, definitely I would try to train soleus as well.
And also too, what people forgetis I think I feel like when we
talk about like the calf musclesand the triceps are everyone
thinks like gastroc, everyone thinks medial lateral.
But honestly, the soleus is actually a really big muscle and
it actually contributes a lot toour force, like our forward
(22:11):
propulsion and just like a lot of load through the ankle.
So the soleus is actually very important to how the Achilles
functions and just how we produce and absorb force.
So yeah, I would definitely. And I, and I do too in my rehab,
attack the soleus a lot through stuff like that.
I'll even when they do calf raises, I'll even have them do
(22:33):
them bent like bent need to. But yeah, then I'll also, I also
like pairing in like the split squats and then do a calf raise
or have them hold the split squat and then just bust out
calf raises there. Oh, I love.
Yeah, I'll do like, oh, that's what I was thinking of, of we'll
have them do like a squat hold and then like a 32nd like straw
(22:56):
hold and then they'll do heel lifts at that.
I mean, it's concentric. It's not, it's not isometric or
eccentric, which we talked about.
But it's kind of getting that like it's getting the endurance
portion. For sure.
Yeah, it would get the enduranceportion for sure.
And then also just working full body, 'cause, you know, we could
go on and on about how it's how important it is to work the
(23:17):
glutes in this and the core glutes.
Especially if you go back to that first episode when we talk
about all that arch work and howthe arch plays a role,
especially in that rated role. Rated Rope.
Yeah, absolutely. And I think in that one too, we
talked about the connection fromthe Achilles to the plantar
fasher moves, plantar fasher UPS, I can't remember, but there
(23:37):
is some connection that does actually fun fact go away as you
get older. Oh, really?
Yeah. It's crazy.
That's in. That's like how?
Like when? I can't remember.
I I know it's like definitely like older adult.
So you're talking someone over 40 / 50 is when they really
(23:59):
don't have that connection as much between the Achilles and
the plantar fascia anymore. Interesting.
Yeah, there is another thing youcould do with your rehab as well
is because again we're talking lateral gas rocks, a disaster
just at what's happening. You can actually tailor your
calf raises to start targeting lateral gastroc and I believe
(24:21):
it's toes out. We'll kind of focus more on
lateral gastroc. OK, I I always see this of like
the heels out toe like heels outor heels in like I don't
understand how it targets the calf, one sided calf more more
(24:45):
because I feel like because the hip is the one internally or
externally rotating, I don't understand how that is coming
from the calf. For sure.
I actually, I saw studies reference it.
I didn't actually read those ones, so I don't know why that
happens. I do need to look at that, but I
(25:07):
do remember seeing that, yeah, that was one way that you can
actually get more activation outof your lateral gastroc compared
to the rest. So if you're really like, I'm
going to teach lateral gastroc who's boss and get it back on
schedule, that would be a way you could do that.
Could you do Russian stem with the lateral gastroc while they
(25:29):
do calf raises? Yes, but I haven't seen anything
that that did it. But theoretically, yes, that
would be the same idea. OK, I feel like this this could
be the action item. Oh, I was going to say for
action item, just really be like, know what you're dealing
with right then whether it's midportion or insertional, because
(25:50):
it does really change. Yeah, what you're going to do
with them. And then don't be afraid to load
them when you're rehabbing them.And obviously, I mean, I tend to
be a little more conservative with my like ecentrics, right?
Like I think research says like,oh, they could be up to A7 out
of 10 of pain. I'm like that's brutal.
Like I'd like to keep mine. Like hey I tell them if it feels
(26:14):
uncomfortable that's OK, but if it's excruciating pain let me
know. I just got a form.
That's a good one too, right? Like if it like because of pain
or just like if it looks not great, it definitely isn't
great. Right.
I tell them that tendon rehab isthe worst rehab that they're
(26:34):
going to do. It's fair that usually I'm not
OK with pain in rehab, but I'm OK with pain in tendon rehab.
Yeah, that's why I give the wiggle room of uncomfortable
hey, like it's not going to feelgreat, but I also don't want
them like this is like excruciating pain like OK, well,
yeah, if it's. Going to make if it's going to
make it worse. Yeah, we're not trying to do
that. Did it say anything about
(27:00):
activity modifications? You're OK to stay in daily
activity up to 5 out of 10 Pain.What about like sport?
5 out of 10 pain like they could.
They could still participate in whatever they're doing.
So we're not making it worse if they're if they're staying under
(27:23):
like 5 out of. 10, That was kindof the barometer of like, hey,
if you're staying around or under 5 out of 10, you could
still do those activities, but if an activity increases that,
then that's what you want to avoid.
So it's a total rest isn't necessarily beneficial.
I mean, I guess if it's like your tendon's super blown up,
you can't do anything without intense pain, then yeah,
(27:45):
probably. Yeah.
Don't rupture these guys, Yeah. Some rest will probably be
needed, but yeah, as long as they're 5 out of 10 pain, they
can do those activities. And again, same thing like the
heel lift for the insertional might be able to help keep them
active while they're rehabbing and treating it.
Heel lift or and or Achilles tendon tape.
(28:07):
Yeah, as long as it's restricting the dorsiflexion.
Well, cool. Yeah, that was our first update
episode. I was really excited about that
and really thinking like how cool that it's been that long
that I could act, that we could act.
Half a decade, yeah. That we could actually look at
what literature has come out since our last episode and how
does that like, I don't know, that's really nerdy, but I
(28:30):
thought it was really cool that.Was really cool.
So if you are interested in claiming this as a category ACU
again, go down to the show notes, click on that clinically
pressed link. It will take you to the course.
You can enroll in it if it's within our latest 5 episodes, it
will be free if it is not withinour latest 5, it will still be
(28:51):
really affordable and again you you will help support the show.
So once you're enrolled in the course, it will you can watch
the episode and claim your certificate.
So if you guys have any questions, just reach out to us
or go to our Instagram. We have a whole tutorial online.
And if you are new, we actually have different types of episodes
(29:13):
other than CE us. We have a lot of interviews this
season. We've actually recorded a ton
already. So we're super excited to share
those throughout the season. And we also have story episodes
where we take stories from real life athletic trainers and we
bring them to you about a special highlight topic, which
is just fun to hear other people's experiences.
(29:34):
And we're super excited to bringyou so much in Season 6.
So thanks for tuning in. Do you have anything else,
Randy? Nope.
Thank you for helping us showcase athletic training
behind the tape. Bye.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
The Breakfast Club
The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy, Jess Hilarious, And Charlamagne Tha God!