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ESSENTIAL SKILLS while standing with the balls of the feet on a step, so that the heels drop below the forefoot. This allows the Achilles tendon to move through its full range of motion while getting stronger. Friction of the distal tendon. Friction of the distal tendon at the calcaneal attachment. Again, have the foot fully plantarflexed on the table so the tendon is relaxed. Place your index fingertips on the calcaneal attachment, with your thumbs under the heel. Press firmly and draw your index fingers across this area by moving your forearms from side to side. Friction of the distal aponeurosis. Palpate the aponeurosis (the broad, sheet-like attachment) covering the calcaneus. After locating a tender area through palpation, place your thumb or index finger on that spot and apply a friction motion. When treating an aponeurosis, you can apply friction in any direction. STRETCHING After two weeks of friction treatment, begin gentle stretching for both the calf and the Achilles tendon. These movements should be done only if and when they cause no pain. Ask your client to sit on the floor with the knee bent at a 90-degree angle and the fingers wrapped around the ball of the foot. Have the person actively dorsiflex the foot as far as possible, then use the hands to pull the ball of the foot toward the shin for up to two seconds (no more), and then place the foot back on the floor. Repeat 10 times, followed by 10 repetitions of the same stretch with the foot everted, and then 10 repetitions of the stretch with the foot inverted. Next repeat all three stretches—straight, everted, and inverted—with the Friction of the distal aponeurosis. knee bent to a 120-degree angle; this position places more tension on the tendon than on the muscle. These brief stretches encourage healing and help to prevent the return of adhesive scar tissue. The intention is not to stretch the Achilles, but to strengthen the structure by repeatedly placing tension on it. At first, use the stretches only during your treatment sessions. When the client clearly understands how to do them and they cause no discomfort whatsoever, have the person do them daily to encourage continued healing in a full range of motion. STRENGTHENING After the acute pain has subsided and the person can walk again without discomfort, begin a strength program for the lower legs. Start with heel raises, keeping the knees straight. Have the client stand on both feet, with more weight on the good leg if it is too stressful on the injured leg to share the weight equally. Over the course of a few weeks, have the client transfer more and more weight to the injured leg, until performing three sets of 10 heel raises with equal weight on both legs causes no pain or fatigue. Then vary the exercise, using three different foot positions: parallel, turned slightly inward, and turned slightly outward. Have the client do 10 repetitions in each position, for a total of 30. Once the client can do these variations easily, add in bent-knee versions of the same three exercises, for a total of 60 repetitions. The final stage is to perform the three variations earn CE hours at your convenience: abmp's online education center, www.abmp.com 101 SURGERY In cases where the tendon has completely ruptured, surgery is required. Once your client has healed from an Achilles injury, make sure you provide one final set of instructions on how not to re-injure the tendon. The best ways to prevent re-injury are to: always warm up before any strenuous activity, make sure to reenter any athletic activity slowly, and stop if there's any pain. Also be sure that your client has well-fitting athletic shoes and plans to continue the stretching and strengthening program you've started together. education and sports medicine, and is founder of the Muscular Therapy Institute. Benjamin has been in private practice for more than 45 years and has taught extensively across the country on topics including orthopedic massage, Active Isolated Stretching and Strengthening, and ethics. He is the author of Listen to Your Pain (Penguin, 2007), Are You Tense? (Pantheon, 1978), and Exercise Without Injury (MTI, 1979), and coauthor of The Ethics of Touch (Sohnen-Moe Associates, 2003). Presently, he is offering continuing education for massage therapists around the world via webinars. He can be contacted at Ben@BenBenjamin.com. Editor's note: Massage & Bodywork is dedicated to educating readers within the scope of practice for massage therapy. Essential Skills is based on author Ben E. Benjamin's years of experience and education. The column is meant to add to readers' knowledge, not to dictate their treatment protocols. Ben E. Benjamin, PhD, holds a doctorate in