Case Study November 2017 – Achilles Tendonitis

Achilles tendonitis is a condition affecting anybody from all walks of life, not just sports participants. In November of 2017, a 47 year old male arrives at the Sydney Heel Pain Clinic in Miranda complaining of Achilles tendonitis of more than 12 months. The condition is only affecting his left ankle and he has no symptoms on the right side. This gentleman plays social football with a local club, and plays 90 minutes of field soccer every Sunday. He is a school teacher by trade and spends extended periods of time on his feet. He reports to the sports podiatrist that the Achilles tendonitis is painful after completing a game of soccer. Before the game, he’s able to warm up and stretch and once he is running the pain from the Achilles tendonitis seems to drop away slightly and he is able to complete the match. Approximately one hour after the game he does report stiffness and pain after being seated. When he gets out of his car and starts to walk he feels an increase in pain and stiffness. He informs the podiatrist that he has been applying ice packs to the affected area after each game. Each morning when he gets out of bed and walks to the bathroom, once again he feels stiffness and pain in the left Achilles tendon. After his morning shower and once he is dressed with his shoes on, he is able to walk without feeling too much pain. However, towards the end of the day after he has been on his feet at work teaching, the pain from the Achilles tendonitis returns. Once again, if he sits down to rest, when he stands up to walk the pain is very noticeable. On occasions, the pain from the Achilles tendonitis has been so severe that he has resorted to taking medication. He was informed by the physiotherapist to perform calf stretches and heel raises, but found that this aggravated the problem. He decided to stop performing these stretches and seek medical advice. He went to see his local GP who referred him for an x-ray, but this revealed nothing relevant. The GP then referred him to the Sydney Heel Pain Clinic for treatment.

Physical Assessment for Achilles Tendonitis

The patient lay prone and the sports podiatrist performed a physical assessment in order to diagnose Achilles tendonitis. Firm pressure was applied to the Achilles tendon just proximal to the heel, and this elicited significant pain for the patient. There was no redness and the Achilles tendon was only slightly enlarged compared to the right side. The patient was able to perform a single leg heel raise on the left side without excruciating pain.The podiatrist informed of the patient that  it was unlikely that he had told the tendon, but that he was suffering with classic Achilles tendonitis.

Biomechanical Assessment for Achilles Tendonitis

In order to determine the cause this patients Achilles tendonitis the sports podiatrist decided to carry out a biomechanical assessment. The patient was asked to walk on the treadmill without shoes and his gait cycle and foot function was captured using digital software on an iPad. The patient was then asked to walk on the same treadmill but this time with his football boots on. Both videos were replayed in slow motion and notes were taken. The podiatrist was able to observe an early heel lift in both legs due to tightness of the calf muscles. When walking barefoot, that was only moderate pronation on both sides. In the football boots, due to the narrow shank and elevated height of the boot, the level of Pronation increased bilaterally. The podiatrist also observed that the patient had a slightly externally rotated left hip which affected foot position. Naturally, this foot pronated slightly more than the right. This could have also been the reason why the Achilles tendonitis was present in the left foot but not the right. However, it is important to note that the restricted range of motion in both calf muscles creates additional stress to the Achilles tendon. Tight calf muscles and Achilles tendonitis go hand in hand, but not exclusively.

Achilles Tendonitis Treatment

Treatment for this patient’s Achilles Tendonitis would involve stretching the soleus and gastrocnemius muscles and the use of 9mm heel wedges inside his shoes to elevate the heel and reduce the load on the tendon. This patient was shown the correct technique for stretching both of these muscle groups and the Sydney Heel Pain mobile app was installed on the patients smartphone. The app containing all the information relating to his treatment which includes details surrounding the stretching technique. Due to the stiff muscle groups, it was decided to apply acupuncture to the affected areas of both legs. Deep tissue dry needling was performed by the sports podiatrist throughout the posterior aspect of the lower leg in order to soften the muscles and reduced tension. This, in turn would reduce load on the Achilles tendon. It was explained to the patient that this would help his stretching, and therefore assist in the recovery of his Achilles tendonitis.

The patient was offered Shockwave therapy which is an excellent form of treatment for Achilles tendonitis due to the increased blood flow that follows treatment. However due to time restraints and a heavy workload, the patient refused Shockwave therapy as he was unable to return for weekly sessions. To this end, the patient was advised to apply ice packs to the affected area on a daily basis for approximately 30 minutes. The ice would reduce swelling around the tendon and therefore allow the Achilles tendonitis to heal quickly. He was also advised to refrain from quick movements sports and ballistic exercise for at least 2 weeks, until his condition improved. His stretching program would be an ongoing  exercise, until the Achilles tendon had made a full recovery, and until the range of motion became acceptable.

The patient was advised to avoid walking without shoes and to avoid footwear with a low heel. Flat and flexible shoes were to be avoided and sports shoes with a more rigid sole and a slightly higher heel were advised. The patient was advised that he would be allowed to slowly and gradually return to exercise once the pain from the Achilles tendonitis had all but gone. He was informed that his Achilles tendon was not weak, therefore trying to strengthen it was not necessary and might irritate it.

8 Week Review

Two months later the patient returned to the Sydney Heel Pain Clinic in Miranda for a review of his Achilles tendonitis. He quite happily reported that the pain had subsided completely and he was back playing football. He did report to the podiatrist that a couple of hours after he had finished the football game, there was some mild stiffness and the occasional shooting pain but these were mild. On palpation of the Achilles tendon there was very mild pain but this was to be expected. The patient reported that first thing in the morning after getting out of bed, the pain from the Achilles tendonitis was 95% better then before. He was advised that the healing of the Achilles tendon is slow and therefore would continue. He was advised to gradually remove the heel lifts from all his footwear. It was also suggested that he be mindful of his work shoes and to always ensure that he is receiving sufficient support from these shoes. The application of ice packs could also continue. When adequate calf range had been achieved, he was able to reduce the frequency of stretching, and simply maintain free muscle movement. He would be less likely to have a recurrence of his Achilles tendonitis with a good range of motion in this muscle group.

Please note that the information contained in this case study is specific to one particular patient. If you have Achilles tendonitis you should seek the help of a suitably qualified healthcare practitioner.