Case Study July 2017 Achilles Tendonitis at the Miranda Clinic

History of Achilles Tendonitis

A 54-year-old female presented to the sports podiatrist complaining of Achilles tendonitis in her left heel. She informed the practitioner that she had been on a medical merry-go-round trying a variety of treatments. Amongst the treatments that she had tried were acupuncture, physiotherapy, massage therapy, stretch techniques and a visit to a surgical podiatrist. She informed the podiatrist that her Achilles tendonitis got a little better after seeing the physiotherapist but the improvement was short lived. She also reports extreme stiffness each morning when getting out of bed and after periods of being seated. Her normal exercise regime involves walking her dog every evening after returning home from work. However due to the Achilles tendonitis, she has been forced to refrain from physical activity. This lady informs the podiatrist that there is mild relief from the Achilles tendonitis pain if she wears shoes with a slightly higher heel. She has committed to wearing sandals around the house in order to keep her heel elevated. At work, she has be wearing office shoes with a 3 or 4 centimetre heel as this seems to help the Achilles tendonitis.  One of her work colleagues informed her that she once herself suffered with the same condition and found relief from Voltaren gel and ice packs.  However, the application of ice packs only provided mild relief from the Achilles tendon pain. After seeing the physiotherapist she commenced a routine of exercises which involved calf stretches and heel raises. She found that the heel raises increased her symptoms and therefore ceased home remedies after 10 days. This lady then sought the help of her GP who recommended an x-ray. The GP also recommended a short course of anti inflammatory’s which she reluctantly took for two weeks to no avail. This lady presents to the clinic today feeling very frustrated and reports that the pain from her Achilles tendonitis feels relentless.

Physical Assessment – Achilles Tendonitis or Heel Spur?

A detailed physical assessment was carried out in order to assist with the correct diagnosis of Achilles tendonitis or heel spur. The podiatrist immediately noted a larger left heel which protruded significantly, posteriorly. The heel of the left foot was noticeably warmer than that of the right foot although there was no erythema. The podiatrist examined the X-ray and noted a hypertrophic calcaneus and an obvious posterior heel spur. The heel spur did not clearly define the Achilles tendonitis. With the patient lying prone, the podiatrist was able to examine the shaft of the Achilles tendon more proximally. The Achilles tendon was slightly thicker on the left side and was noticeably swollen. The patient reported instant pain on palpation of the Achilles tendon proximally and also on palpation of the distal aspect at the insertion. The patient was advised that she was suffering with Achilles tendonitis and insertional Achilles tendinopathy.

Footwear – The Cause of the Achilles Tendonitis

Quite commonly the cause of Achilles tendonitis is unsuitable footwear. The sports podiatrist carried out an assessment of the patients work shoes, casual shoes, and running shoes. Each pair of shoes that the patient presented with demonstrated poor stability and increased flexibility. It was explained to the patient that this type of shoe requires the foot, ankle and calf muscles to work much harder, leading to stiffness and a restricted range of motion. Due to the fact that this lady had been spending most of her days in this type of shoe, for approximately 3 months, it was suggested that this was the  likely cause of her Achilles tendonitis. She had been using Skechers, Nike Free, and ballet flats.

Biomechanical Assessment – Other Causes of Achilles Tendonitis?

In order to determine which other contributing factors had led to this patients Achilles tendonitis, the sports podiatrist carried out a biomechanical assessment on the treadmill.  Bisection lines were drawn on the posterior aspect of the calcaneus and Achilles tendon, and the patient was observed walking on a treadmill in her bare feet. Her gait cycle was recorded using digital software on an iPad and the footage was replayed in slow motion, and then analysed. As is to be expected in patients with Achilles tendonitis, the podiatrist observed an early heel lift due to a restricted range of motion through the Achilles tendon and soleus muscles. Biomechanically, this lady demonstrated good foot function with moderate amounts of pronation bilaterally. A mild forefoot valgus was noted on the left foot and a slightly arthritic metatarsal phalangeal joint on the right foot –  first toe joint. Leg length appeared to be equal.

Achilles Tendonitis Treatment

This patient was informed that the treatment of her Achilles tendonitis would involve the following factors. Footwear changes, calf stretches, Shock Wave therapy, and the application of ice packs on a daily basis. She was recommended to use a firm shoe with a more rigid soul and a slightly higher heel. The podiatrist recommended the Asics 2000 for recreational use and for walking the dog. The podiatrist then demonstrated, and the patient practiced, very specific calf stretches. It was advised that she refrain from eccentric loading exercises such as heel raises. She was advised to refrain from walking in Skechers, ballet flats and thongs. She was also advised that walking barefoot was bad for patients with Achilles tendonitis. She was instructed to apply ice packs to the affected area every evening before bed for approximately 30 minutes. The podiatrist also informed the patient that she would receive Shock Wave therapy treatment during this initial consultation and would be coming back for more Shockwave therapy sessions over the next two weeks. Due to the poor blood flow into the Achilles tendon, patients with Achilles tendonitis usually recover more quickly with the use of Shockwave therapy. 2000 reps of Shockwave therapy were applied at a rate of 7 HZ and 2.4 bar of pressure. This was gradually increased to 2.8 bar and was well tolerated by the patient. As usual, the patient reported less pain from the Achilles tendonitis immediately after the treatment. One week later, the second treatment of Shock Wave therapy was conducted, and the patient tolerated 2.9 bar of pressure at a rate of 7 Hz. At the third appointment the patient was treated with 2000 reps of Shockwave therapy at 3.1 bar pressure and 10 Hz.

Progress

The patient reported that her pain level at the first appointment, on a scale of 1 to 10, was approximately 8 out of 10. At the second appointment she reported that the average pain level was 6 out of 10. At the third appointment, following the third session of Shock wave therapy, she reported that her average pain level from the Achilles tendonitis was only 3 or 4 out of 10. The patient was advised that the treatment could now stop and that over the next few weeks there would be further healing. The patient was informed that she must continue to stretch out calf muscles, apply ice packs, and continue to use supportive footwear mentioned above.

6 Week Follow Up

After a further 6 weeks the patient returned for a check up of her Achilles tendonitis. She reported that the pain had gone completely and she was able to walk comfortably without soreness. On palpation, there was mild pain as the podiatrist assessed the Achilles tendon but the pain level was acceptable and not uncommon. The patient was informed that she could resume normal activity and commence the use of more regular and less functional footwear. She was advised to return to the podiatrist if her symptoms returned.

Please note, the information contained in this case study is specific to one particular person with Achilles tendonitis. If you have foot pain or if you think you have Achilles tendonitis you should seek the help of a suitably qualified sports podiatrist or other healthcare practitioner.