In April of 2017, 44-year-old self employed builder arrived at the Sydney heel pain clinic complaining of Achilles tendonitis in his right leg. He reports chronic pain in his Achilles tendon of more than 6 months, and acute pain for approximately 4 weeks. He describes heat and a pulling sensation and the feeling of burning in the back of his Achilles tendon while walking. He informs the podiatrist that his Achilles tendon is sore to touch and is particularly painful towards the end of the day after he has been on his feet for extended periods. He is suspicious that his Achilles tendonitis developed after he changed his work boots from one brand to another. He has both pairs of work boots in the clinic today. This patient is approximately 6 feet 1 inch tall and weighs 112 kilos. He informs the podiatrist that he is pre-diabetic but takes no medication and his blood sugar levels are controlled with appropriate diet. He has never suffered with Achilles tendonitis before but informed the podiatrist that he did once experience a grade 1 calf muscle tear in his right leg. This patient reports extreme pain when climbing up and down ladders or when walking up steps and stairs. He finds temporary relief when he applies a cold ice pack to the back of his leg surrounding the Achilles tendonitis. He also informs the podiatrist that he frequently attempts to stretch the Achilles tendon by lowering his heels off the back of a step when at work. While this provides short-term relief, his Achilles tendonitis is not improving and has become much more painful over the last 4 weeks. This patient did report the problem to his doctor but there was no treatment plan put in place. His doctor informed him that if his Achilles tendonitis did not resolve within 2 months he would offer him some prescription medication or refer him for an injection of cortisone.
The podiatrist applied mild compression and lateral pressure to the shaft of the Achilles tendon proximal to the heel, to assess the severity of the Achilles tendonitis. During palpation, the patient reported a pain similar to the pain that he experiences throughout his day to day life. Visually, the right Achilles tendon appeared slightly thicker than the left. The patient was informed that he did in fact have all the symptoms associated with Achilles tendonitis and that further assessment was needed in order to determine a successful treatment plan.
Both the podiatrist and the patient were suspicious about the onset of this patient’s Achilles tendonitis coinciding with the change in work boots. It became apparent that his original work boots were more robust and inflexible then the replacement pair of boots. His replacement boots had a slightly lower heel drop and were made from a lighter compound which compressed more easily under load. The podiatrist was easily able to twist and manipulate the boot and it felt lighter in his hands. The patient was advised that there was a good chance that his Achilles tendonitis had developed due to the lack of support in his newer work boots. It was explained to the patient that heavier and more rigid work boots that don’t flex so easily, offer more support and are advised in circumstances such as his, where patients are on their feet for extended periods. His Achilles tendonitis would heal quicker after he purchased new boots offering more support.
In order to determine the underlying biomechanical anomalies that contributed to the onset of this patients Achilles tendonitis, it was important to carry out a biomechanical assessment with the patient walking on a treadmill in his bare feet. Bisection lines were drawn on his skin on the back of his heel and Achilles tendon. The podiatrist captured his gait cycle using digital software on an iPad. The footage was replayed in slow motion and observations were noted. This patient demonstrated a stable foot type and it was apparent that his feet did not over pronate. The lines on the back of his heel and Achilles tendon remaining vertical. (It should be noted here, that some patients will develop Achilles tendonitis, when the foot over pronates and the Achilles tendon becomes distorted, but this was not the case with this patient and his Achilles tendonitis had developed due to other factors.)
The podiatrist was able to observe an early he left on the patients’ right leg, in comparison to his left. This early heel lift is usually a result of tightness and a shortening of the calf muscle. In this particular case, the shortening of the calf muscle was probably a result of the patient’s old muscle tear. The patient was advised that his calf muscles would need some attention and that this bio mechanical issue was the likely cause of his Achilles Tendonitis.
Achilles tendonitis is a condition that has limited healing due to insufficient blood flow. To this end, the patient was booked in for six sessions of Shockwave therapy, which would stimulate blood flow and accelerate healing. The first of his treatments was carried out immediately and was well tolerated. 2000 reps were applied to the Achilles tendon at 2 bars of pressure and a maximum of 6 Hz. The patient felt immediate relief after standing and walking around the treatment room.
The podiatrist carefully demonstrated one specific calf stretching technique that the patient was advised to do several times a day. He was also fitted with 2 x 9mm heel lifts inside his work boots. The heel lifts would reduce the tension through the Achilles tendon allowing the inflamed tendon on the right leg to settle. The patient was instructed to install the Sydney heel pain mobile app for his smartphone. The app contains important information surrounding the treatment of his Achilles tendonitis, including the calf stretching technique, footwear advice, and shockwave therapy.
As is usually the case with Achilles tendonitis patients, following the Shockwave therapy the patient reported approximately 5 days of pain relief. On day 6 and 7 the pain started to return as the effects of the treatment began to wear off. The patient was assured that this was normal and that he was now ready for his next treatment. Overall, during week 1, the patient reported a very small improvement in pain but an overall feeling of increased mobility through the lower leg. Weeks 2,3 and 4 brought about similar results and further improvement. The patient was compliant with stretches and the use of his heel lifts. He had also purchased another pair of work boots that were much more suitable. At the 5-week check-up, the patient reported that his Achilles tendonitis was approximately 70% better. Again, he had been compliant with stretching and home remedies as per the mobile app, and had continued to cease the stretches whereby he lowered his heels off a ledge. The final shockwave therapy treatment was applied at week 6. As the pain from the Achilles tendonitis was much more bearable, the podiatrist was able to increase the treatment to 3.4 bars of pressure and 7 Hz. The treatment was well tolerated. The patient was informed that this would be his last treatment but that he should continue with the heel lifts and the treatment advice. There would be further healing to take place over the next 4 to 6 weeks. The patient was asked to return in six weeks for one final check-up of his Achilles tendonitis.
At this appointment, the patient informed the podiatrist that the pain from his condition had all but subsided. He confessed that occasionally there would be some mild pain after a very physical day, but the pain would reduce very quickly. He no longer felt pain first thing in the mornings but did report some mild stiffness occasionally. He was advised to slowly reduce the use of the heel lifts and to ensure that he continued to stretch his calf muscles thoroughly during this transition. Once again, he was informed that further healing would continue to take place, even though the shock wave therapy treatment had finished. He was informed that he did not need to come back to the Sydney heel pain clinic but the podiatrist requested he contact the clinic immediately if there was any deterioration and his condition.
Patient: NOT NAMED
Podiatrist: Karl Lockett
Please note the information contained in this case study is specific to one particular person. If you suffer with Achilles tendonitis you should seek the help of a sports podiatrist or suitably qualified medical practitioner.