In March 2018 a 55 year old lady presents to the Sydney heel pain clinic complaining of Achilles tendonitis of approximately 18 months. She feels a hot stabbing pain at the base of the Achilles tendon attachment, around the calcaneus. She reports to the sports podiatrist at Sydney heel pain clinic that there is also a stabbing pain and stiffness. She explains to the practitioner that the symptoms of her Achilles tendonitis came on following a holiday where she walked extensively. The patient was on a European trip and spent approximately 10 days walking around cobbled streets and flat roads using ballet flats and non-supportive shoes. She remembers feeling tightness in her calf muscles and was experiencing night cramps while on holiday in France. Throughout the day, her lower legs would feel tired and achy and she would find herself needing to stretch regularly. The Achilles Tendonitis came on approximately 4 days into her holiday and she remembers on one particular day feeling a snapping sensation in the lower part of her Achilles tendon. She was forced to sit down and quite quickly she returned to the hotel room to rest and apply ice packs to the Achilles tendonitis. The patient did not attend a medical centre nor did she consult with any doctor at this time. Instead she decided to take anti inflammatory medication and apply ice packs to the affected area. The anti inflammatory medication did not reduce the pain significantly therefore the patient decided to combine the medication with codeine. She reports that the pain reduced by approximately 50% and she was able to continue sightseeing so long as she wore her running shoes. The symptoms of the Achilles tendonitis persisted for the remainder of the holiday. Upon returning to Sydney, and after a long haul flight, the patient reports a sudden increase in the symptoms of her Achilles tendonitis, to the point where she was unable to bear weight on the affected leg. After her first night at home, she informs the sports podiatrist that when she woke she could see and feel inflammation around the back of her heel bone, where the Achilles tendon attaches. Once again, she was unable to bear weight on the affected leg as she was forced to hold on to the walls while she hobbled around her home. Her husband drove her to the local GP who organised an x-ray. Her GP did not mention Achilles tendonitis at this stage, but instead mentioned a heel spur. The patient returned to her GP who confirmed the presence of a heel Spur at the base of the Achilles tendon, around the back of the heel bone. The GP did not recommend further medication, but instead recommended that she seek the help of a sports podiatrist. This lady has experienced previous foot problems such as plantar fasciitis and shin splints, but she has never been diagnosed with Achilles tendonitis before.
The sports podiatrist carried out a thorough physical assessment of the Achilles tendonitis in order to determine the severity of the condition and the exact location of the affected area. Her response was great, and the patient retracted her foot quickly when gentle finger pressure was applied to the Achilles tendon. It was noted that the medial portion of the Achilles tendon attachment was significantly more tender than the rest. The sports podiatrist confirmed that the patient demonstrated all of the common symptoms of insertional Achilles tendonitis, but that there was a chance that the Achilles tendon had become partially torn. The patient was also informed that at this stage that retro calcaneal bursitis could not be ruled out. Therefore, the patient was referred for ultrasound imaging in order to assess the Achilles tendon in more detail.
The patient returned to the Sydney heel pain clinic 4 days later to discuss the results of her ultrasound, and she reported no improvement in the symptoms of her Achilles tendonitis. The sports podiatrist explained to the patient that the report confirmed a small intrasubstance tear along the medial portion of the Achilles tendon, at the attachment into the calcaneus. There was no retrocalcaneal bursitis nor superficial adventitial bursitis.
The sports podiatrist informed the patient that the treatment of her Achilles tendonitis would involve a few factors. The patient was fitted with a medium sized, full height rebound airwalker, immobilisation boot. The podiatrist inserted a 12 millimetre heel wedge inside the boot in order to elevate the heel and reduce further load on the Achilles tendon. A heel wedge was also inserted into the shoe of the patients other foot in order to attempt to lift the hip on that side and reduce the likelihood of lower back stiffness or pain. The patient was also informed that her Achilles tendonitis would take up to 12 weeks to heal and that she would remain in the immobilisation boot until she felt comfortable and able to walk without it. The sports podiatrist advised that patients with Achilles tendonitis usually improve quickly if they receive shockwave therapy to the affected area. The patient was reassured that treatment of the Achilles tendonitis and the tear, with immobilisation boot was extremely reliable, however should the tear fail to heal she may be referred to a surgeon for further discussion and treatment. She was also informed that the pain that she was experiencing was not a result of the heel spur and that she should feel better and make a full recovery once the tendon was treated successfully.
The patient was informed that Achilles tendonitis is more often than not, a result of restricted calf muscle range. She was informed that the onset of her condition was a result of extended walking in non supportive footwear, which leads to fatigue and stiffness through the muscles of the lower leg. She was advised to carry out regular calf stretching in order to reduce load on the Achilles tendon, allowing it to heal. Patients who receives treatment for Achilles tendonitis from the podiatrist, can experience a lack of healing, or an extended healing time, if they fail to carry out calf stretches. The patient was given the Sydney heel Pain mobile app which includes a diagram and instructions of how to perform calf stretches.
In order to ensure a speedy recovery of this lady’s Achilles tendonitis, and small intrasubstance tear, the podiatrist arranged 4 shockwave therapy sessions. She engaged in one session of Shockwave therapy every 5 days for approximately 3 weeks.
She was advised not to apply ice packs to the affected area as this would reduce blood flow and counteract the benefits of the shockwave therapy.
After the course of shockwave therapy, the patient was booked in for a 6 week follow up. Assessment revealed that after 6 weeks, there was an improvement in pain levels with palpation of the affected area. However, the patient still demonstrated all of the symptoms of Achilles tendonitis. She was advised that her treatment with the immobilisation boot should continue. The patient informed the sports podiatrist that her symptoms were improving. She was able to bear weight on the affected leg without the immobilisation boot for short periods of time without experiencing significant pain from the Achilles tendonitis, around the back of the heel bone. However, she did not walk for more than 15 minutes without the immobilisation boot as she would feel mild pain and significant stiffness. The patient was rebooked for a further four weeks. At this appointment the patient reported further Improvement with respect to the symptoms of her Achilles tendonitis, and she was eager to have the immobilisation boot removed. She informed the sports podiatrist that she was in fact able to walk with regular shoes and the heel lift, without experiencing any pain. She’s confirmed that the Achilles tendonitis was slightly tender first thing in the morning and there was a mild pain and significant stiffness each morning. The patient was advised that her Achilles tendonitis had not healed completely and that treatment must continue, but that she was able to remove the immobilisation boot. Instructions were that the patient should remain in supportive shoes with elevated heels at all times. She could now apply ice packs to the affected area each evening to reduce any protective inflammation around the calcaneus. The patient enquired about a follow-up ultrasound in order to assess the healing of the Achilles tendonitis and intrasubstance tear. A referral was handed to the patient but she was advised that the results of the ultrasound would not influence the management of her case and that she should continue to treat her foot based on her symptoms alone. The patient was advised to return to the clinic in a further 4 weeks if she felt any deterioration in her condition or an increase in her symptoms. No further appointments were noted, and it can be assumed that the patient made a full recovery due to her lack of communication with the Sydney heel pain clinic.
It should be noted that the information contained in this case study is specific to one patient. This case study should not be taken as general advice. If you have foot problems or if you think you have Achilles tendonitis you should contact a qualified sports podiatrist.