On the 10th July 2017 a 44 year old man arrived at the Sydney Heel Pain clinic for assessment of suspected Achilles Tendonitis. He complained of pain in the lower left Achilles area which had been an issue for approximately 6 weeks. This gentleman was a healthy individual without any chronic illnesses and who took no medication. His typical running regime included running 5 days per week covering approximately 7 km with each run. He informed the podiatrist that he thinks he has Achilles tendonitis and that he feels extreme stiffness and pain when he tries to walk on his left leg each morning after getting out of bed. He describes that after walking for approximately 10 minutes and after a hot shower that he is able to walk more easily with less pain. This gentleman explains tha in the past he has experienced plantar fasciitis in his left foot but never Achilles tendonitis.
This gentleman confessed to the podiatrist that after 4 weeks of constant pain he tried to resolve the Achilles tendonitis with some home treatments. He began to roll his calf muscles and apply ice packs to the heel on a daily basis. He did explain that there was temporary pain relief for half an hour following the application of cold ice packs, however, he was also performing calf raises while hanging his heel off the back of a step. There is contradictory advice surrounding treatment of Achilles tendonitis and some practitioners will recommend such eccentric loading exercises, while others disagree. The patient informed the podiatrist that his Achilles tendonitis felt painful after performing these exercises and so he stopped.
The sports podiatrist applied gentle pressure to the Achilles tendon in the lower 3rd, just proximal to the insertion at the heel bone. This test reproduced the pain that the patient experienced throughout the day. Visibly, the Achilles tendon appeared thicker than the tendon on the right foot and was noticeably swollen. The podiatrist confirmed to the patient that he had all the symptoms of Achilles tendonitis.
In order to determine the cause of this patients Achilles tendonitis the sports podiatrist carried out a thorough biomechanical assessment. The patient was placed on the treadmill and was observed walking and running with his regular running shoes on. He was then asked to run in his bare feet with bisection lines drawn on the Achilles tendon and the back of the heel bone. His running style was recorded using digital software and played back in slow motion. Observations were made and notes taken. This patient demonstrated significant over pronation in his left foot but minimal in his right. The patient did report a pre-existing ankle sprain in the left foot of approximately 3 years which could possibly account for the weakness in these ligaments and over pronation of this left foot. The likely cause of the Achilles tendonitis would be the distortion of the Achilles tendon during gait – something referred to as the bowstring effect. While running in the Asics Gel Nimbus it was clear that the left shoe compressed medially and allowed the foot and ankle to drift. The Nimbus being a neutral shoe was too soft for this patient and did not provide the support that he needed for his Achilles tendonitis.
It was explained to this patient the likely cause of his Achilles tendonitis was the neutral running shoe which offered insufficient control. The podiatrist explained to the patient that he needed to change his running shoes into a motion control shoe. He was advised to purchase the ASICS Gel Kayano.
This patient was also treated with 2000 reps of shockwave therapy at 5 HZ and 1.8 bar of pressure. Patients with Achilles tendonitis respond very well to this treatment due to the increase in blood flow and stimulation of tissue regeneration. The treatment was well tolerated and the patient was booked in for 4 sessions at weekly intervals. He was also provided with the Sydney heel Pain mobile app which provided all the information he needed surrounding his Achilles tendonitis treatment. This included but was not limited to the application of ice packs and a very specific stretching technique, in addition to general footwear advice.
The patient reported the pain from his Achilles tendonitis was reducing each week. This gentleman was compliant with treatment advice and was responding well to the shock wave therapy. Following the fourth application of shockwave therapy the patient reported he was approximately 60% better. It was decided to carry out two more sessions of shockwave therapy at weekly intervals. Throughout treatment the patient was continuing to exercise and engage in his regular running regime. He was advised to stop running if the treatment was not helping to reduce his pain.
After 6 weeks the patient reported some mild stiffness in his Achilles tendon and only mild pain on rare occasions. He had also resumed his full running regime on flat surfaces but was avoiding hills and steps, as advised.
The patient was advised that if his Achilles tendonitis did not completely resolve or if there was a relapse then careful consideration would be given to orthotic therapy. An inverted orthotic below the left heel would help to realign the Achilles tendon, reducing strain and allowing healing.
Please note that the information contained in this case study is not general advice and is specific to one particular patient suffering with Achilles tendonitis. If you have any form of foot pain or if you think you have an Achilles tendon problem you should seek the help of a suitably qualified sports podiatrist or consult with your medical practitioner.
Sydney heel pain clinic is a group of sports podiatrist with a special interest in Achilles tendonitis and plantar fasciitis. The head office at Martin Place and the satellite clinics around Sydney’s inner West & far Western Suburbs offer treatments such as shock wave therapy and bio mechanical assessments for these conditions. Treatment is also available at the Miranda clinic in the Sutherland shire.
Written by Karl Lockett