A 58 year old female presents to the Sydney heel pain clinic complaining of Achilles tendonitis in her left foot. She has a history of plantar fasciitis in both feet but this has been resolved for quite some time. She reports that her Achilles tendonitis has been a problem for approximately 6 weeks and coincides with her increase in exercise. This lady is a keen hiker and her preferred form of exercise is off-road tracking and overseas holidays involving long walks and hikes. She is preparing for an overseas trip to India where she will be on her feet for extended periods of time during off road trekking. After she increased her level of activity and engaged in much longer walks and more challenging routes she began to feel pain in her left Achilles tendon. The pain from the Achilles tendonitis is quite apparent first thing in the morning when this lady starts to walk. After 10 to 15 minutes of walking around the house there is a slight improvement in the pain and she becomes a bit more mobile. During exercise, she feels stiff and sore for the first 20 minutes. The Achilles tendon then seems to warm up and she’s able to walk a bit more easily. However, after walking for approximately 60 minutes the pain from the Achilles tendonitis returns and her walking style is affected. This lady has not engaged in any treatment for her Achilles tendonitis but has been using medication to reduce the pain and inflammation. She also reports that the pain from her Achilles tendonitis is worse when using flat shoes. She feels much more comfortable using footwear with a small heel raise. Soft issues such as Skechers and Nike Free tend to exacerbate the problem so she has been avoiding this type of shoe. This patient is fairly anxious to treat her Achilles tendonitis as her overseas trip to India is approximately 7 weeks away.
Achilles Tendonitis – Physical Assessment
The sports podiatrist carries out a thorough physical assessment to confirm Achilles tendonitis and to assess the severity of the condition. Vsibly there is a small nodule Approximately 6 millimetres in diameter in the Achilles tendon, just above the heel bone. The left Achilles tendon appears thicker than the right. The patient reports significant pain on palpation of the nodule. The sports podiatrist confirms the patient’s suspicion and informs her that she has Achilles tendonitis in the left heel.
This patient currently uses prescription orthotics inside the hiking shoes and everyday footwear. She is already well informed and uses functional footwear most of the time, due to her previous experience with plantar fasciitis. Her hiking shoes are firm and still very supportive. Her day-to-day shoes are a little softer and slightly flexible but she does not spend extended periods of time on her feet on a day to day basis. The sports podiatrist decides to carry out a biomechanical assessment in order to determine the cause of her Achilles tendonitis.
Biomechanical Assessment for Achilles Tendonitis
Anatomical landmarks were drawn on the back of the patient’s Achilles tendon and she was asked to walk on the treadmill in her bare feet. The podiatrist was able to record the gate using digital software on an iPad. During replay, it was evident that this patient demonstrated a relatively unstable foot type with significant over-pronation bilaterally. When comparing notes from this patient’s file, approximately 3 years ago, the results were consistent. During propulsion, the podiatrist was able to observe early heel lift on the left side compared to the right. Further examination revealed some shortening of the soleus muscle group in the left lower leg. It was quite likely that the biomechanical anomaly in the left lower leg had contributed if not caused this patients Achilles tendonitis. The podiatrist performed an orthotic check to ensure that the patient’s current orthoses were still intact and providing sufficient control in both feet. No abnormalities were detected and the orthotics were deemed appropriate. There were no other contributing factors to consider as a cause of this patients Achilles tendonitis.
Achilles Tendonitis Treatment
This patient was informed that in order to treat her Achilles tendonitis she would benefit tremendously from weekly sessions of Shockwave therapy. She was also informed that her Achilles tendonitis would improve if she was able to perform stretches to the tight muscle group in her left lower leg. The application of ice packs would also reduce the swelling in the Achilles tendon and would therefore accelerate healing. The Shockwave therapy stimulates blood flow and improves circulation into the affected area, accelerating the healing process and ensuring a full recovery.
Shock Wave Therapy Session 1
2000 reps were applied – 1000 reps at 1 bar and 1000 reps at 1.3 bar
Treatment was well tolerated and the pain from the Achilles tendonitis fell away after treatment. Patient was able to walk more comfortably and reported the tendon felt free and looser.
Shock Wave Therapy Session 2
One week later 2000 reps were applied – 1000 reps at 1.2 bar and 1000 reps at 1.5 bar. Again, the patient reported an improvement and less pain when walking. She also reported that the Achilles Tendonitis had been more manageable throughout the week, especially when hiking.
Shock Wave Therapy Session 3
One week later – 2000 reps were applied – 1000 reps at 1.4 bar and 1000 reps at 1.7 bar.
Treatment was well tolerated. Further improvement was noted.
Shock Wave Therapy Session 4
Shock Wave Therapy Session 5
One week on – 2000 reps were applied – 1000 reps at 1.8 Bar and 1000 reps at 2.2 bar.
Treatment was well tolerated and there was less pain from the Achilles tendonitis immediately after.
The patient reported that in general she felt very minimal and very mild pain from the Achilles tendonitis. Each morning there was very mild stiffness but this was short-lived and very manageable. It was decided to cease further treatment as the patient had made a significant recovery from her Achilles tendonitis.
However, this lady was informed that she should continue to be mindful of footwear and orthotics and be sure that she maintains good range of motion in the affected muscle groups. During her hikes and after her long walks she was advised to perform calf stretches. The Sydney heel Pain mobile app was loaded onto the patient’s phone which contained important information and ongoing advice.
Please note that the information contained in this case study is specific to one particular person. If you are suffering with foot pain or if you think you have Achilles tendonitis you should consult with a qualified sports podiatrist.
Written by Karl Lockett