A Sports Podiatrist Account of a Patient with Achilles Tendonitis
In April 2018, a 38 year old man presents to the sports podiatrist complaining of Achilles tendonitis in his left leg. This patient reports a sharp pain through the shaft of the Achilles tendon that has been problematic for more than 18 months. The patient feels a dull ache and a stiffness through the Achilles tendon each morning when walking from his bed, and reports a throbbing sensation following a busy day on his feet. This patient reports to the sports podiatrist that there is a constant aching sensation and often when he is seated or driving he feels a burning sensation to the back of the ankle. He reports to the sports podiatrist that he has never suffered with Achilles tendonitis before nor has he experienced in any other chronic or acute foot condition. He informs the podiatrist that he is a keen runner but also enjoys CrossFit trainig at least 3 times a week. His Achilles tendonitis was a problem prior to the CrossFit regime, but has increased significantly since becoming a member of the local CrossFit gymnasium.
This patient spoke to several of the gym members who recommended certain and specific home remedies for Achilles tendonitis such as eccentric loading exercises, the application of heat packs, cold packs, and self massage therapy. The patient informs the sports podiatrist that he found no relief from the above therapies and was becoming increasingly frustrated. His intentions were to continue running and to continue the exercise sessions at the CrossFit gym while continuing to treat the Achilles tendonitis, and that he would only stop exercising as a last resort. This patient informed to sports podiatrist that his ideal weight is 87 kilos and that he’s currently 93 kilos and struggling to lose the extra pounds. This patient does not suffer with any autoimmune disease nor does he disclose any chronic medical conditions that cause inflammation or pain. This patient has a high protein low carbohydrate diet and consumes adequate amounts of good fats in his diet. He reports at gluten intolerance and a mild dairy intolerance but no food allergies.
Achilles Tendonitis Assessment by Sports Podiatrist
The sports podiatrist carried out a thorough physical assessment in order to diagnose and measure the severity of the patient’s Achilles tendonitis. Pressure was applied to the mid shaft of the Achilles tendon and the pinch test and pressure test elicited significant pain consistent with Achilles tendonitis. The podiatrist also appled pressure to the posterior aspect of the calcaneus centrally, medially, and laterally. As can be expected with insertional Achilles tendonitis, the patient reported significant pain when pressure was applied to the medial aspect of the insertion. The sports podiatrist informed the patient that not only did he have Achilles tendonitis, but that he was also showing signs of insertional Achilles tendinopathy.
Achilles Tendonitis Assessment by Sports Podiatrist
The sports podiatrist carried out an assessment of the patient’s running shoes and CrossFit shoes in order to determine whether or not they were partly responsible for the onset of the Achilles tendonitis. The patient was running with a Brooks adrenaline stability shoe which provides adequate support for this individual who demonstrated mild instability, and moderate over pronation. However, the patient was using a low profile, more lightweight and flexible CrossFit shoe which provided minimal support for his foot style and CrossFit activity. The patient informed the sports podiatrist of his explosive activity at the CrossFit gym which included lunges and box jumps. In addition to these activities the patient would also carry out short bursts of running and sprinting. The sports podiatrist advised the patient that his footwear selection at the CrossFit gym was a probable cause of his foot strain and Achilles tendonitis and that he should temporarily avoid the use of these shoes. He was advised to replace this CrossFit shoe with his Brooks adrenaline throughout the course of his treatment.
Shock Wave Therapy for Achilles Tendonitis
The patient was informed by the sports podiatrist that he would be given a course of Shockwave therapy to treat the Achilles tendonitis and that this would increase the blood flow and stimulate healing. He would receive sex sessions with a 1 week interval between each session of therapy. In addition to the Shockwave therapy the patient was informed that he must cease all “homework” and refrain from loading the Achilles tendon. Eccentric loading in patients with Achilles tendonitis can delay the onset of healing when the condition is still acute.
Do We Apply Ice Packs to the Ankle with Achilles Tendonitis?
The sports podiatrist informed this patient that he would not be using ice packs to treat is Achilles tendonitis, due to the fact that he was receiving Shockwave therapy. The application of cold packs to the tendon would counteract the Shockwave therapy which was designed to increase the blood flow and promote revascularisation.
The patient was also given 2 x 9 mm to heel raises to wear inside both of his running shoes which would elevate the heel and reduce to load through the Achilles tendon, allowing it to heal naturally. The patient posed the questions of PRP injections and cortisone injection therapy. The sports podiatrist informed the patient that he would possibly consider these other treatments if the current treatment plan failed to provide relief.
The patient was also advised to avoid walking in flat shoes, thongs and bare feet until his condition had resolved. He would also need to gradually reduce the use of the heel lifts following recovery.
After 6 sessions of Shockwave therapy the patient reported to the sports podiatrist that his Achilles tendonitis had all but resolved. Fortunately for him, he was able to maintain his regular training regime without having to restrict activity. The patient was compliant with the use of heel lifts and reported to the sports podiatrist that he had also been complaint with the use of his Brooks adrenaline trainers. The patient did not apply ice packs and reported that he did not need to use anti inflammatory medication.
Please note that this particular patient did not need to carry out calf stretches due to the fact that his ankle joint range of motion was adequate. There did not appear to be a restricted range of motion to the gastrocnemius nor the soleus muscle groups.
The patient did report to the sports podiatrist that on occasions that was mild pain in Achilles tendon and that’s right the mornings that was occasionally some mild stiffness. There was no throbbing and the patient did not feel any burning sensations through the Achilles tendon.
The patient was informed by the sports podiatrist that there was possibly some further healing to take place and that this would happen over the course of the next 4 to 6 weeks. He was advised that he would not need any further Shockwave therapy but that he should continue to comply with the treatment plan. No further appointments were made but the patient was advised to return to the Sydney heel pain clinic if his pain did not completely subside.
Please be aware that the information contained in this case study is particular to one specific patient at the Sydney heel pain clinic. This case study should not be taken as general advice. If you feel that you have Achilles tendonitis you should consult with a suitably qualified sports podiatrist.
Written by Karl Lockett