Plantar Fasciitis and Achilles Tendonitis

Two of the most common conditions that we treat at the Sydney Heel Pain clinics are plantar fasciitis and Achilles tendonitis. These two conditions seem to affect people from all walks of life. While our typical patient is a female aged in the latter half of her life, these conditions affect men and women, both young and old. There are several contributing factors to consider when looking at the cause plantar fasciitis.  Interestingly, the contributing factors that are commonly associated with this heel pain condition,  are also associated with Achilles tendonitis. It is true that there is no one singular cause of either of these conditions, but calf muscle issues occur time and time again.

Case Study – December 2017

A 55 year old female presents to the Sydney heel pain clinic complaining of plantar fasciitis of approximately 3 months. She reports classic symptoms, such as pain under the ball of her heel which is very prominent first thing in the morning when she begins to walk. She describes pain after being seated and also pain whilst driving for long distances. She informs the podiatrist that when she stands up to walk from a seated position, the pain under the base of her heel causes her to limp somewhat. She informs the podiatrist that she has never had plantar fasciitis before but did experience Achilles tendonitis in the same leg approximately 18 months ago. Since developing plantar fasciitis, this patient has reduced her level of activity due to the pain. Ordinarily she would walk each morning with her husband for approximately 7 km. She would also enjoy weekly sessions of Zumba. She advises that she feels extreme pain the evening of a Zumba class, and an increase in symptoms the following morning. She has not engaged in any treatment for the plantar fasciitis but has been rolling her foot on a Frozen bottle at home. She describes temporary relief from the heel pain following the rolling on the bottle, but that the relief is short-lived. She reports to the podiatrist that her Achilles tendon on the same leg is starting to feel stiff, and similar to how it felt when she developed Achilles tendonitis. She is adamant that she wants to treat this problem as soon as possible, as she does not want to experience the pain that she experienced 18 months ago from the Achilles tendonitis. The sports podiatrist advised the patient that both plantar fasciitis and Achilles tendonitis are very common problems in the clinic, and that both of them are treatable. She was reassured that she will make a full recovery, but that improvement of these conditions can sometimes be quite slow.

Sydney Heel Pain Mobile Application

Firstly, the podiatrist installs the Sydney heel Pain mobile app onto the patient’s smartphone, so that she has clear instructions on the treatment of the plantar fasciitis. The mobile app contains information, including but not limited to, a range of home remedies that can aggravate or assist with the problem. She is advised to “wipe the slate clean” and cease all home remedies, even if they provide short term relief of her plantar fasciitis. She’s advised that some of these home remedies can create short term pain relief but can aggravate the condition long term. The mobile phone application also contains information surrounding the successful treatment of Achilles tendonitis. The app contains diagrams and instructions pertaining to calf stretching technique. When treating plantar fasciitis footwear selection is also crucial and the app contains a page of information surrounding footwear. Specific shoe models are also included.

Physical Examination for Plantar Fasciitis

Pressure was applied to the base of the heel around the attachment of the plantar fascia. The patient confirmed pain. The podiatrist also applied pressure to the medial slip of the plantar fascia from the base of the heel and into the arch of the foot. Mild pain was also present in these areas. The sports podiatrist confirmed that the patient was presenting with all the classic signs and symptoms of plantar fasciitis.

Further examination was carried out in order to determine the cause of the plantar fasciitis. One of the most striking, but not surprising findings, was an extreme tightness in both calf muscles. As mentioned above, restricted range of motion through the calf muscles is one of the most common causes of plantar fasciitis and Achilles tendonitis. The tightness increases the pulling sensation through the Achilles tendon and furthermore increases the pulling of the heel bone away from the plantar fascia. The patient was advised that her calf muscles were probably the likely source of her problem, and that this same biomechanical anomaly was more than likely the cause of her Achilles tendonitis that she experienced 18 months ago.

Treatment – One Stretch Treats All

In addition to the information contained in the mobile phone application, the podiatrist pointed out to the patient that one of the most important things that she needed to do in order to get on top of her plantar fasciitis, was perform regular and specific calf stretches. She was advised that the tightness in her Achilles tendon would also improve following this stretching program. This would significantly reduce the likelihood of an Achilles tendonitis recurrence. The podiatrist performed the stretches and the patient observed. Roles were reversed. The patient performed the stretches and the podiatrist observed and made small adjustments. Stretching technique, frequency of stretches, and number of stretches per session were all outlined in the mobile phone application. A diagram was also pointed out in the mobile phone application. The patient performed the stretches well and felt confident and happy with the technique. She understood and committed to the footwear changes and the specific information contained in the app.

This patient had done some research and requested shock wave therapy treatment. The podiatrist denied, but informed the patient that if she did not feel any improvement with the current treatment plan that had been put in place, then he would commence shockwave therapy at a later date. The patient returned after 4 weeks and reported significant improvement. She informed the podiatrist that the plantar fasciitis had all but subsided and that she did not fear a recurrence of the Achilles tendonitis, as her calf range and Achilles tendon felt free. The patient was advised to continue with the same treatment plan, with no modifications, until her pain had completely subsided. She was informed to return to the clinic if her plantar fasciitis deteriorated or if she felt a recurrence of the Achilles tendonitis. No further appointments were taken.

Please note that the information contained in this case study relates to one particular individual. This case study should not be taken as general advice. If you think you have plantar fasciitis or Achilles tendonitis you should seek the help of a suitably qualified sports podiatrist.

 

Written by Karl Lockett

Plantar Fasciitis History

A 32 year old female who came to Sydney on holiday from Poland, presents to the Sydney heel pain clinic complaining of plantar fasciitis. She reports to the podiatrist that she has been walking around the city every day for approximately 10 days. Prior to this she was sightseeing and travelling around Queensland and spent some time on her feet in the city of Brisbane. She reports that the plantar fasciitis became painful while in Queensland, but has become much more painful while here in Sydney. She has been walking around in flat and flexible shoes, namely Converse All Star high top boots. She informs the podiatrist that prior to the symptoms of plantar fasciitis, her feet became fatigued and hot. She felt strain and a pulling sensation through the sole of her foot that ran from the arch and into the base of the heel. She also reports that her calf muscles felt tight and she was driven to attend massage therapy sessions. She has plans to travel the rest of Australia over the next 6 weeks and therefore is keen to fix her foot problem and resolve the plantar fasciitis as soon as possible. This patient reports pain under the ball of her heel which is very apparent first thing in the morning when she puts her foot to the floor. She also describes severe heel pain after she has been seated for long periods, such as traveling on the train or the bus. The patient reports good general health and has never experienced plantar fasciitis before nor any other significant foot conditions. The condition is affecting the left foot only and her right foot is asymptomatic. She presented with no x-rays or ultrasounds and has not engaged in any treatments aside from the remedial massage to the calf muscles. In addition to the Converse all-star, this patient has been walking with Havaiana thongs. The patient informs the podiatrist that the pain has been so bad that she has resorted to anti-inflammatory over the counter medication. The medication provided little relief. The patient informs the podiatrist that she is in Sydney for a further 4 weeks only before she travels to Melbourne. Therefore, the podiatrists designs a treatment plan for the plantar fasciitis inside of these time constraints.

Physical Examination for Plantar Fasciitis

The podiatrist carries out a detailed physical examination in order to make a full diagnosis and to assess the severity of the plantar fasciitis. Pressure was applied to the base of the heel around the attachment of the plantar fascia, which elicited significant pain. Pressure was also applied to the medial aspect of the heel and more distally into the proximal arch area. This also triggered a reaction from the patient, which confirmed the diagnosis of plantar fasciitis. Calf range was assessed and it was determined that there was average range of motion through the ankle. However, both calf muscles were tender on palpation particularly through the medial head of the gastrocnemius. The Achilles tendon was asymptomatic. The patient was informed that she did in fact have all the symptoms consistent with plantar fasciitis and that she would need immediate treatment.

Biomechanical Assessment for Plantar Fasciitis

In order to determine the cause of this patient’s plantar fasciitis, the podiatrist carried out a detailed biomechanical assessment. Anatomical landmarks were drawn on the back of the patients calf muscle and heel, and she was asked to walk on the treadmill in her bare feet. Her walking style was captured using digital software on the iPad and replayed in slow motion. Some static measurements were also taken with the patient standing in a relaxed calcaneal stance position and a subtalar joint neutral position. Medial arch heights were measured and noted. On some occasions, patients with plantar fasciitis will present with no abnormalities. This 32 year old lady demonstrated acceptable foot biomechanics but did have a slightly lower arch contour on her left foot by approximately 5 mm. This may not be relevant in the onset of a plantar fasciitis.

Footwear Changes for Plantar Fasciitis

The patient was advised that in order to rectify her plantar fasciitis she would need to change her footwear to something more substantial. She was advised to avoid flat and flexible shoes as these are less supportive and allow the foot to work harder, which adds strain to the plantar fascia. She was given a specific recommendation of a more functional walking shoe that would suit her foot type and dress style.

Shockwave Therapy for Plantar Fasciitis

The patient was advised that her plantar fasciitis would recover quicker if shock wave therapy was applied. Shockwave therapy stimulates blood flow and accelerates healing by increasing the turnover of new tissue cells. The patient consented to treatment and agreed to receive her first session.

Sydney Heel Pain Mobile App

The Sydney heel Pain mobile app was installed on the patient’s smartphone so that she had all the information she needed relating to the treatment of her plantar fasciitis. Within the app, she was directed to the pages containing footwear information and calf stretch advice. The main plantar fasciitis page, containing advice on things to avoid and things that would be beneficial. This included but was not limited to the application of ice packs on a daily basis.

The sports podiatrist also applied rigid sports tape to the affected foot in order to reduce strain on the plantar fascia, and allow healing of the plantar fasciitis. The patient reported the feeling of extra support and more comfort with the strapping in place. She was advised to return to the clinic in a further 5 days to receive another session of Shockwave therapy and to have the strapping replaced.

Treatment Plan for Plantar Fasciitis

This patient returned to the clinic on a weekly basis to receive shockwave therapy treatment and to have rigid sports tape applied to the affected foot. She was compliant and purchased the footwear that the podiatrist had recommended, and brought these to the  second appointment for the sports podiatrist to assess. She received the 4 sessions of shockwave therapy for the four weeks that she had remaining in Sydney. At each appointment, the patient reported that the pain from her plantar fasciitis was reducing. At the second appointment she reported an improvement of approximately 30 to 40%. As is usually the case with plantar fasciitis and shock wave therapy, the improvement between appointments after this, was slower but nonetheless still evident.  After the 4 sessions of shockwave therapy she reported an overall Improvement of approximately 70%. She was given the contact details of the Melbourne heel pain clinic who are associated with Sydney heel pain clinic.

Please note that the information contained in this case study is particular to one person and should not be taken as general advice. If you think you have plantar fasciitis you should seek the help of a suitably qualified podiatrist.

 

Written by Karl Lockett

A 12 year old boy presents to the Sydney heel pain clinic in Miranda, complaining of Sever’s disease in his right foot. The child’s mother reports to the podiatrist that her son has been suffering with heel pain for approximately 7 months. She took her boy to see the doctor who referred her for an x-ray, and who then diagnosed Sever’s disease. The boy is going through a growth spurt and has shot up in the last 8 months. He is a very active boy and plays approximately 6 periods of sport each week. He plays for the school basketball team and soccer team. During physical activity, the pain from Sever’s disease has been affecting his performance. He is forced to limp and cannot run freely. Each morning when getting out of bed, the pain from the Sever’s disease is extremely prominent and causes the patient to limp. The child’s mother also reports to the podiatrist that he seems to have a funny walk, and that he bounces with each step that he takes. The patient reports he has experienced some calf cramping and pain in his Achilles tendon in addition to the Severs disease. The patient has spent some time with a local physiotherapist who has encouraged some exercises but these have not helped. The family purchased some heel cushions to sit inside his school shoes and sports shoes. The patient reports mild relief from the use of these heel cushions but not sufficient to treat the condition properly. The child’s mother informs the podiatrist that the pain from the Sever’s disease has warranted the use of Voltaren gel, which she would apply to her child’s foot each evening before bed. Once again, there was mild relief from the Voltaren gel but the Sever’s disease persists. The family returned to the local GP who advised they seek the opinion and treatment of a podiatrist. The patient has not experienced ill foot health before and he has never suffered with Sever’s disease. The patient arrives today with his school shoes, basketball shoes and soccer boots, and with the gel heel cushions that he has been using inside the shoes. He also presented with his x-ray films and a report. The report quite clearly states that the patients exhibits Sever’s disease. The child’s mother also informs the podiatrist that she would prefer her son to continue to be physically active and maintain his positions within the school sports teams.

Physical Assessment for Sever’s Disease

Sever’s disease is a condition affecting the growth plate of the heel bone, usually between the ages of 7 and 14 years. Pain is usually located around the posterior and plantar aspect of the heel bone. The podiatrist applied moderate pressure to these areas which elicited heel pain. Moderate pressure was applied to the same areas of the left foot and there was no reaction from the patient. The podiatrist agreed with the diagnosis that the patient demonstrated Sever’s disease in his left foot.

Biomechanical Assessment

Sever’s disease usually develops in association with physical and biomechanical factors. The podiatrist carried out a thorough biomechanical assessment to see which factors may have led to the onset of this patient’s condition. Using black ink, the podiatrist highlighted anatomical markers on the posterior aspect of the patients calf, Achilles tendon and heel bone. The patient was then observed walking and running barefoot on a treadmill. The podiatrist captured the patient’s foot function using digital software on an iPad. The video was replayed in slow motion and observations were made. The podiatrist was able to observe early heel left bilaterally, which is a common finding in patients with tight calf muscles and / or Sever’s disease. The tight calf muscles become shorter and they pull the heel off the ground early in the gait cycle. This pressure from the calf muscles creates  pulling and physical irritation on the growth plate of the heel bone – alas Sever’s disease.

Due to the tight calf muscles, this patient did not demonstrate over pronation. Instead the podiatrist was able to observe good arch contour and stable foot architecture. During running, there was naturally a little more pronation, but again the level of pronation was not of concern.

Treatment for Sever’s Disease

The family were informed that several factors were to be considered in the treatment of the child’s Sever’s disease. The Sydney Heel Pain mobile phone application was installed on the patient’s iPad and the Mother’s iPhone. The application contains important information surrounding the treatment of Sever’s disease.

1: Calf stretching

2:  New school shoes

3:  The application of cold ice packs

4:  The use of heel lifts inside the shoes

The family were informed that in order to relieve the pain from Sever’s disease, the patient must improve the range of motion in his calf muscles. The podiatrist demonstrated the calf stretches and the patient performed them under guidance. The stretching technique and the frequency of these stretches was outlined in the mobile phone application.

The podiatrist assessed the patient’s school shoes which were due for replacement. The parents were advised what to look for when purchasing the next pair of school shoes. The wear and tear on the existing school shoes would not provide sufficient control for the patient’s feet and the Severs disease would likely persist.

Sever’s disease involves irritation and swelling around the growth plate of the heel bone. To this end, the application of ice packs would assist and accelerate healing by reducing said swelling. The ice packs would also reduce the pain and give the patient some relief from the Sever’s disease.

In order to reduce the load on the heel bone and the Achilles tendons, 9 mm heel lifts were provided. These were to be inserted under the liner of the shoe beneath the heel. These were to be used at all times in all shoes.

Other general information surrounding treatment of this patients Sever’s disease was to be found in the mobile phone application and was to be followed.

2 Week Check

At the two-week check up, the patient reported that the pain from the Sever’s disease had improved by approximately 50%.  He was still participating in all periods of sport and physical activity.

4 Week Check

Improvement had plateaued and was reported to be approximately 60%. The patient was advised to pull back on quick movement sports.

6 Week Check

The patient reported further improvement and described approximately 80%. He no longer experienced pain throughout the day but was aware of some mild pain each morning when starting to walk.

8 Week Check

After 8 weeks the patient reported that he no longer felt pain from the sever’s disease. The podiatrist applied moderate pressure to the posterior and plantar aspect of the heel bone and there was no reaction from the patient.

The patient was advised to slowly return to physical activity and to maintain good calf range via the stretches shown. The 9mm heel lifts were swapped for 5mm. The patient was advised to wean off the 5 millimetre lifts in due course.

Naturally the patient was advised to return to the podiatry clinic if his Sever’s disease returned.

Please note the information contained in this case study is specific to one particular patient. If you are concerned about Sever’s disease, you should seek the help of a suitably qualified sports podiatrist.

 

Written by Karl Lockett

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

As above

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

History of Achilles Tendonitis

A 54-year-old female presented to the sports podiatrist complaining of Achilles tendonitis in her left heel. She informed the practitioner that she had been on a medical merry-go-round trying a variety of treatments. Amongst the treatments that she had tried were acupuncture, physiotherapy, massage therapy, stretch techniques and a visit to a surgical podiatrist. She informed the podiatrist that her Achilles tendonitis got a little better after seeing the physiotherapist but the improvement was short lived. She also reports extreme stiffness each morning when getting out of bed and after periods of being seated. Her normal exercise regime involves walking her dog every evening after returning home from work. However due to the Achilles tendonitis, she has been forced to refrain from physical activity. This lady informs the podiatrist that there is mild relief from the Achilles tendonitis pain if she wears shoes with a slightly higher heel. She has committed to wearing sandals around the house in order to keep her heel elevated. At work, she has be wearing office shoes with a 3 or 4 centimetre heel as this seems to help the Achilles tendonitis.  One of her work colleagues informed her that she once herself suffered with the same condition and found relief from Voltaren gel and ice packs.  However, the application of ice packs only provided mild relief from the Achilles tendon pain. After seeing the physiotherapist she commenced a routine of exercises which involved calf stretches and heel raises. She found that the heel raises increased her symptoms and therefore ceased home remedies after 10 days. This lady then sought the help of her GP who recommended an x-ray. The GP also recommended a short course of anti inflammatory’s which she reluctantly took for two weeks to no avail. This lady presents to the clinic today feeling very frustrated and reports that the pain from her Achilles tendonitis feels relentless.

Physical Assessment – Achilles Tendonitis or Heel Spur?

A detailed physical assessment was carried out in order to assist with the correct diagnosis of Achilles tendonitis or heel spur. The podiatrist immediately noted a larger left heel which protruded significantly, posteriorly. The heel of the left foot was noticeably warmer than that of the right foot although there was no erythema. The podiatrist examined the X-ray and noted a hypertrophic calcaneus and an obvious posterior heel spur. The heel spur did not clearly define the Achilles tendonitis. With the patient lying prone, the podiatrist was able to examine the shaft of the Achilles tendon more proximally. The Achilles tendon was slightly thicker on the left side and was noticeably swollen. The patient reported instant pain on palpation of the Achilles tendon proximally and also on palpation of the distal aspect at the insertion. The patient was advised that she was suffering with Achilles tendonitis and insertional Achilles tendinopathy.

Footwear – The Cause of the Achilles Tendonitis

Quite commonly the cause of Achilles tendonitis is unsuitable footwear. The sports podiatrist carried out an assessment of the patients work shoes, casual shoes, and running shoes. Each pair of shoes that the patient presented with demonstrated poor stability and increased flexibility. It was explained to the patient that this type of shoe requires the foot, ankle and calf muscles to work much harder, leading to stiffness and a restricted range of motion. Due to the fact that this lady had been spending most of her days in this type of shoe, for approximately 3 months, it was suggested that this was the  likely cause of her Achilles tendonitis. She had been using Skechers, Nike Free, and ballet flats.

Biomechanical Assessment – Other Causes of Achilles Tendonitis?

In order to determine which other contributing factors had led to this patients Achilles tendonitis, the sports podiatrist carried out a biomechanical assessment on the treadmill.  Bisection lines were drawn on the posterior aspect of the calcaneus and Achilles tendon, and the patient was observed walking on a treadmill in her bare feet. Her gait cycle was recorded using digital software on an iPad and the footage was replayed in slow motion, and then analysed. As is to be expected in patients with Achilles tendonitis, the podiatrist observed an early heel lift due to a restricted range of motion through the Achilles tendon and soleus muscles. Biomechanically, this lady demonstrated good foot function with moderate amounts of pronation bilaterally. A mild forefoot valgus was noted on the left foot and a slightly arthritic metatarsal phalangeal joint on the right foot –  first toe joint. Leg length appeared to be equal.

Achilles Tendonitis Treatment

This patient was informed that the treatment of her Achilles tendonitis would involve the following factors. Footwear changes, calf stretches, Shock Wave therapy, and the application of ice packs on a daily basis. She was recommended to use a firm shoe with a more rigid soul and a slightly higher heel. The podiatrist recommended the Asics 2000 for recreational use and for walking the dog. The podiatrist then demonstrated, and the patient practiced, very specific calf stretches. It was advised that she refrain from eccentric loading exercises such as heel raises. She was advised to refrain from walking in Skechers, ballet flats and thongs. She was also advised that walking barefoot was bad for patients with Achilles tendonitis. She was instructed to apply ice packs to the affected area every evening before bed for approximately 30 minutes. The podiatrist also informed the patient that she would receive Shock Wave therapy treatment during this initial consultation and would be coming back for more Shockwave therapy sessions over the next two weeks. Due to the poor blood flow into the Achilles tendon, patients with Achilles tendonitis usually recover more quickly with the use of Shockwave therapy. 2000 reps of Shockwave therapy were applied at a rate of 7 HZ and 2.4 bar of pressure. This was gradually increased to 2.8 bar and was well tolerated by the patient. As usual, the patient reported less pain from the Achilles tendonitis immediately after the treatment. One week later, the second treatment of Shock Wave therapy was conducted, and the patient tolerated 2.9 bar of pressure at a rate of 7 Hz. At the third appointment the patient was treated with 2000 reps of Shockwave therapy at 3.1 bar pressure and 10 Hz.

Progress

The patient reported that her pain level at the first appointment, on a scale of 1 to 10, was approximately 8 out of 10. At the second appointment she reported that the average pain level was 6 out of 10. At the third appointment, following the third session of Shock wave therapy, she reported that her average pain level from the Achilles tendonitis was only 3 or 4 out of 10. The patient was advised that the treatment could now stop and that over the next few weeks there would be further healing. The patient was informed that she must continue to stretch out calf muscles, apply ice packs, and continue to use supportive footwear mentioned above.

6 Week Follow Up

After a further 6 weeks the patient returned for a check up of her Achilles tendonitis. She reported that the pain had gone completely and she was able to walk comfortably without soreness. On palpation, there was mild pain as the podiatrist assessed the Achilles tendon but the pain level was acceptable and not uncommon. The patient was informed that she could resume normal activity and commence the use of more regular and less functional footwear. She was advised to return to the podiatrist if her symptoms returned.

Please note, the information contained in this case study is specific to one particular person with Achilles tendonitis. If you have foot pain or if you think you have Achilles tendonitis you should seek the help of a suitably qualified sports podiatrist or other healthcare practitioner.

 

Written by Karl Lockett