Case of the Week 10-3-11: The Achilles Tendinosis With the Weakest Link Being the Original Provider
Subjective: MOI was getting hit by a grocery cart 1.5 years ago in the left achilles. This resulted in pain and swelling with no real change or improvement. This was worsened by the same accident happening two weeks prior to the evaluation. She currently c/o achilles pain that has been worse since getting hit by the second shopping cart, rated 5-7/10 on average. Her complaints are worse with lifting heavy objects, stairs, and walking prolonged distances. She had been seeing a new podiatrist for the past two weeks. He told her to place her entire left lower leg into a bucket of ice water for 30 MINUTES at least once a day. He also had her wearing a compression sleeve but took out her arch support in her left shoe to fit it in. This caused her right hip to hurt. The compression sleeve didn't have it's own arch support.
Sigh... just when I told my current intern, "Sometimes I think I will run out of things to write regularly." A patient gets advice that just baffles me. She told me her foot was literally cold for the remainder of the night after the ice bath. Similar treatments are done, only they're typically used in studies involving pain tolerance, with most subjects falling well short of the 30 minutes she was supposed to do.
Observations: increased width and posterior girth of left Achilles compared to right, this was diminished currently as she had just taken off her sleeve. The sleeve however, cannot change the increase in infiltrate and nature of the tendon away from organized type 1 collagen. The patient also had increased pronation in static standing that worsened during mid-stance to terminal stance in gait.
Ankle Dorsiflexion Left 0/hard end feel Right 8/firm end feel
Passive accessory motion: grade 1 severe restrictions in left talocrural posterior glide, calcaneal rock bilaterally and distraction.
Myofascia: moderate restrictions in left calf posteriorly and superolaterally. This is a common area of restriction I find in many lower quarter dysfunctions. Lack of separation/muscle play in medial and lateral anterior Achilles from posterior tibia.
Assessment: Signs and Sx consistent with chronic achilles tendinosis with accompanying joint and soft tissue restrictions.
Treatment: TASTM to posterior calf, followed by subtalar distractions and posterior glides. For HEP, eccentric loading of left achilles on a step 20 reps, as slow as possible, 1-2 times/day. I use the Alfredson Study's findings and augment them with manual therapy. I find that it speeds along the recovery.
Follow up #1: Pain is less intense and stairs are less painful. TASTM to gastroc/soleus, medial/lateral anterior achilles/posterior tibia, thrust distraction of talocrural joint followed by posterior glides. Dorsiflexion was improved to 5 degrees, still hard end feel. Reviewed eccentric loading protocol.
I'll keep you updated! Try eccentric loading for other chronic tendinosis conditions like lateral epicondylagia, and rotator cuff issues!