Achilles Tendinopathy

Practice: Resonance Podiatry & Gait Labs

Patient: 47 year old female netball player

The Achilles tendon is the strongest tendon in the body, it joins the calf muscles (soleus, gastrocnemius and plantaris) to the calcaneus. Achilles tendinopathy is a condition causeing pain, swelling and stiffness in the Achilles tendon and is thought to be caused by repeated micro trauma to the tendon. There are two types of tendinopathy – non-insertional where the mid portion of the tendon is affected, usually 2-6cm from the insertion to the calcaneus and insertional this involves inflammation at the insertion of the Achilles tendon to the calcaneus, pain is generally felt directly over the insertion point.

Current Situation

The patient, a 47-year-old female, presented with left side generalised mid portion Achilles tendon pain that had been ongoing for 12 months. The onset of pain was triggered by a return to social netball and umpiring of netball matches. Initially sought physiotherapy treatment, this resulted in improvement of symptoms and less pain, however ongoing residual postgame pain, and morning pain and stiffness of the Achilles tendon remained.

Past Medical History

• Previous left side inversion ankle sprain in 2005

• Recalls a left leg tibial fracture at age 12

Goals

• To play netball pain-free

• Umpire pain-free

• Trek Abel Tasman Track pain-free

Assessment

There was palpable thickening to the left Achilles tendon 3cm proximal to the insertion. There was no heat or swelling present to the site of pain. No pain present with double or single leg serial tip toe test. Weak resupination with tip toe on the left leg.

Biomechanical Examination Findings

There was limited first ray, subtalar joint, and ankle dorsiflexion range of motion, left side more than right. Relaxed calcaneal stance in mild varus position left side more than right. The subtalar joint was supinated on stance.

Manual supination: Decreased resupination on the left side, heel inversion occurring however laterally unstable at end range ankle plantarflexion.

Jack’s Test: Positive. Hard, full windlass functionality available. Single knee bend: Medial knee deviation occurring owing to proximal insufficiencies.

Thomas Test: Rectus femoris tight bilaterally. Iliopsoas slightly tight. Iliotibial band flexibility good.

Hamstring Length: Slightly restricted hamstring 90:90 test. Able to achieve 70 degrees of hip flexion with knee extended on straight leg raise, bilaterally.

Lunge test: Negative, bilaterally. Left: 7 cm Right: 8 cm.

Biopostural Assessment Overview

Static Pressure: The body's centre of gravity is decentralised, shifted laterally to the left side. Left side mild hyperloading, 57%. Maximum load concentration in the left forefoot, excessive load concentration. Excessive anterior overload, forefoot loading 56% left side. Static peak loading pressure revealed hyperloading in the central forefoot of the left foot.

Dynamic Pressure: Central forefoot yperloading, minimal rearfoot loading; Minimal 1st MTPJ loading bilaterally; Low weightbearing surface area L > R; Minimal lateral midfoot column loading; Dynamic pressure revealed high forefoot loading, minimal rearfoot loading, and minimal first MTPJ loading

Treadmill Video Gait Analysis

There was lateral heel strike on the left side; remains fairly supinated on left side throughout gait. There was a mild medially driven abductory twist, with a lateral toe off.

Video Gait Analysis

Contralateral Trendelenburg occurring during midstance, and consequently quite a lateral low gear toe off. Significant pelvic rotation occurring in the transverse plane. Decreased hip flexion and hip extension bilaterally. Thus, resulting in increased propulsion required from the posterior calf complex/Achilles tendon.

Diagnosis

Overview

The patient's definitive diagnosis is left side midportion (3cm proximal to AT insertion) Achilles tendinopathy, secondary to previous injury and ongoing high impact activity with inadequate proximal and lower limb strength, and insufficient foot mechanics.

Differential Diagnosis Considerations

Achilles tendon partial tear; Retrocalcaneal bursitis; Posterior ankle impingement. Inflammatory arthropathy

Causes

Subjects Risk Factors

Age, Increased BMI, sudden increase in training intensity, training error, inappropriate footwear (Simpson & Howard, 2009), possible family history of AT tendinopathy (Kraemer et al., 2012).

Biomechanical reasons the patients Achilles tendon pain has failed to settle due to the patients supinated foot mechanics on the left side, with limited joint range of motion resulting in decreased sagittal plane facilitation, reduced propulsion, lack of shock absorption, and decreased weightbearing surface area throughout both walking and running gait. Increased AT loading forces owing to laterally driven ground reaction forces, and external rotation forces occurring at the tibia.

Additionally, her proximal weakness and inflexibility is contributing to increased Achilles tendon loading owing to minimal glute max activation and lack of propulsion occurring proximally, forcing her posterior calf complex to compensate.

Treatment

Footwear

Replace netball footwear to a neutral, stable netball shoe with minimal forefoot flex resistance for propulsion, 10mm pitch/drop, comfort, fit and feel.

Formthotics

Dual Density Formthotics customised with bilateral lateral forefoot postings extending from styloid process distally through to webbing, to optimally decrease supinatory forces occurring from early midstance, through to propulsion, and optimally engage the windlass mechanism. Thus, increasing weightbearing SA, increasing shock absorption, and reducing lateral bowing of the Achilles tendon. Research has suggested laterally directed forces occurring at early stance phase of gait with medially driven forces at late stance may be risk factors for Achilles tendinopathy (Van Ginckel et al., 2008). Customised orthoses in conjunction with eccentric Achilles tendon loading programmes are effective in reducing pain in symptomatic patients with Achilles tendinopathy.

Strength Training

Eccentric Achilles Tendon Loading programme-Eccentric strength training, which involves actively lengthening the muscle, is an effective therapy that helps promote the formation of new collagen (Simpson & Howard, 2009). 15 repetitions on the symptomatic leg, performed in 3 sets. Performed with both the knee in flexion, and the knee in extension to maximally load soleus and gastrocnemius calf muscles. Perform this twice per day, every day. For 12 weeks. Increasing load in 5kg increments as dictated by alleviation of symptoms.

Calf stretching to improve ankle dorsiflexion range of motion, as 10 degrees of ankle dorsiflexion is required during the stance phase of the walking gait cycle. Hamstring and gastrocnemius-soleus complex-soleus inflexibility is a diagnostic factor for Achilles tendinopathy (Simpson & Howard, 2009).

Proximal gluteal strengthening - Altered knee kinematics and reduced muscle activity are associated with Achilles tendinopathy in runners (Azevedo et al., 2009). Studies have found there is a correlation between the activation of gluteus maximus and gluteus medius and their impact on the kinematics occurring at the leg and ankle, which can result in increased rearfoot inversion and eversion which is a risk factor for Achilles tendinopathy (Franettovich Smith et al., 2014).

The patient is currently working on proximal strength work of her gluteus medius and gluteus maximus. Stretching of iliopsoas and rectus femoris were also important.

Functional activation - it is imperative the gluteus maximus is optimally functioning throughout walking and running gait, as this controls hip extension. It has been found in the literature that with reduced hip extension, there is increased ankle plantarflexion, and early and excessive plantarflexion moments at the ankle have been found to correlate with Achilles tendinopathy (Frannetovich Smith et al., 2014). Thus, glute max activation can be a crucial proximal component to AT tendinopathy.

Management Plan (Patient Follow Up)

Patient education - Ensure exercises are performed daily for maximum benefit and positive outcomes. Gradual breaking in of orthoses. Appropriate footwear, good footwear parameters for all activities. Modification of exercise regime to reduce risk of overload. Patient review - Patient seen at 2/52, then 6/52 after having orthotics implemented. By this stage, the patient had been working on eccentric loading and proximal work for 8 weeks, and all pain had resolved. The patient continued with the above for a further 4/52, then could discontinue. 12-month review due unless any issues prior.

Goal Related Outcomes

Pain-free during game, post-game, and pain-free the following morning Completed the Abel Tasman Track pain-free

Further Information for Outcome Measures

Pain and Disability measure

The VISA (Victoria Institute of Sport AssessmentAchilles Questionnaire) provides an index to indicate the clinical severity of Achilles tendinopathy. This is a condition - specific numerical scale, which research suggests will typically provide a higher sensitivity and specificity than general purpose scales (Robinson et al., 2001). This is questionnaire completed by the patient which provides a total numerical value out of 100 (100 is the perfect score) based on domains of pain, function in daily living, and sporting activity. The higher the score, the less severe the Achilles tendinopathy. Patients who score 100 are asymptomatic.

PDI (Pain and Disability Index)

This questionnaire measures the impact pain has on the ability of the person to perform essential activities of daily life (Chibnall, 1994). Complex is too tight (https://www.aofas.org/footcaremd/ treatments/Pages/Achilles- Tendinosis-Surgery. aspx).