Patient Case Study:
Subjective: Patient, Pt, is a 53-year-old female who was referred for a 3-year history of right sided Achilles tendinopathy. Pt arrived to physical therapy in a boot prescribed by her physician. Pt reports 7/10 pain at baseline that can increase to 10/10 at its worst when not wearing the boot. Pt mentions that she always uses the boot when weight bearing. Pt describes her pain as stabbing and achy. Pt states that she has a large growth on the posterior aspect of her Achilles. Pt mentions that she has swelling at the lateral malleolus. Pt mentions that using the boot and non-WB help to return her symptoms back to baseline. Pt states that she has been to multiple trials of physical therapy in the past without improvement in symptoms and function. Pt’s goals for physical therapy are to ambulate without the boot and reduce symptoms.
Objective measures on the right:
AROM:
- Dorsiflexion with knee straight = 10 degrees
- Plantarflexion = 65 degrees
- Inversion = 22 degrees
- Eversion = 35 degrees
PROM:
- DF with knee straight = 15 degrees
- Talocrural Eversion = -5 degrees
MMT:
- Dorsiflexion = 5/5
- Plantarflexion = 3/5 (limited due to pain)
- Inversion = 5/5
- Eversion = 5/5
Sensation:
- Unremarkable
Palpation:
- Tenderness along the Achilles tendon.
- Thickened nodule at Achilles tendon about 5cm proximal from the calcareous.
Joint Mobility:
- Grade 1 hypomobility of the talocrural joint into eversion with a hard end-feel
Neurodynamics:
- (+) Straight leg raise
Gait:
- Pt ambulates with a short step length on the right, right knee in excessive flexion during initial contact and mid stance, and a contralateral hip drop on the right.
Treatment:
- Home Exercise Program – Day 1
- Gastrocnemious Stretch – hold for 30 seconds x 3
- Soleus Stretch – hold for 30 seconds x 3
- Eccentric Heel Raises – 20-25 pounds of weight in backpack that she wears during exercise; complete full heel raise with both lower extremities and eccentrically lower on right lower extremity at a 3 second count; 15 repetitions or to tolerance (increase in discomfort during activity with a reduction in symptoms to baseline with rest and discontinuation of exercise for a day if symptoms remain elevated for greater than 24 hours) 2-3 times a day
- Self Joint Mobilizations – mobilization of talocrural joint into eversion for 1 minute a day
- Home Exercise Program – Week 3
- Soleus and Gastrocnemius Stretches
- Eccentric Heel Raises – increase weight in backpack by 10 pounds with the rest of the parameters the same.
- Single Leg Heel Raises – holding two 10 pound weights in hands; complete concentric contraction of plantarflexors and eccentric lowering of heel to ground at a 6 second count; 10 repetitions or to tolerance (increase in discomfort no greater than 5/10 on a pain scale during activity with a reduction in symptoms to baseline with rest and discontinuation of exercise for a day if symptoms remain elevated for greater than 24 hours) one time a day.
Results:
- Pt has a reduction of symptoms to 3-4/10 at baseline, a reduction in size of Achilles nodule upon visual assessment and palpation, ability to complete 25 single leg heel raises on the right without increases in symptoms >5/10 on the VAS, no use of boot during ambulation or throughout the day, but continued increases in discomfort at the end of the day greater than baseline when in bed going to sleep.
Research Studies Used:
(Click on the link for access to the article)
- The purpose of the study was to investigate the effect of a 12-week eccentric rehabilitation program on local collagen turnover in the area surrounding the Achilles tendon in 12 high-level soccer players with chronic Achilles tendon disorders.
- Protocol: Two training sessions daily for 12 weeks that consisted of 15 eccentric repetitions of heel raises on a straight leg (full weight on the injured leg, forefoot on a step, going from maximum heel lift to maximal dorsiflexion, and using the healthy leg to lift back up to maximal heel rise) and 15 repetitions of the same exercise with the knee bent. The subjects were instructed to complete exercises while wearing a backpack containing 20% of their body weight. The subjects were instructed that their symptoms may increase for the first 3-4 weeks. The load was increased when the patient was able to complete the protocol without increased pain immediately after completion.
- Results: There was a significant increase in collagen synthesis after training at the injured tendon. There was no significant increase in collagen degradation when compared to the health tendon. The experimenters found a significant decrease in VAS after the 12-week protocol but did not fully eliminate the pain. All subjects were able to return to sports.
(Click on the link for access to the article)
- Purpose: To evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome.
- Protocol: The exercise training group (n=19) continued without their Achilles tendon loading activities, such as running and jumping, following a pain-monitoring model. The pain-monitoring model consisted of using the VAS. Individuals were allowed to reach 5/10 during activities with 10 being the worst pain imaginable. The pain was allowed to reach 5/10 but should have subsided by the next morning and pain/stiffness at the Achilles was not allowed to increase week to week or the activities were discontinued.
- Results: There was no significant improvements between the experimental group compared with the control/rest group. Both groups showed improvements in outcome measures. There were no negative effects for individuals with Achilles tendinopathy continuing to participate in their recreational activities during their rehabilitation process when using the pain-monitoring scale.
Thoughts: Any thoughts on how to improve the patient’s discomfort that she is feeling at night when in bed or now that she is ambulating, has a reduction in nodule size, and a reduction in symptoms overall, it is a waiting game to let it continue to heal?
FirstAscent Physical Therapy 
My initial thoughts are that if it is a 3 year history then we would already assume that the tissue healing is already complete? I would want to look at PROM DF in WB versus non-WB…so maybe try double limb squat or knee to wall test? And why do you think she doesn’t get more extension during initial contact and MSt of gait? Quad strength?
Good point about the tissue healing. The patient made progress but since the symptoms have not completely subsided she would be considered in chronic pain? I like your thought on the ROM difference in WB and non-WB. What would you expect to see and what would the difference indicate? I think the limited extension in gait is do to protecting the Achilles. I think that keeping the knee flexed limits the load on the Achilles by isometrically contracting as opposed to the eccentric load during tibial progression. That is a good point about quad strength as a reason to maintain in flexion during gait.
in Non-WB you’re looking at MM length as a driver for DF ROM – gastroc/soleus length and not very function vs in WB you can look at the gastroc/soleus length and you can assess compensations like femoral IR, pronation and you also get an assessment of talocrual mobility depending on where they get their symptoms first (ant or post). I’m not quite sure about the eccentric load on tibial progression because in gait we think more of gastroc/soleus and quad controlling tibial progression vs achilles? And please elaborate on knee flexed limits load on Achilles – cause i’m not following that?
That makes a lot of sense about assessing the difference in open and closed chain positions. I will have to use that. Nice thinking outside the box.
I was combining gastroc/soleus with Achilles because if the muscles are activated then the tendon will be affected. The way I perceive and reason out her gait pattern is that the flexed knee also entails a lack of a heel strike because the patient’s initial contact is from a flat foot contact. So the patient does not go from neutral ankle position in initial contact, progresses to plantarflexion and knee flexion during loading response, and leading to knee extension and dorsiflexion from loading to midstance (which would cause an eccentric lengthening of the gastroc/soleus/Achilles complex from the ankle and the knee joints). If the patient maintains that ankle and the knee in a flexed position throughout that then the ankle and foot will not go through it’s rockers limiting the need to activate her problem area. I figure that if the patient maintained her ankle in a certain position during those phases and did not have the excessive knee flexion that I saw I would probably see a stiff-legged gait with ipsilateral vaulting. But I do not recall seeing that but I could be mistaken.
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