Chronic painful injuries of the Achilles tendon are relatively common in athletes, especially among runners.1–7
The annual incidence of Achilles disorders in top-level runners has been reported to be between 7% and 9%.2
In such cases, overuse is generally considered to be the inducing factor, however, the exact pathogenesis has not been demonstrated.1–4
Postulated alternative theories include poor vascularity, diminished flexibility, heredity, age, gender, as well as endocrine and/or metabolic factors.3,6
Realistically, the pathogenesis is likely a combination of multiple intrinsic and extrinsic factors.2
Alfredson (2005) theorizes that physical activity may be involved with provocation of symptoms as opposed to acting as the primary cause of the pathology.4
The lack of a conclusive pathogenesis for chronic achilles tendon disorders has resulted in considerable debate regarding the diagnostic terminology used in the literature.1–3,5,7,8
The terms “tendinitis” and “tendonitis” have been used, despite the absence of scientific evidence indicating inflammation.1–4
Under diagnostic ultrasound (DxUS) and magnetic resonance imaging (MRI), tendons exhibit a localized area of structural degeneration which has provoked the use of the term “degenerative tendinosis”.5
Recent investigations have indicated that the morphology of tendinosis involves changes in collagen fiber structure and arrangement, an increased amount of interfibrillar glycosaminoglycans (GAGs), and local vasculo-neural growth (neo-vascularisation) within the tendon structure.4,5,9
Alfredson (2003,2005), an authority on achilles pain disorders, states that it is now common opinion among investigators and clinicians that for chronic pain symptoms arising from a tender area of mid-substance tendon tissue, the term “tendinopathy” should be applied. Alternatively, when chronic pain symptoms are combined with diagnostic imaging showing changes in tendon fiber structure, arrangement, and/or evidence of local neo-vascularisation (via colour doppler ultrasound), the term utilized should be “tendinosis”.4,5,8
These terms could simply be interpreted as representing an academic continuum of severity and/or chronicity, with the former indicating a less progressed, and therefore less severe stage. This is an important distinction when developing a plan of management, as approaching treatment with the sole purpose of reducing inflammation is unlikely to resolve the condition as seen with the use of anti-inflammatory agents for chronic tendinopathies.10
Terminology aside, clinically determining the diagnosis of chronic Achilles tendinopathy via comprehensive patient history and physical exam is typically not difficult.
This report will describe the clinical presentation and treatment of a case of chronic Achilles tendinopathy which resulted from repetitive athletic activity (running). This case is of particular interest due to the rapid and successful patient response to a treatment plan incorporating an active and passive tissue warm-up, followed respectively by soft tissue mobilization utilizing both Graston Technique® (GT®) and Active Release Techniques® (ART®), eccentric training, and static stretching in combination with cryotherapy. The report will provide an overview of symptomatology, rationale supporting the management strategy, and expected outcomes associated with the diagnosis of chronic Achilles tendinopathy.
A 40-year-old physically active male presented with intermittent bilateral Achilles pain of approximately 3.5 years duration which initially was felt in the right Achilles following a 7-minute dash in street shoes. Later, the patient began to notice an achy stiffness first thing in the morning, when starting to walk after prolonged sitting, and during the beginning of a regular fitness jog (10 km). The symptoms started out relatively mild and intermittent depending on activity level. Approximately six months later, the patient began training for a marathon and greatly increased the volume of running. During this period, the symptoms in the right Achilles gradually worsened, and the left Achilles began to exhibit similar symptoms. Approximately four months later, the stiffness and discomfort progressed to the point where the patient was limping while walking and was unable to continue training for the marathon. The patient then felt it was necessary to seek care. Orthotics were obtained from a chiropractor, a topical anti-inflammatory from a primary care physician, and physical therapy which included rest, therapeutic ultrasound, general massage, basic calf stretching, and needle acupuncture. The patient attended 10–15 physiotherapy sessions, 10 massage treatments and stated that the sessions provided only temporary relief, as the symptoms would re-occur with even light physical activity. Six months after the initiation of treatment the patient no longer pursued the goal of running a marathon, had greatly reduced his physical activity, and discontinued the physiotherapy sessions due to no evidence of long term improvements.
After almost a year of reduced activity and self-care, during which time the symptoms lessened but did not resolve, the patient then attended the author’s clinic. The patient characterized the pain (present in both achilles tendons but slightly worse on the left) as a bothersome “stiff, achy painful” sensation, with an intensity rating of 6–7 out of 10 as reported on a numeric pain rating scale (zero indicating “no pain” and 10 equalling the “worst pain ever”). Pain was described to be worse in the morning, and after prolonged inactivity, but too much activity also aggravated the pain. Based on self-report, the patient was able to run short distances of not greater than 5 km, but both Achilles were always very painful afterward. The patient had no previous history of significant foot or ankle injuries, related surgeries or traumas, medication or supplement use, and was a non-smoker and non-drinker. As an information technology manager, the daily job demands involved sedentary activities. Systems review and illness history was non-contributory.
Gait and postural observation were unremarkable. Physical examination revealed bilateral Achilles tendon pain induced by palpation which was slightly worse on the left. Upon visual inspection, the left tendon was mildly red, showed no evidence of ecchymosis and also exhibited a visual and palpable enlargement of the mid-substance tendon, just proximal to its insertion at the calcaneus. Mild pain in both tendons was provoked with resisted plantar flexion, passive dorsiflexion, and with bodyweight heel raises. Bilateral palpation of the posterior calf muscle complex subjectively revealed tightness and tenderness in the following muscles; soleus, flexor hallucis longus, flexor digitorum longus, and tibialis posterior. Orthopedic lower limb joint provocative testing indicated normal ligament structure and joint function. Chiropractic evaluation of lumbar, sacroiliac, knee, ankle mortis, subtalar, and tarsal joint motion were within normal limits. Neurological and vascular functions were likewise determined as normal.
Following the examination, the patient was diagnosed with chronic bilateral Achilles tendinopathy. The plan of management included two in-office treatments per week for three weeks, followed by one session every seven to ten days for an additional three sessions. Therefore, the patient received a total of nine sessions over an eight week period. The treatment plan (see ) began with active and passive tissue heating accomplished by five minutes of heat pack application in combination with stationary cycling (see ). This was followed respectively by GT®
(see ) and ART®
(see ) applied to the affected muscles of the posterior leg (gastrocnemius, soleus, plantaris, flexor digitorum, tibialis posterior, and flexor hallucis longus). Slow eccentric calf lowering exercises (see ) were performed after the soft tissue mobilizations utilizing the sets and repetitions prescription consistent with previously published protocols.17–22
Finally, static gastrocnemius and soleus stretching was utilized in conjunction with ice pack application (see ). The patient was also required to follow a specific protocol of home therapy which included ice application, calf stretching, and eccentric heel lowering exercises (See ). The patient was instructed to maintain his current level of physical activity, but not to increase it. During re-evaluation on the sixth visit, the pain level was reduced to 3–4 out of 10 (a 50% improvement), and Achilles discomfort was experienced less often in the mornings, as well as during and after running. Upon conclusion of the plan of management, the patient reported minimal discomfort in the Achilles tendons when squeezing or rubbing them, little to no discomfort with running, no pain with activities of daily living, and a pain level of 0–1 out of 10. Resisted plantar flexion and passive ankle dorsiflexion was non-painful. The patient considered the condition to be almost completely resolved and was thus discharged with instructions to continue with the home therapy protocol for an additional three weeks and to incorporate the eccentric calf lowering exercises into a regular training routine.
Active and passive tissue warm-up utilizing a heat pack in combination with stationary cycling.
Graston Technique® performed on the Achilles tendon.
Active Release Techniques® performed on the gastrocnemius muscle.
Eccentric calf strengthening exercise. a) Start position, b) End Position.
Static stretching with ice pack application. a) Gastrocnemius stretch, b) Soleus stretch.
Patient Home Therapy Protocol
During follow up seven months later, the patient reported equal or perhaps slight improvement over the discharged status. Orthopaedic and manual muscle testing were non-provocative and the patient reported a pain level of 0–1 out of 10. It was also noted that the weekly training routine was altered to include cross-training activities (cycling, swimming, circuit training, weights, yoga), and therefore the load on the Achilles was perhaps less than when training for a marathon, but significantly more loading than when the patient initially presented for therapy. The change in exercise pattern to include alternative forms of exercise may have also contributed to the overall improvement in symptoms. In summary, the patient reported to be at, or near, pre-injured physical status with the only residual symptom being a non-painful thickening of the Achilles tendons which was more pronounced on the left compared to the right.