Case Histories: Achilles Pain in a Triathlete (Biomechanical Approach)

• 

  Richard Blake KRM team

  1/7/24, 7:17 PM

  All answers at the end of the blog post

   

  Achilles Pain in a Triathlete

  

  History and Chief Complaint

  • While training for his first Ironman Triathlon in Kona, Hawaii, this 40 year old man began developing bilateral achilles soreness with the right much worse than the left. 
  • He had participated in several half Ironman in his 30s and had taken a year off work to train for this event
  • It started while swimming laps with long fins, but had gradually progressed to running.
  • Only cycling was non painful at the time of the office visit, although he was trying to stay on the seat and not do too much hill work
  • A week before the visit he noticed pain walking, and he has had morning soreness from day 1 arising from bed
  • There does not appear to have swelling
  • If he tries to run, the soreness comes on at the 2 mile mark and just gets worse
  • Definite bouts of achilles issues in the past which were always easy to treat with icing, limited rest, and stretching

   

  Question #1: When you hear the word bilateral from the patient, why does that typically lessen your anticipated severity of the injury?

   

  Gait Evaluation

  • Limping slightly after sitting in the office, but this disappeared quickly
  • Running shoes were zero drop Altra Olympus
  • Moderate overpronation right greater than left (he was right handed) also worse running versus walking
  • Slight limb dominance to right (opposite of what you expect if he was favoring his much sorer right side)
  • Greater internal patella rotation also right

   

  Question #2: The worse side is on the right, and the pronation is worse on the right. What side is the longer leg based on 2 observations so far?

   

  Physical Examination

  • Palpably sore in the zone of ischemia 2-5 cm above the achilles attachment right greater than left
  • Only the right side was swollen
  • No achilles tightness noted
  • Could easily do single heel raises 2 position but only tested to 5 due to bilateral soreness

  Question #3: This is another patient stating no swelling on historical review, only to have some on physical examination. What is the significance of the achilles zone of ischemia?

   

  Cursory Biomechanical Examination  and Asymmetry Noted

  • Limb dominance right with ⅜ long right leg
  • RCSP 8 everted right and 2 everted left
  • AJDF right side 17 knee straight and 28 knee bent with left side 14 knee straight and 20 knee bent
  • Weak External Hip Rotators both side
  • Forefoot Varus 12 degrees right and 7 degrees left
  • Bilateral Tibial Varum 4 degrees

   

  Question #4: Is the achilles complex too tight or too loose based on the measurements above (both imply weakness based on Force Length Curves)?

   

  Tentative Working Diagnosis 

  • Right greater than left achilles tendonitis

   

  Question #5: How do you differentiate between Grade l, ll, and lll achilles injuries?

   

  Common Differential Diagnosis (2ndary Working Diagnosis)

  • Right Achilles Tendinosis suspected

   

  Question #6: Would the history and physical examination imply Grade ll or Grade lll?

   

  Occam’s Razor and Rule of 3

  • Simplest solution is achilles strengthening since already too flexible (normal AJDF 10-15)
  • Rule of 3 looks deeper into the biomechanics of the stresses on the achilles. The obvious changes we can make for less stress on the achilles are: no fins during swimming due to the torque on the achilles, change to traditional running shoes with 14 mm heel drop and add heel lifts, and begin to correct the over pronation (due to the patient’s goal custom orthotic devices to be made with varus canting)

   

  Question #7: Ideally you want to align the heel with the tibial varum to find neutral rearfoot functioning. After your dispense of custom orthotic devices, where would you want to find RCSP standing on the orthotic devices (called OCSP or Orthosis Calcaneal Stance Position)? At least you want to move in that direction. 

   

  What Phase of Rehabilitation?

  • Re-Strengthening (no need to Immobilize and not ready to run as part of Return to Activity)

   

  Question #8: This is why an MRI is crucial for many of these cases. Grade l almost never has to be immobilized, and Grade ll the majority of cases need some form of Immobilization. How does this align with our Tentative Diagnosis?

   

  Should We Image?

  • Getting an MRI now for the swollen right achilles makes sense due to the patient’s goal 

   

  Question #9: Can a partial tear of the Achilles tendon be diagnosed on ultrasound like an MRI?

   

  First Decision: How to Reduce Pain 0-2

  • Physical Therapy could be started right now to begin to bring down the inflammation 
  • Ice Massage 5 minutes to each achilles 3 times a day
  • No barefoot as stay in elevated heeled shoes as much as possible
  • Cycling should not be increased, swimming with limited foot kicking or buoy between ankles, no running for now, and limited walking (consider a cam walker for walking if the pain over 0-2)

   

  Question #10: Many times the goals of the first two decisions are the same, except the first decision is more mechanical in this situation. Why do heeled shoes help achilles problems?

   

  Second Decision: Inflammation Concerns

  • Ice, PT, and NSAIDs

   

  Question #11: Is ultrasound or electric galvanic stimulation (EGS) best for inflammation? 

   

  Question #12: How is iontophoresis used for inflammation, both electrical and non-electrical?

   

  Third Decision: Any Nerve Component?

  • Not apparent

   

  Question #13: What nerve is mainly involved with achilles injuries?

   

  Question #14: What disc is involved in achilles pain caused by neuritis? Hint: There are two equally good answers.

   

  Fourth Decision: Initial Mechanical Changes

  • Started the patient with two ¼ inch heel lifts and told him to switch shoes to Brooks Beast for higher heel and pronation control (this was done on both sides)
  • An extra ⅛ inch sulcus length lift given to the short left leg
  • Achilles taping was to be taught by the PT with KinesioTape, and probably advanced in tension to Leukotape
  • Patient told to schedule an orthotic casting. Inverted Orthotic Technique to be utilized due to the highly everted heel that I want to set more vertical

   

  Question #15: What is the starting position of the Inverted orthotic device if the patient is 8 degrees everted?

       If we look at the mechanical checklist from Chapter 7, we can get more ideas to help him through his rehabilitation. 

  Common Mechanical Changes for Achilles Tendon Injuries

       1.  Cam Walker 

       2.  Stretching for both gastrocnemius and soleus 

       3.  Strengthening for both gastrocnemius and soleus

       4.  Heel lifts to take some pressure off the tendon

       5.  Athletic shoes with heel elevation if possible

  6. Avoid negative heel positioning and stretching (where the heel is lower than the front of the foot)

        7.Correction of varus or valgus heel positioning if present

        8.Taping to support the Achilles 

  9. Rigid AFO

       Luckily for this athlete the MRI was negative for any acute tears, but the right achilles was thicker than normal indicating repeated stress on the achilles. The physical therapy and biomechanical changes helped ease the stress on the achilles. Just prior to the Triathlon, in which he both competed and completed in 2014, he remained over flexible in the achilles although improved. 

  The progression of the treatment was:

  1. Work on strength, biomechanics, and inflammation during the first 2 months (during this time both modified cycling and swimming allowed)
  2. During the next 2 months, the strength gains continued and a Walk Run Program initiated.
  3. During the final 2 months, his running progressed to 8-9 miles with taping. Amazingly at the time of the Ironman, he completed the 26.2 miles without achilles pain only extreme fatigue. 
  4. An important point during these 6 months he was never allowed to push the pain over 0-2 to ensure safe progression.
  5. Another very important point is that it was safe to dispense a 35 degree Inverted right orthotic device and 15 degree Inverted left orthotic device since he was not running at the time (it would be dangerous to dispense corrective orthotic devices at a time he was increasing his running)

  Answers to the Questions in this Blog Post:

  1. The word bilateral typically points to overuse and not an acute injury. It is rare to injury a body part severely on both sides at the same time.
  2. Long right side
  3. Achilles zone of ischemia (2-5 inches above the calcaneal attachement) is an area of poor blood supply. 
  4. Both the gastrocnemius and soleus are over-flexible
  5. MRI--Grade l just inflammation, Grade ll partial tearing, Grade lll complete tearing
  6. The gradual onset of symptoms and the ability to run 2 miles painfree points to Grade 1 Achilles Tendonitis.
  7. 3-4 Degrees Inverted
  8. Grade 1 tendon injury is an "itis" and needs no imaging. Grade 2 or 3 implies partial to complete rupture and imaging should be done.
  9. Ultrasound can accurately diagnose tendon tears either partial or complete
  10. Heeled shoes mean that the achilles does not have to dorsiflex as much during midstance, therefore less tension on the achilles.
  11. EGS
  12. Iontophoresis drives topical cortisone into the tendon 
  13. Sural
  14. L5SI and S1S2
  15. 35 Degree Inverted to gain 7 degree correction or your lab's equivalent
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