TA probs that just wont go away

[physiogeneve]

This is a colleague in the pilates world who does not know what to do next. My thought was Podiatrist/biomechanical review . Any other suggestions or referral to good Ankle specialists of any specialty (physio/Dr/Podiatrist) etc to help her.

This is her explaination for what has happened. i am only advising her as a friend and not as a practitioner.

Indications of: retrocalcaneal bursitis seen in the UltraSound, the MRI shows achilles tendinopathy and degeneration in the achilles with a large piece of scar tissue between the achilles tendon and the calcaneum. We are about to do another ultrasound (October 20th) to see if the achilles is attached to this scar tissue thereby limiting it’s physiologic gliding capacity. Eight months no improvement.

History:

Ø 1977 Laterally sprained ankle, continued to dance (on tour) for 6 weeks.

Ø 1978 Operation (Evans procedure) on subluxating peroneals, deeper groove created in malleol to better accommodate the peroneals. Bone spurs removed. Achilles tendon sectioned lengthwise to use to tie up the peroneals. (This is all I can remember of my conversation with Dr. William Liebler at Lenox Hill Hospital in New York City).

Ø 1978 (six months later) Repeated for better tracking of the peroneals which still subluxated. Doctor Liebler hoped to give me maximum stability with sufficient plantar flexion to maintain a good “point” for ballet. I feel he succeeded.

Ø 1979-1988 Continued to dance full time classical ballet with markedly different dorsiflexion between the two feet. The heel never touched the floor while being a “jumper”, producing chronic tendonitis in the achilles during those eleven years.

Ø 1988 Tore the plantar fascia from taping too tightly (not by me !) implemented for the chronic conditions of inflammation during past 10 years.

Ø 2000 Plantar Fascitis, improved with orthopedic insoles. Used only about 6 months, no problem afterwards.

Ø 2006 February, following a slight heel irritation in boots ( a couple of hours only - boots were thrown away) retrocalcaneal bursitis developed, until the achilles became tender and medial and lateral sides of heel tender and inflamed. This is not your standard achilles… after all the surgery and years of tendonitis.

The condition has worsened despite a multitude of alternative therapeutic approaches.

Ø Techniques implemented:

Manual: Chiropractics, massage, deep massage (SOMA), acupuncture, night splint, AirCast for plantar fascitis/achilles tendon pump BioResonance, myofascial treatments. Crutches for two weeks. Ultrasound, MRI.

Medicinal: homeopathy, oligo-elements, magnesium, BioSet Soft Tissue enzymes, ice, moxa, rest with crutches. Injection of anaesthetic into retrocalcaneal burse without diminution in pain, actually augmentation of pain! The doctor doing the injection noted the hardness of the tissue when trying to insert the needle.

Most effective were deep massage, night splint, myofascia work, ice relieves pain temporarily, but does not improve the condition for any longer than the time it is cold. Ultrasound shows inflammation and the retrocalcaneal burse detaching from the calcaneum, plus significant scar tissue from the surgery. MRI results show the achilles in a degenerative state with a large piece of scar tissue between the tendon and the calcaneum.

I am currently using the Nitro Dur patches directly on the tendon (topical glyceryl trinitrate) following the article in the Journal of Joint and Bone Surgery 2004. The side effects are headaches and nausea (with occasional vomiting). Any ideas there?

Current state: Painful most of the time (burning, electric, knives) at the insertion points in the heel, lateral, medial and posterior sides of the calcaneus, achilles is tender and “fibrous” (lumpy) , and calf spasms. It is has been months since I could even walk at a quick pace much less run, any impact on the heel is very painful. The most pain comes from standing too long. I sleep in a night splint and is nonetheless very painful in the morning. It warms up a bit, then the pain kicks in from standing. Even with the strong massage, the minimal increase in flexibility gained, lasts for a maximum 15 minutes. After sitting down for as little as 5 minutes, standing again provokes the pain equal to what it was before sitting. The pain has increased significantly in the last 2-3 weeks.

My “uneducated” concerns:

Regarding cortisone or cortisone type injections- I am concerned as I understand it augments the likelihood of rupture in the tendon. The suggestion is not to inject the tendon but the area that is the large piece of scar tissue (ultra-sound guided this time). I didn’t use cortisone 30 years ago, so I don’t want to start now… most information says that the achilles have a greater likelihood to rupture after injections. The doctor believes the injection was so difficult as the tissue was very hard, which the MRI shows to be scar tissue and NOT the retrocalcaneal bursa as suspected in the ultrasound. The same contraindications are mentioned for ESWT. (Shockwave Therapy)

What can I expect from surgery in such an old injury? Since the achilles has degenerated and the surrounding tissue isn’t great what are the prospects for full recovery of movement? In surgery, what are the chances of sural nerve damage, infection?

One piece of information: In many of the alternative therapies I tried it was discussed that my poor circulation (vascular) is having an effect, will this have any impact on my recovery? I am 51, post menopausal – which from what I have read, also has an effect as well on tendons….

My livelihood (sole source of income as well), my joy, is movement and teaching, I own a Pilates studio.

[physiobob]

Wow, what an excellent client presentation. Well done.

You know I sat and thought about this for a few minutes and then thing that stands out like a sore thumb is that the focus of the persons complaint is entirely on the achilles area, the area that is damaged because of to much "attention". I would therefore say that doing anything direct to the tendon itself in the calcaneal region is continuing this focus and although there might be some short lived reduction in pain, the actual approach is nothing but a reactive attempt to reduce pain.

I would suggest that in all tendinosis cases that the biomechanics are at fault. Diet and footware are factors but so is personality. We need to look back to the initial causes and look at the chain of events from the spine down in order to look at the stress on the insertion. Also the foot up is considered and we can see orthotics have given her more time but now aren't enough (another reactive measure).

This is most likely a slow moving degenerative condition with a acute episode lying on top (bursitis etc). I would make a thorough biomechanical assessment, especially on the role of soleus in eccentric dorsiflexion (this is bound to be terrible). Hips, glutes etc would all be looked at. We have had some good previous discussion on soleus control and how the affects to achilles. I'll look up the posts and place them below.

I have now added a few of the discussions to the tag system. Click on TAGS in the main menu and then on achilles to look as summaries of the posts. Then click on each post to have a read and gain some insite into the whole achille area.

Best of luck and thanks again for this informative post.

[Lachlan]

From what i have learnt the most important treatments for tendinopathy are strengthening (mainly eccentric) and stretching. Rest and ice are not beneficial. Rest is thought to contribute to the problem as the problem is one of degeneration of the tendon. Tendons respond to load by increasing the collagen production, immediately after exercise collagen production is at its lowest which can explain why tendinopathy is considered a chronic overuse injury (not giving time to allow the collagen production). However as time goes the collagen formation increases and reaches its peak at 4 days after the exercise (although strengthening should be done every 2nd day). Rest will not stimulate this response and the degeneration will slowly continue to occur.

Therefore we can conclude that to restore collagen in the tendon it is important to load the tendon, obviously high load exercises would be used very late in the treatment so initially strengthening using weights is prescribed as they exert a low load on the tendon. As the treatment goes on high load exercises such as running etc can be incorporated but make sure it is alternated along with the strengthening.

In terms of the strengthening; eccentric strengthening is considered much better as it is thought to have an effect on reducing the vascularisation that occurs with tendinopathy but it is important to eventually get to strengthening functionally as it is the eccentric to concentric turnaround which places the most strain on tendons. Pain is not a bad thing while strengthening, a study was done in which eccentric strengthening was done and the patients had to work through the pain and 90% improved.

Imaging such as ultrasound is considered unreliable as there can appear to be pathology but the patient has no pain and there can be pain but there does not appear to be any pathology on the imaging.

[physiosteo]

Hi - I, too, have a very long history of achilles problems and have had the surgery etc etc.
One of the ops I had included resection of the retrocalcaneal bursa and shaving of the Haglunds bump at the back there. It was a nightmare afterwards and just would not settle. I could be wearing a shoe (ouch) and hold my hand six inches away from the back of my heel and still feel the heat of the inflammation. This went on for eighteen months and I was pretty much crippled. Then I had an aprotinin injection! It was miraculous: within hours of having the jab, the inflammation had settled right down. At least it enabled me to work with two feet on the floor again and released me from spending half the night hunting around for a cool place on the sheet to rest my heel.
Yes of course you must examine all the biomechanics involved - but I'm sure you have. And of course you must deal with the trigger points and fascia in the whole leg and hind quarter. But I guess you have. We achilles pro's have done it all!
I have also had autologous blood injections. But that's a story for another day.

[physiosteo]

Oh - I forgot to mention that the other thing that has really helped was the Graston Technique. I don't know where your friend lives in the UK but if she can find a GT practitioner that might be worth a try. (for those of you who don't know, this is a soft tissue techique which is performed with stainless steel instruments) I have a patient who had a dreadful chronic bursitis, had surgery on it, but only really got sorted out with GT.

[mageshanand]

Hello there physio geneve,

i have a suggestion try it out and see if it helps,

i want you to tape the ankle/calf/calcaneum, not the regular taping that is done for plantar fascitis,

this time i want you to splint the calf muscle with the tape,

here is how you should do it,

place the foot in around 15 - 20 degrees plantar flexion from neutral, apply the tape vertically extending from the bottom of calcaneum till the gastroc muscle bulk, probably till the origin, apply arould three tapes one for the lateral bulk, the other one medial bulk and the third central, and then apply the regular tapes to stabilize the applied tapes,

i expect the tapes to splint then gastrocs and the tendon from further rupture or minor trauma while walking and the tapes will infact help her to propel forward while walking which would demand less muscle work as well,

Do not be worried about the calcium deposits inside and the fear of these tapes causing more injury, get back to me once you see the results we will discuss further on this..

[physiogeneve]

This lady has tried everything including the taping. In fact one of the problems is that she is too well informed and in my opinion is over focused on the condition.
Having said all that she has finally decided to go down the surgery route as her pain is 24 hours a day. She tells me now that she has not put her heal down for 20 years following her original Evans procedure.
I am not formally treating her instead acting as another source of information.

I just hope the tendon lengthening technique suggested is going to be the answer. I do feel that she has gone past trying all the manual techniques, biomechanics and medication. I will reply with the outcome of the surgery for interest on the forum.

Many thanks for all the information sent through from all experiences (clinician and/or personal).

[mageshanand]

well ok thats sounds alright, actually i would be happy if you can also let us know, what role the surgery has got to do with this pain...!

[physiogeneve]

From what I can understand the tendon has been ultra sound scanned and reviewed structually and functionally. The feeling is a tendon that is so short is affecting the biomechanics of the foot and the fear is that firstly it will rupture if they try to "chemically" break down the fibrous tissues and secondly it is compromising the bursae/synovial tissue.

In all honnesty I feel the pain cycle has to be broken and so far manual techniques have not done this. I always think very carefully before surgical intervention but may be in this case with a good surgeon and proactive rehab post op we will see a change. The jury for me is out on this one. I hope the procedure correlates with a reduction in pain. I will update the forum with the outcome.

[physiobob]

Yep I agree. I suppose wish her luck. One would have thought that a good old heal raise would have worked if one considers that the lengthening procedure would as well? That said the structural issues with tendinosis are still unclear:- less type 1 collagen, proliferation of blood vessels into the tendon structure, increase neural sprouting into the same etc. The research I believe has shown then pain can be present with and without any of the aforementioned issues and so no one is considered to account for chronic pain.

I think what we do know is that these tendons functionally are weak. She may or may not also have neural issues and trigger points in the soleus and surrounding structures. If she were mine I would make a deal that we would first of all really go to town on the strengthening aspect with proper weights training/ weighted jacket to get the tendon behaving more like a tendon. I would work on any trigger issues as the same time, I would ice following every workout and I would record pain levels using a simple VAS (visual analogue scale). Only after this fails would I resort to surgery but that should be with a solid rationale for what they are going to do and why?

Seems like she may have tried the above so lets see what the surgery discovers? Tell her she is a great case study for us all right now