Case Presentation: 55 year old female presents chronic pain to left posterior heel for the past 5 years
55-year-old female, presents with chronic pain to the left posterior heel for the past five years. The patient has seen several orthopaedists, podiatrists and physical therapists, but the pain persists, causing a limitation in daily activities and exercise. Patient states that the pain is greatest in the morning, decreases slightly during the day and then increases again at the end of the day. There’s a sharp pain and it’s rated a six out of 10, no associated tingling or numbness. The patient does not recall an acute injury and it’s been a gradual increase over the past five years.
Dr. Emily Splichal quickly presents her thoughts on this case presentation.
I’m obviously very excited that this is a case that involves the foot. [chuckle] So then I can kind of use my podiatry very specific to this complaint. We obviously know that… Sometimes, where the patient presents with pain is not… It can be a little bit misleading if you just hone in on the pain. One thing that I do wanna mention, though, particularly in this patient who’s complaining of mid-tendon Achilles tendon pain. When I look at Achilles tendonitis or Achilles tendinosis in my patients, is insertional tendonitis is treated or is associated with stressors different than mid-tendon Achilles tendonitis. Typically when I see insertional Achilles tendonitis, it’s usually on impact and those patients will present with pain when they’re contacting the ground. I typically look at the patients as far as how their body is anticipating the ground and are they pre activating their stabilizers and their decelerators before their foot contacts the ground. If they have a delay in that preactivation sequencing, then they typically present with that insertional Achilles tendonitis.
When they have mid-tendon tendonitis, then I start looking at their recoil or their catapult effect potential of their Achilles tendon. We know that the Achilles tendon is the largest, strongest tendon in the body and really, it’s that late mid-stance peak loading that stresses the mid-tendon part of the Achilles tendon. So I would be looking at their gait cycle and their movements to see if there’s some sort of compensation or breakdown during that late mid-stance phase or the peak loading phase of the Achilles tendon. As far as the MRI supporting with the clinical presentation of a hypertrophic mid-tendon, then that would make me start thinking about the mucoid degeneration that typically happens in tendinosis. And when these patients present with that tendinosis, I often explain to them that our tissue, our connective tissue needs to be like a rubber band. And when we have inflammation that sits around our tissue for a very long time, here a patient had it for five years. We have five years of inflammation that’s sitting around this tendon. It starts to change the composition of that tendon. It starts to become what’s almost like a dried-out rubber band, is what I’ll give the analogy to my patients. Or if you think about mucoid degeneration, which is classic within an Achilles tendon, the central part of the tendon is almost like mush.
And even though everybody has been kind of going into biomechanical feeders of instability here, something in the upper extremity, pelvic floor etcetera, etcetera. All of that is 100% true and I agree with everybody’s presentation on that. Where I try to look at these patients is I look at it from a local perspective, which is what’s the health of that tendon as well as a global perspective. So correct all of the movement dysfunction that may be existing, but you still have to look at it from a local perspective which means that we have to get that dried-out rubber band like a young, healthy rubber band again and that’s where you’re looking at regenerative medicine. I know Dr. Brandon mentions this a lot where… In my office, I do amniotic injections, there’s bone marrow aspirate PRP. There’s a really good surgical procedure called Tenex Invasive and you essentially… A needle sucks out that mucoid degeneration kind of goop that’s in the tendon, and then you can follow that with doing the amniotic injections, growth factor injections, etcetera. So then you’re getting that tendon to be young and healthy again, so that it then responds to all of these corrective programmings and movement correctives that you’re using on that patient.
So that’s definitely what I would look for. I feel like patients that haven’t addressed the tendon locally, kind of keep hitting their head against the wall in the sense that they’re doing the rehab, and the correctives, and the taping and all of that. And if they’re not getting better or responding to it, then that’s when I start speaking to them about surgery. It could go to the extreme of an open debulking of the Achilles tendon and I would always follow that with the appropriate correctives that everybody has mentioned above. However, because of scarring and all of that, I would do the Tenex procedure over an open debulking if appropriate. And she doesn’t have any tears. Her MRI was negative for partial tears, so then the Tenex procedure would be appropriate for her. And, again, all of the integrative correctives that everyone had mentioned.
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Dr. Emily Splichal DPM, MS, NASM, NSCA-CPT
Dr Emily Splichal, Podiatrist and Human Movement Specialist, is the Founder of the Evidence Based Fitness Academy and Creator of the Barefoot Training Specialist®, BarefootRx® and BARE® Workout Certifications for health and wellness professionals. With over 15 years in the fitness industry, Dr Splichal has dedicated her medical career towards studying postural alignment and human movement as it relates to foot function and barefoot training.