1. ACHILLES TENDINOPATHY
CLINICAL CASE CONDITION: DANIELLE LAWSON, SPT

2. What is Achilles Tendinopathy?1,2
24% of athletes develop the condition2
An estimated 50% of runners will experience Achilles pain in their running careers2
An irritation of the Achilles tendon, a thick band of tissue along the back of the lower leg that connects the calf muscles to the heel.
Occurs when the demand placed on the tendon is greater than its ability to function.
Injuries can occur after 1 episode (acute injury) or after repetitive irritation or “microtrauma” (chronic injury).
Males versus females statistics, investigated in The Journal of Strength and Conditioning Research
Supported by Move Forward and APTA
Males experience 89% of all Achilles tendon injuries1,2

3. Graded based on the amount of damage to the tendon
Grade 1: mild strain, disruption of a few fibers. Heals with conservative treatment
Grade 2: moderate strain, disruption of several fibers. Heals with conservative treatment
Grade 3: complete rupture, requires surgery

4. What causes Achilles Tendinopathy?
Ankle stiffness, calf tightness, calf weakness, abnormal foot structure, abnormal foot mechanics, improper footwear, a change in exercise routine or sport activity
How can a physical therapist help?
Physical therapy will address issues such as pain or swelling of the affected area, and any lack of strength, flexibility, or body control

5. Case Report: Henry Allessandrini
23 year old male, height 6’2”, weight 185 lbs, BMI 23.75
Referred to PT for left grade II insertional Achilles tendinopathy, suspected result of half marathon training that began 2 months ago
Chief complaint: patient reports weakness, stiffness, and 7/10 pain on posterior left ankle. ADLs manageable but with increased symptoms. Unable to stand >60 minutes w/o taking a break.
PROM dorsiflexion
Left ankle 0-5 firm end-feel
Right ankle 0-15 firm end-feel
Strength: gastrocnemius and soleus
Single leg heel raise/Ankle plantarflexion
3/5 left with 2 reps
5/5 right with 25 reps
Fatigue and loss of balance noted with left ankle

6. Case Report: Henry Allessandrini5,10
Figure 8 for edema
5 cm positive L ankle swelling in comparison to R ankle
Posture
Unequal weight distribution noted with L foot pronation, L internally rotated lower extremity, and L downward hip tilt
Palpation
Pain and tenderness reproduced on posterior L ankle

7. Case Report: Henry Allessandrini
Patient goals:
Return to half marathon training 5 days/week running ~6-13 miles on inclined concrete surfaces
Work through an 8 hour shift squatting, digging, lifting trees and equipment without taking breaks every 60 minutes
Drive pick-up truck to and from work 2x/60 minutes day without having to stop
8-week rehabilitation main concerns to focus on:
(Manage pain) Equal L and R ankle circumferential measures & diminishment of edema
(Ranging stretching) 0-15 L Prom dorsiflexion
(Build strength) 5/5 L gastrocnemius and soleus
(Endurance) Return to sport in a safe, adaptable, and progressive manner.

8. Intervention Plan7,9
Outpatient therapy 3x/week for weeks 1-3, 2x week for weeks 4-6, and 1x week for weeks 7-8
HEP twice a day 7x/week
WEEK
INTERVENTION
HOME EXERCISE PROGRAM (HEP) 1
Initial examination
Education: RICE, PowerPlay cold and compression wrap, muscle setting techniques, active toe curls to assist with circulation
Determine 1rm Theraband
Pain: soft tissue mobilization
Ranging: 3x15 sec slant board
Endurance cool down: 5 mins stationary/airdyne bike
Pain: L ankle elevation & ice pack 15 mins
Ranging: 3x15 sec standing calf lunges towards wall (wear shoes for support & traction against wall to keep foot in place)
Air ABCS 2x slowly
Towel stretch 3x15 sec
Strength: 3x10 long sitting green Thera-band plantarflexion
HEP strength in week 1 not to involve weight bearing exercises
2-3
10 minutes low volt electrotherapy
Ranging: 3x15 sec slant board (+incline each week)
Strength: 3x10 heel drops—slow bilateral heel raises with eccentric lowering/loading while standing on level surface. One exercise with straight knees and 1 with bent knees (level surface week 2 stairs week 3)
Endurance cool down: 5 mins stationary/airdyne bike low velocity (may lower seat height to increase df)
Pain: L ankle elevation & PowerPlay wrap 15 mins (replace ice pack)
Ranging: Standing calf lunges 3x15 sec
long sitting df towel stretch 3x15 sec
Strength: 3x15 long sitting green Theraband plantarflexion (+5 reps in week 2 +blue band in week 3)
3x10 bilateral eccentric heel lowering on level surface (level surface week 2 stairs week 3)
Every session will include a 5-10 minute warm up and cool down with either soft tissue mobilization/manipulation, low-moderate intensity stationary bike cycling, and/or low volt electrotherapy
As Henry’s strength and range of motion (rom) progresses, advancements will be made through increasing number of repetitions, number of sets, Thera-band resistance strength, added weight packs, and incorporating aerobic and plyometric exercises in the pool and on land. Training on a stationary/airdyne bike will also prove useful for developing ankle endurance musculature.

9. Intervention Plan7,9
Outpatient therapy 3x/week for weeks 1-3, 2x week for weeks 4-6, and 1x week for weeks 7-8
HEP twice a day 7x/week
WEEK
INTERVENTION
HOME EXERCISE PROGRAM (HEP)
4-6
Pain: soft tissue mobilization, 10 minutes low volt electrotherapy
Ranging/stretching: 3x15 sec slant board (+incline/week)
Aquatic therapy (plyometrics and endurance):
3x10 vertical jumps (bilateral week 4 unilateral weeks 5 & 6)
20 min water walking (running in week mins +boot for resistance in week 6)
All aquatic exercises progressed with immersion from chest hip (deep water to mid-water)
Pain: Elevation & PowerPlay wrap 15 mins
Ranging/stretching: Standing calf lunges 3x20 sec (+5 sec replace with 1x60 sec in weeks 5 and 6)
Strength: 3x15 long sitting black Theraband plantarflexion (replaced blue band)
3x15 bilateral/unilateral eccentric heel lowering on stairs (+5 reps since week 3 progress to unilateral stance in weeks 5 & 6)
7-8
Pain: soft tissue mobilization , 10 minutes low volt electrotherapy
Stretching: 3x20 sec slant board (+5 sec, same incline)
Plyometrics progressed to land:
3x10 vertical jumps (+ 5 lbs. ankle weight in week 8)
3x10 box jumps (+box height in week 8)
3x5 depth jumps (+box height in week 8)
Endurance: 15 minute treadmill run (+incline in week 8)
Endurance cool down: 5 mins stationary/airdyne bike
Stretching: Standing calf lunges 1x60 sec with banded distraction anterior bias and posterior bias. Drive knee forward and out to side, keeping entire foot in contact with ground, oscillating in and out of end range (prop ball of foot on block in week 8 to challenge more end range df)
Strength: 3x15 long sitting black Theraband plantarflexion
3x15 unilateral eccentric heel lowering on stairs (+5 lbs. ankle weight in week 8)
depth jumps= advanced jumping from box and squatting to absorb shock and then jumping and reaching as high as possible

10. Results of 8 week rehabilitation plan
Case condition results
Literature
Patient is able to resume half marathon training after 8 weeks of physical therapy
Achieved full range of motion in L df with firm end-feel, 5/5 strength in gastrocnemius and soleus, resolved swelling and pain in L foot, & ability to transfer with equal weight distribution
Eccentric heel lowering & loading exercises + progressions incorporated throughout entire program with Therabands and standing heel raises/drops
No longer experiencing pain or stiffness, & able to resume desired training program after 8-week therapeutic regimen2
Eccentric loading regimens for tendinopathy have been widely accepted as the treatment of choice1,6,7
Electrotherapy supplements conservative treatment for Achilles Tendinopathy

11. References
Joseph M, et. al. Achilles tendon biomechanics in response to acute intense exercise. Journal of Strength and Conditioning Research. DOI: /JSC
Mumbleau A. Physical therapist’s guide to Achilles tendon injuries (tendinopathy). Move Forward PT; APTA [serial online]. February 26, Available from Accessed June 21, 2016.
Insertional Achilles Tendinopathy. American Orthopaedic Foot and Ankle Society Web Site. ankle/Pages /Insertional-Achilles-Tendinitis.aspx. Accessed June 21, 2016.
Goom T. Insertional Achilles Tendinopathy. Running Physio Better Faster Stronger Web Site. tendinopathy/. Published July 4, Accessed June 21, 2016.
Magee DJ. Orthopedic Physical Assessment. St. Louis, MO: Elsevier Saunders; 2014 (p.892 referenced in “History” section; p and Ch. 13 referenced in “Systems Review”)
Kadakia AR. Achilles Tendinitis. American Academy of Orthopaedic Surgeons Web Site. Updated June Accessed June 21, 2016.
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques, 6th ed. Philadelphia, PA: FA Davis; (p. 868) (Ch. 22 p. 883, 888 referenced in “intervention plan section”)
Created November 17, Accessed June 21, 2016.
Starrett K, Cordoza G. Becoming a Supple Leopard: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance, 1st Ed. USA: Victory Belt Publishing, 2015 (p. 80)
Alfredson H, Cook J. A treatment alogorithm for managing achilles tendinopathy: New treatment options. British Journal of Sports Medicine Apr; 41(4): doi: /bjsm Accessed June 21, 2016.

12. Questions? Comments? Concerns?