Follow-up appointment with a patient with chronic insertional Achilles tendinopathy
Duration: 1 hour Cumulative hours: 138.30
Today I was seeing a patient in a follow-up consultation regarding his chronic insertional Achilles tendinopathy. I had inherited this patient from one of my peers. I had sat on his first F2F appointment to observe the consultation so I had knowledge of the case history. The plan today was to check on the patient’s progress with the rehabilitation plan which included eccentric exercises for the ankle to improve the strength of the ankle and the Achilles tendon as per the current evidence-based research (Jonsson, Alfredson, Sunding, Fahlström, & Cook, 2008). He was also prescribed quad extension and hamstring curl exercises with a resistance band to improve strength in the upper limb.
In preparation for the appointment I had researched additional exercises for the glute medius, which I intended to add to the patient’s rehab programme to improve strength in the hip and upper limb. The aim was to improve the patient’s gait, so that his right foot doesn’t turn out. The patient had adopted a compensatory movement pattern initially to protect the left knee after an ACL injury which he did not seek treatment for, and secondly as a result the insertional AT.
When the patient arrived I asked him to complete a VISA-A form. The VISA-A score was 51/100.
The patient’s general health has been good. Although the patient hasn’t kept a pain diary because of his recent work commitments, he has kept a mental note of his pain level. He has experienced the usual early morning stiffness and pain which improves once he gets out of bed and becomes more mobile.
At the beginning of the week the patient had been fairly active walking and hadn’t experienced any issues. The two days before his appointment the patient has been busy working but the movement has been more static. He has noticed that the Achilles has become more niggly and pain has increased to approximately 3-4 NPRS. Home-based exercise (HBE) has been fine and the patient intends to increase the load during the next week with the heel drop exercises.
Knee extension and flexion exercises with the resistance band have also been fine and the patient has increased the load by using a higher strength resistance band. Originally he started with the green band, and is now using the blue band.
I asked the patient to perform a knee to wall test and there was little change from last week’s record: left ankle – 7 cms and right ankle – 7 cms. There was a noticeable change in the thickness at the Achilles insertion point on the left foot – it appeared less inflamed.
I went through the exercise program with the patient and observed an improvement in eccentric strength during the straight leg and bent leg heel drop. We agreed that the load could be increased by adding a weight to a backpack, or a 1 litre milk bottle filled with water. As the patient had already increased the resistance for the banded quad extensions and hamstring curls, we agreed to continue performing the exercises with the blue band.
I added three more exercises to improve the strength around the knee and the hip. The additional exercises were side-lying abduction, lateral band walks, cams and side-lying adduction. This will make the muscles around the knee much stronger to support the knee and improve the strength of the glute med to control the internal rotation of the pelvis when walking.
The patient was advised that he could run but on a soft flat surface such as grass and for short intervals so long as it did not aggravate the injury and increase the pain – 2/10 NPRS was acceptable.
I was very pleased with the patient’s progress and felt that I am slowly building rapport and trust with him. I felt that my positivity about his progression has increased his confidence and hopefully adherence to his rehab. The plan after the Easter period was to progress towards building power by introducing plyometric exercises such as double-leg heel pulses, double-leg pogos and progressing further to single-leg loading.
Home–based Exercise Programme
Eccentric exercises to be performed on a flat surface as follows:
3 sets of 15 repetitions – twice daily, 7 days per week of
- Straight Leg Heel Drop
- Bent Leg Heel Drop
Load can be increased by adding a 1 – 2 litre plastic milk bottle filled with water OR Tins of Beans, or 3-5 Kg weight to a rucksack
Exercises to strengthen thigh and glute muscles
3 sets of 15 repetitions – twice daily, 3 days per week.
- Banded Quad Extensions
- Banded Standing Hamstring Curl
- side lying abduction
- clams
The link below leads to a YouTube video demonstration of the side-lying abduction and clams. Click on the ‘skip ad’ on the right-hand side of the screen. Ignore exercise 2 in the video – https://www.youtube.com/watch?v=B0Nvn_Xcs3I
- Inner thigh raise
This YouTube video demonstrates the above exercise (The bent leg does not need to be so high as demonstrated in the video – just bend the top leg and rest it on the floor, rather than resting it on the foot) – https://www.youtube.com/watch?v=bP9W4-vgSgA
4 x shuttles of side-steps with resistance band on each leg
We discussed running. Please let the pain symptoms that you have experienced the last couple of days, settle down before trying to run. I would advise running on fairly flat, soft ground such as a local field. Keep the running to a minimum as you are gradually building up again – so a couple of laps or lengths of the field should be enough to begin with. As always pay attention to your body’s pain response to any activity. If pain levels rise to 4/10 and above – rest the next day. A pain level of 2/10 is acceptable.
References
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. https://doi.org/10.1136/bjsm.2008.051193
Jonsson, P., Alfredson, H., Sunding, K., Fahlström, M., & Cook, J. (2008). New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: Results of a pilot study. British Journal of Sports Medicine, 42(9), 746–749. https://doi.org/10.1136/bjsm.2007.039545
Areas for further improvement plus action plan
Research plyometric exercises for insertional Achilles tendinopathy. The objective was to include more explosive movements to improve single-leg power and strength.