Achilles Pain in a Triathlete (based on a 14 point workup protocol)
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.
- Kona Ironman was 6 months away
- 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 affect his running.
- Only cycling was not 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 did 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
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
Physical Examination
- Palpably sore in the zone of ischemia 2-5 cm (about 1.97 in) 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 positions but only tested to 5 due to bilateral soreness
Cursory Biomechanical Examination and Asymmetry Noted
- Limb dominance right with 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
Tentative Working Diagnosis
- Right greater than left achilles tendonitis
Common Differential Diagnosis (Secondary Working Diagnosis)
- Right Achilles Tendinosis suspected
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 (about 0.55 in) 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)
What Phase of Rehabilitation?
- Re-Strengthening (no need to Immobilize and not ready to run as part of Return to Activity)
Should We Image?
- Getting an MRI now for the swollen right achilles makes sense due to the patient’s goal
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 (clogs should feel good around the house)
- 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)
Second Decision: Inflammation Concerns
- Ice, PT, and NSAIDs
Third Decision: Any Nerve Component?
- Not apparent
Fourth Decision: Initial Mechanical Changes
- Started the patient with two . inch heel lifts and told him to switch shoes to Brooks Beast for higher heel and pronation control
- An extra inch sulcus length lift given to the short-left leg
- Achilles taping was to be taught by the PT with Kinesio Tape, and advanced in tension to Leukotape
- The patient was 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 If we look at the mechanical checklist on achilles injuries, we can get more ideas to help him through his rehabilitation.
Common Mechanical Changes for Achilles
Tendon Injuries
- Cam Walker
- Stretching for both gastrocnemius and soleus
- Strengthening for both gastrocnemius and soleus
- Heel lifts to take some pressure off the tendon*
- Athletic shoes with heel elevation if possible*
- Avoid negative heel positioning and stretching (where the heel is lower than the front of the foot)
- Correction of varus or valgus heel positioning if present*
- Taping to support the Achilles*
- 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:
- Work on strength, biomechanics, and inflammation during the first 2 months (during this time both modified cycling and swimming allowed)
- During the next 2 months, the strength gains continued, and a Walk Run Program initiated.
- 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.
- A crucial point during these 6 months he was never allowed to push the pain over 0-2 to ensure safe progression.
- Another especially crucial 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 (KevinRoot accomplishes the equivalent of a 35 degree with 15 degrees Inversion, 4 mm Medial Heel Skive, and 2 degree RF and FF varus extrinsic posts)
It would be dangerous to dispense corrective orthotic devices at a time he was increasing his running
