Case Study May 2017 – Sports Podiatrist Performs Injection Therapy as a Diagnostic Technique

Initial Assessment with Sports Podiatrist

A 37 year old male presents to the Sports Podiatrist complaining of Achilles Tendonitis in his left heel of approximately 6 months. He is a keen soccer player and plays at a high, amateur level. He trains twice in the week and competes in a league that play matches on a Saturday. He has ceased all sporting activity due to the heel pain and informs the Sports Podiatrist that he has been seeing a physiotherapist. Several sessions with the physio have provided short term relief and this was achieved by eccentric loading and calf muscle massage. Mr X reports extreme pain first thing in a morning when he walks away from his bed and also pain after long periods of being seated. On occasions he has applied ice packs and once again, this has provided short term relief. Mr X informs the Podiatrist that he has not experienced  acute foot pain like this before, and certainly not anything that had lasted for so long. He takes no medication aside from sports drinks and nutritional supplements around sporting sessions. He has never seen a foot specialist before but was advised by a team member to seek the advice of a Sports Podiatrist.

Foot Assessment by Sports Podiatrist

The Sports Podiatrist carried out a physical examination of both lower legs and feet. With the patient lying prone, there was visible swelling around the posterior aspect of the heel, at the insertion of the Achilles Tendon. Mr X reported pain when mild pressure was applied to this part of his foot. Pain and swelling were noted centrally, but also more medially, into the bursal space. The Achilles Tendon of the left foot was thicker than that of the right and a small nodular area was noted, approximately 25mm from the heel. The Sports Podiatrist applied lateral pressure to the nodule and this also elicited pain, which caused the patient to wince and retract his foot. Calf muscle range was tested and appeared to be good. Range of motion in the joints of the foot and ankle were good and the leg length appeared to be equal. There was no pain in other areas of the foot and ankle.

Diagnosis

The Sports Podiatrist advised the patient that he had Achilles Tendonitis. This related to the nodule that sat 25mm above the heel bone. There was also the possibility of an insertional Achilles Tendinosis and / or a retro calcaneal bursitis around the insertion of the Achilles Tendon, at the bony insertion of the heel. The most reliable way to determine which of these latter conditions were present was to perform Ultra sound or MRI, therefore the Sports Podiatrist wrote a referral.

Bio Mechanical Assessment

With the patient unshod, he was asked to walk on a treadmill. His foot function was observed by the Podiatrist and recorded using digital software. Mr X demonstrated good foot function , just pronating mildly through his left rear foot. When running, he pronated a little more, which is to be expected, and this may have been an influencing factor in the onset of his Achilles Tendon issues. His stride length was long and his heel strike was heavy, both of these factors encouraging further pronation. His left foot was externally rotated in comparison to his right. Again, the Sports Podiatrist advised the patient that this can encourage further pronation.

Sports Podiatrist Treatment

The report from imaging confirmed 3 things: Achilles Tendonitis, Retro Calcaneal Bursitis and a small deep surface tear in the Achilles Tendon.

Due to the severity of pain the Sports Podiatrist fitted Mr X with a full height Immobilisation boot. The patient was unable to mobilise without limp and was extremely tender to palpate and so the boot would allow him to walk pain free. The boot would physically unload the affected areas and allow some of the swelling to subside. Mr X was advised to wear the boot for 3 weeks before returning to the clinic for a follow up with the Sports Podiatrist.

After 3 weeks the patient reported that he was a lot more comfortable and his pain had reduced significantly. Mr X underwent weekly sessions of Shock Wave Therapy and was able to come out of his boot. The Shock Wave Therapy assisted with further heeling and the nodule / Achilles Tendonitis became asymptomatic. The insertional Achilles area also improved but there was residual pain on palpation.

The patient reluctantly joined his team mates and played 60 minutes of soccer due to a player shortage, which caused a flare up in his condition. The pain became excruciating again. The Sports Podiatrist decided to deposit some local anaesthetic into the bursal tissue to see if the pain subsided, which it did. This allowed the Podiatrist to determine that the small tear in the Achilles Tendon was not the cause of the pain, but rather the bursitis was.

The patient took a course of anti inflammatory medication and applied ice to the affected area daily for 2 weeks. This made no difference to the pain that was coming from the bursa. To this end, and after lengthy discussions and consideration the Sports Podiatrist deposited Dexamethasone combined with Lignocaine into the bursa. The patient was instructed to immediately use the Immobilisation boot and to remain in it for 2 weeks.

Follow up with Sports Podiatrist

3 weeks on from the injection the patient is completely pain free and has commenced a light training programme. The Sports Podiatrist palpated the area and Mr X reported no pain or stiffness. He has been advised to return to running and football slowly and gradually and to stop playing immediately if his pain returned.

Please note: The information provided in this case study is specific to one particular patient, and should not be taken as general medical advice. The application of cortisone into bursal tissue, when the Achilles Tendon comprises a deep surface tear should not be taken lightly. There is always a risk of tendon rupture and these risks should be measured against the desired outcome. If you have foot problems you should seek the help of a suitably qualified Sports Podiatrist.