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Past ruptured achilles tendon

Discussion in 'General Issues and Discussion Forum' started by Katie123, Jun 14, 2011.

  1. Katie123

    Katie123 Active Member

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    Hi Everyone

    I have a patient booked in on Friday for a biomechanical assessment. When he made the appointment he advised that he didn't feel that his foot was functioning properly. He suffered a ruptured achilles tendon approximately 9 years ago and still feels that this is effecting him and he is a runner.
    I realise that there isn't a lot of information to go on at the moment but I haven't had any previous patients with this and just wondered if anyone has any pointers/specific tests/similar case studies.

  2. Admin2

    Admin2 Administrator Staff Member

  3. RobinP

    RobinP Well-Known Member

    I think reading through the threads noted by Admin2 will help to think about the anatomy of the tendo achilles (TA) and how it can affect how you assess and prescribe.

    I found this quite helpul when I first started looking at sports injuries.


    It is a blog by Podiatry Arena's Ian Griffiths and although the David Beckham story is for the lay people mainly, there are some good references and there is a good link to to this page from his website talking about the mechanism of injury - very easy to understand


    I hope this helps.


    IG - hope you don't mind the mention;)
  4. drsarbes

    drsarbes Well-Known Member

    Hi Katie:
    I can give some insight to this as a doctor and a patient (I ruptured mine Sept. 2009)
    The main problem is recalcitrant weakness and habitual altered gait.
    You want to test his muscles strength (entire lower extremities including knee extensors and flexors) and his gait.
    Even if his strength is symmetrical (unlikely) he still may have a habitual altered gait from chronic weakness post rupture.

    In addition, I would not be surprised if even the intrinsics are weak.

    It's an injury that has far reaching effects on function. Depending on his age, some are difficult to overcome.

    Good luck

  5. Deborah Ferguson

    Deborah Ferguson Active Member

    Interestingly though I had the same injury several years ago and after several months of intensive physiotherapy and exercises post operatively, I found that the muscle strength, flexibility etc. on the affected side was actually better than on the uninjured leg !
  6. Katie no full text but

  7. drsarbes

    drsarbes Well-Known Member

    Hi Deb
    May I ask how old you were when you ruptured it and if you considered yourself in "good shape" at the time of the rupture?
    also; what did your "intensive Physio therapy" entailed.

  8. efuller

    efuller MVP

    The real question is how much ankle plantar flexion power he has with both knee flexed and extended. This a functional test not a manual muscle testing test. Have him stand on one foot and lift his heel off of the ground (ok to hold the wall for balance) How many times can he do that on each leg. You could have him sit in a chair with his feet on the ground a put a weight on his knee and do the same test to asses just soleus strength. Isolating the soleus may not be functionally important. As mentioned above you should watch walking and running to assess ankle plantar flexion power.

    I've been amazed at what patients do to work around muscle weakness. It's possible to run without plantar flexing the ankle.

    If he is weak, have him do the single leg heel raises.

  9. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi Steve
    I was 40ish when I ruptured the AT. Generally fit and active , although not super fit. My physio consisted of twice weekly hydrotherapy for 6weeks then twice weekly in gym for another 6 weeks with daily exercises at home.
  10. Katie123

    Katie123 Active Member

    Following the assessment of my patient on Friday, more information and findings:-

    Started running in 1996

    2000 started experiencing tendinopathy in both achilles

    2001 steroid injections in both achilles and a 2nd injection in his right

    2002 intermittent swelling on achilles area but continued running until swelling became extensive and unable to run. Diagnosed with partial rupture of right achilles tendon and had a cast to hip level for a number of weeks followed by physio.

    2003 patient went to a private consultant surgeon and he shortened right achilles followed by some physio.

    Patient advises that he feels the right foot "doesn't feel right" and that it feels like it is never flat to the floor. From footwear extensive lateral calc wear especially on the left foot. Muscle bulk in gastroc/soleus region less in affected limb (right) and single leg heel raises shows weakness in this area, my initial treatment would be to try and improve the muscles in this area before looking at some kind of orthotic tx but patient not motivated to do more physio. He is feeling frustrated that this has continued for so many years and still not remedied.

    No problems with joints, no leg length discrepancy, in left foot I noticed a small forefoot equinus. Reasonable dorsiflexion at ankle joint. Patient advises that his muscles are generally "tight all the time" but it doesn't appear that he has a daily stretching programme, he runs when he feels up to it. He is not in any pain his feet just "don't feel right".

    My experience is biomechanics is limited and this is why I am seeking further advice. This man has seen many other podiatrists, being provided with orthotics which he doesn't think make any difference and has spent a lot of money looking for a solution.

    Thanks in anticipation
  11. Katie has he had any pressure testing done of the Gastroc/sol complex

    Does he get massage ?

    Heel lifts ?
  12. Katie123

    Katie123 Active Member

    Thanks for the ideas.
    No I am not aware that he has had any pressure testing done and he gave me a pretty informative history.
    One pair of orthotics he brought with him were bespoke 3/4 medium density EVA with a medial wedge but no heel lift, heel lifts never tried, he was a bit anti-heel lift when I brought the idea up as he has been doing a lot of internet research!
  13. Love the internet :bang:

    Why ?
  14. Katie123

    Katie123 Active Member

    He said in his opinion and lot of opinions he found on the internet that this would make the problem worse by shortening his muscles
  15. also
    lengthened ?

    Only if used in isolation, but you won´t do that so a heel lift will reduce the tension in the Gastroc/sol complex a good thing.

    I would suggest getting some pressure tests done. If as you say the problem is - Patient advises that his muscles are generally "tight all the time". I would be looking at compartment syndrome

    tx - depending on results

    Surgery - depends on results

    massage and lots of it
    heel lifts
    stretch program
    Look at muscle imbalance ankle dorsiflexors/plantarflexors
  16. Katie123

    Katie123 Active Member

    Thanks for your help and ideas. Where would you suggest for pressure testing, is this something that can be done through an NHS referral? or a specialised private podiatrist. Forgive my ignorance only qualified last year so I am still learning a lot!!

  17. Sorry Katie no idea in the UK, not from there.

    also for some info maybe this thread might be of interest - http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=43205

    Good luck
  18. RobinP

    RobinP Well-Known Member

    Hi Katie,

    I don't know of many places that do it on the NHS based on my research from the thread that Mike linked to. Probably only available privately unfortunately althoug a very interested sports injury orthopod might take some notice. however, compartment syndrome is seldom in their repetoire of DDXs in my experience. Only one I have sent for compartment testing was to somewher in London, the name of which escapes me but Ian griffiths (Ian G)knows the details - maybe he could advise?

    Regarding heel raise, tell the guy to stop being a pillock. I read on the internet that I could have a certain male anatomical part enhanced by taking some wonder pill.

    Do I believe it? No.

    Is there a lot of literature on the internet that GUARANTEES that it will work? Yes.

    Does that make it true? NO

    And another thing, he has had a ruptured TA and a surgical shortening. What are the chances that it is not going to "feel right"? Pretty bloody high i would say.

    This guy sounds like he should be a triathlete

  19. Griff

    Griff Moderator

    Saw my name so thought I'd pitch in too!

    I've glanced throught the thread, and can't see any suggestion of chronic exertional compartment syndrome (CECS). Have I missed something? Why are we talking pressure testing here? Katie, do his 'symptoms' (from what I can gather he has none??) raise a high index of suspicion for CECS for you?

    Infact, what is our working diagnosis here? What are we actually dealing with?

    No physio to this point and he kept running despite increasing pain...


    This chap has either had inappropriate/poor Physiotherapy or he did not do what he was told (from the sounds of it the latter may be more likely)

    When? Non-weightbearing? What's 'reasonable'?
    What are his weightbearing ankle joint dorsiflexion stiffness/lunge test results? Symmetrical?

    This guy sounds like a nightmare... Refer him to an enemy immediately... ;)

    On a semi-serious note, I suspect he has hit this plateau due to a combination of poor management and poor compliance. Explain to this guy that you understand his frustrations. If you want him to get on board with your management plan you will have to win him over and earn his trust - these sort of patients are the toughest ones to do that with, as they are on the defensive the second they walk into your office (makes you wonder why they booked the appointment in the first place sometimes)

    I suspect needs Physio. Period. Explain this to him, but say you will hold off for now. Give him some EVA bilateral heel raises (at least 6mm) explaining to him why you are doing so and how you think they may help. Tell him to wear them at all times. Stress the importance of the local tissues being conditioned enough to tolerate the demands of running. Just give him 2 exercises to do to start with; gastro-soleal stretches and eccentric loading of the Tendo-Achilles. Show him how do to these properly, and explain why he is doing them (link it back to the demands of running). Tell him there is next to no chance of improvement if he does not do them, and remind him that you can't do them for him. Have him avoid hill running or speedwork until you review him. Review his footwear - decide if you feel it is appropriate for what you are trying to achieve. If not advise accordingly. He needs to subscribe to and have confidence in your treatment plan - ensure this is the case before he leaves.

    Review him 4-6/52 later. If he's done his homework like a good boy you'll know. Don't tell him off if he hasn't - just give him a look which says "I'm not angry - its you that isn't going to get better". Its a look you'll perfect over the years I promise. Once he sees some improvements, refer him to a good Physio who you trust who can take him through some rehabilitation more thoroughly. By this point he's more likely to be on board with this.

    And most of all - enjoy the challenge! This type of patient can be daunting at first, but you'll see hundreds of them over the years, and when your intervention makes a difference they are often the most grateful. And then you'll end up seeing every single member of their family/running club.
  20. Katie123

    Katie123 Active Member

    Thanks for your help and advice
  21. RobinP

    RobinP Well-Known Member

    Very true. It's when they start saying things like, "I didn't want to get my hip replacement done until you gave me the OK" that you have to worry

    I'd agree with Ian, doesn't sound like CECS and the patient understanding his problem will probably make a big difference to how much he follows your advice and ultimately how good his results are.

    He may not have a solveable problem but in cases like this it is important that you go the extra mile to prove that that is the case.

    Oh yeah.......and get him to wear some damn heel raises!
  22. Griff

    Griff Moderator

  23. efuller

    efuller MVP

    If the guy can't tell you what's wrong, you can't fix it. However, you need to explore "is never flat on the floor." If there is a deep impression in the heel of the shoe, then he is getting his heel to the floor. The next question is how long does it stay there in gait. It may not feel flat on the floor because he is not getting weight on to the forefoot because of a weak gastroc soleus or it might be he doesn't have range of motion to keep the heel on the floor. Does he have an early heel off? Does he have no heel off?

    You have identified a problem of a weak gastroc soleus. If you don't see anything else to fix..... what are you going to do. If it is the lack of plantar flexion power that causes his "feeling" then explanation of why he is having the feeling may get him back to muscle strengthening.

  24. drsarbes

    drsarbes Well-Known Member

    Hi katie:
    looks like you opened a can of worms!
    Apparently he never had a ruptured achilles. Partial maybe; treated with cast.
    The surprising Historical item is that he tells you he had the achilles shortened!
    I doubt it. He may have had an achilles revision due to chronic tendinopathy/fibrosis. I don't know
    of anyone who would purposely shorten the achilles.

    IMHO....there are some achilles patients out there who will not be able to run without symptoms. He may be one of them.

  25. Ian Harvey

    Ian Harvey Active Member

    Forgive my ignorance, but if he had compartment syndrome would his muscles be "tight all the time", or more likely mainly during exertion???

  26. Depends Ive had compartment syndrome and I was tight all the time with a ´full´sensation in my gastroc/sol complex if I tried to run the pain got much worse

    - Ive had patients with neurological changes in their feet because of increased pressure in the posterior compartments ie the lost feeling all day everyday - of to surgery

    I believe we have 2 types of compartment syndrome - exercise induced or only a problem when exercising and a constant increased pressure in the posterior compartments which will obviously increase under load.

    Why Ian Robin are pretty sure it is not I think it might be.

    Also a Question to Ian G why would you -
    when from Katie "patient history" she says the patient complains of -
    Just asking cause I´m confused why you would load up the muscle complex where as far as I can tell Katie has not written that the patient complains of Achilles pain anymore.

    Also Katie you wrote that the patient had the Achilles shortened did he cause if he did shortening the Achilles will change the torsional make-up and structure of the Achilles and will load up the Gastroc/Sol Complex Achilles and if he did have it shortened then send him off to another surgeon - reduce the length of the Achilles increase the tension in the Gastroc/Sol complex - patient will feel tight all the time in the muscles - unless he lengthens them by stretching and stretching and stretching - Just seems very weird to get the Achilles shortened.
  27. Griff

    Griff Moderator

    I suspect we are going to need Katie to answer some of our questions, as without any more information this ongoing discussion may not be that fruitful.

    Mike, my rationale for recommending TA eccentric loading is as follows:

    1. He clearly needs to get in the habit of performing daily exercises at some point, and TA eccentric loading tends to be fairly well subscribed to for its ease
    2. There aren't many weekend warriors/sporadic runners who wouldn't benefit from it (in my opinion)
    3. If he has had a shortening procedure previously then in my mind this increases the risk of future tendinopathy - always worth trying to get the tendon in as best condition as possible (prevention rather than cure and all that).

    Not saying its right, just my opinion.

    But as I said, we need some of the questions in this thread answered for a fuller picture as we are kinda talking round in circles here.
  28. Good points I agree with your thought process now I see them - just an asking guy.:drinks

    be good if Katie can go thought each post and answer the questions I agree - over to you Katie
  29. RobinP

    RobinP Well-Known Member

    Occum's Razor I suppose

    On a patient who has not yet tried heel lifts to reduce his tight calf feeling, I wouldn't be going for compartment syndrome as the first thing to rule out.

    As ever though, I could be wrong. Always happy to be proven so, makes me think harder the next time.;)

  30. Katie123

    Katie123 Active Member

    Hi Everyone

    First of all thanks for all your comments and your time spent debating this.

    Didn't realise I would open such a can of worms and as I said not a great deal of biomechanical experience in this area. I can confirm a couple of things from your posts - he definitely said that the TA was shortened by the surgeon. I was trying to dig to get more information on past physio to see how extensive this had been and what he had actually done, he tried to brush over it really and said he couldn't really remember, which makes me wonder about his compliance levels.

    I think the first line of treatment should probably be 6mm heel raises and a referral to a physio if I can persuade him.

    Thanks again Katie

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