Achilles Pain - Track And Field

Abstract

HISTORY: An 18-year-old, female, Division 1 collegiate track and cross-country athlete presented mid-season with acute on chronic, right posterior ankle pain after running. She was treated the season prior for insertional Achilles tendinopathy with protected weight bearing, manual therapy, eccentric strengthening, night splints, oral and topical NSAIDs, nitroglycerin patches and intra-tendinous prolotherapy. Her pain returned this season with running or direct contact of the Achilles tendon. PHYSICAL EXAMINATION: On inspection there was bilateral pes planus and slight swelling of the Achilles tendon 1-2 cm proximal to the insertion with tenderness to palpation. She had full ankle range of motion with mild pain only on end range of passive dorsiflexion. There was a non-antalgic gait pattern and no pain with toe and heel walking or with heel pumps. Ankle strength was normal and sensation to light touch was intact throughout. DIFFERENTIAL DIAGNOSIS:1. Achilles tendinopathy, recalcitrant2. Achilles paratenonitis3. Retrocalcaneal bursopathy4. Posterior ankle impingement TEST AND RESULTS: Diagnostic musculoskeletal ultrasound showed a normal appearing Achilles tendon without fusiform swelling, hypoechogenicity, fiber disruption, neovascularization or cortical irregularities FINAL/WORKING DIAGNOSIS: Achilles paratenonitis TREATMENT AND OUTCOMES:1. Referral to sports physical therapy for a progressive tendon loading program and return to run program using a weight assisted treadmill2. Despite strength and flexibility gains, the patient was unable to return to run without pain3. We performed an ultrasound guided, percutaneous Achilles paratenon brisement with saline to dissect the tight, adhesive paratenon from the tendon itself4. Additionally, during the same procedure, we performed an ultrasound guided, percutaneous, Achilles tendon scraping to disrupt peritendinous neovessels and neonerves5. After 1 week of protected rest, patient returned to physical therapy and was able to complete a return to run program and return to sport without pain within 1 month.