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Wednesday, January 31, 2018

Insertional Achilles Tendinitis: Email Advice

Dr. Blake,

I have been diagnosed with insertional Achilles calcification in my left ankle. X-rays showed a pretty large buildup, which was actually the cause of a very visible bump on my ankle. I stopped all activity for 30 days and wore an elevated shoe, to avoid the boot. It helped but the pain is definitely less frequent but still there. I can’t get back to all of my regular activities I had enjoyed, like running or just horsing around with my son. Any period of activity of more than a couple minutes results in pain a couple hours later.

My ortho has suggested a boot for 30 days and if that doesn’t work, surgery. I read one of your earlier responses that icing down the area immediately after a workout is a good thing. Could I create more of an issue trying this and reincorporating activity or should I keep chasing a fix? My trainer saw the x-ray and agrees that it’s large enough to where it’s not going to go away.


Dr. Blake's Response: I have always taken the approach that pain from a bone spur is suspect since the bone spur has been there for a long time, so why is it just now hurting. I know that there is more to your story so I will add it on if you reply. When the "S" word is used, my deep-seated gut is looking for ways out.  You have to take out the bone spurs, and really just think of Achilles tendinitis at its insertion. How do we treat general tendinitis? The mnemonic is BRISS: Biomechanics, Rest, Ice, Stretch and Strengthen. The Achilles is now your weak spot that you have to make stronger. Maybe that will ultimately require surgery, but maybe not.
     The Biomechanics that help is a plantarflexed or pointed foot. This is why an elevated heel helped. Women have the advantage here by hanging out longer in wedges and heels and avoid flat foot. You must also take that rule and apply to stretching--only stretch to the ankle at a right angle, not negative heel, where the heel drops below the front of your foot. Strengthening you want to work the range first of your heel on a 1-inch lift and go up and down from there, not lower.
     The Rest is for Activity Modification. It normally takes 9 months to completely rehab an Achilles tendon. You are in month 2. The first few months are the Immobilization/Anti-Inflammatory to create a 0-2 pain level. The next Phase is Restrengthening. The final Phase is Return to Activity. You can not jump to Return to Activity now, that is reasonable. What we need in the good Physio approach to the restrengthening and gradual increase in activities.
     The Ice is anything that helps us reduce the inflammatory. Ice pack 2-3 times a day for 10 minutes is good. If there is a lot of swelling, then contrast bathing. You can use oral meds for 5-10 day bursts of the full dose, and then 2-4 days off to rest your system. Physical therapy and acupuncture are wonderful at reducing the inflammation, increasing blood flow, and PTs can give you exercise advise.
     The First "S" is Stretch. For any Achilles problem way down at the heel, the best stretch is the plantar fascial wall stretch. The second best is the soleus bent knee Achilles stretch. PTs have some heel. But, since stretching the Achilles in some cases is painful, you must consider only during deep calf massage to loosen its force on the heel. 
     The Second "S" is Strengthen. This is crucial for the achilles. Even relatively strong athletes can improve their strength 30-50% where it can help symptoms. Here is where range of motion comes in. You only want to strengthen the tendon from an ankle neutral to ankle plantar flexed position. Try to stay away from an ankle dorsiflexed position to start the strength work, like starting a heel raise from a deep squat or where the heel is dropped off the step. 
      These are some points I hope help. The more information you can share the better. Thanks and good luck. Rich

The Patient's Response:

I appreciate the response. This started early 2017, which had coincided with me picking up running after taking a break for several years. I was able to start doing 4-5 runs a week, typically on a treadmill, for 3-4 miles each time. I started noticing that my ankles would get very stiff several hours after running. I then started waking up with soreness but once I was moving around or running, the pain would wear off eventually, usually after pushing through. 

It early in 2017 though, it got to the point where the pain was constant and would last for days at a time. I am in Texas and a fan of cowboy boots and I noticed that wearing them seemed to help. After consulting with an orthopedic surgeon, it was determined that I had calcification at the Achilles. That is essentially where I currently am at. I will say that at this point, when I do have pain I can sometimes manipulate my ankle by twisting it around until it feels like it pops and that provides instant relief. I have avoided running but have replaced it with long walks and about 50% of the time I will have pain while other times it is totally fine. Basketball, tennis, anything with sudden side to side movement is out mainly due to the fear of pain from a couple of times I have tried it.

Dr. Blake's comment: This is extremely interesting, and it is good the pain is not constant. The fact that you can release pressure, means that the ankle joint is more involved. That sign of popping and feeling better is a joint symptom. I am hopeful you do not rush into surgery and give this proper time. Hopefully, some imaging can be sent here. See the blog post on WeTransfer. I would love to see a good MRI to look at the Achilles, spurs, and ankle joint. Good luck!


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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.