Achilles Paratenonitis: A therapeutic case study
By Dr John DeFinney DC FCCSS(C)
Canadian Chiropractor- October 2001
Dr John DeFinney is a 1976 graduate from the Canadian Memorial Chiropractic College with a specialty in sports chiropractic. He is also one of the founding members of the College of Chiropractic Sports Sciences and one of its first three Fellows. He is the clinical director of a multi-disciplinary practice in Markham and is also a worl-class age group runner who has published journal papers and articles on the topic of running. Dr. De Finney a director of sports sciences and a research consultant with a specific interest in running and sports injuries and rehabilitation at Trigenics® Institute.
A 38-year-old amateur runner presented with left-sided Achilles pain. He had begun a new exercise program six months earlier, which involved two to three miles of daily running with weight training and dieting. After four months he developed sharp pain in the area of his Achilles tendon. He noticed swelling of the Achilles tendon and experienced pain on simple walking, especially after he was off his feet for a while. The pain and the swelling in his Achilles worsened. He stopped running for approximately one month and tried unsuccessfully of return to running the day prior to his initial visit. He reported having no previous problems with his feet or legs.
On examination, his left Achilles tendon was visibly swollen to about 5 cm above the calcaneal insertion. The swelling was evident on the medial and lateral aspects of the tendon. On palpation, pain was elicited in the area of swelling and at the calcaneal insertion. The medial aspect of the tendon was more tender. There was hypertonicity and tenderness throughout the soleus and gastrocnemius muscles with the medial side of the lower leg more involved. Active and passive dorsiflexion of the left ankle was slightly restricted and he was unable to toe rise due to pain in the Achilles. The tarsal joints were hypomobile on joint play assessment and the plantar fascia and muscles on the volar aspect of the foot were shortened and hypertonic. His gait was assessed and he walked with a limp, not being able to fully dorsiflex his left ankle or push off his left foot. He was diagnosed as having Achilles Paratenonitis.
Achilles tendon injuries are one of the most common overuse injuries to afflict athletes (1). The tendon is covered by two thin layers of tissue, the epitenon and the peritenon, which form a space(mesotenon), that provides the blood supply to the tendon (2). The covering of the tendon is called the paratenon (3). The tendon and the paratenon can be injured by a direct blow, an acute traumatice stress or through overuse. The etiologic factors can be categorized as: anatomic, systemic diseases, direct trauma, training errors and surface or equipment. Soft tissue therapies for these injuries have traditionally involved different forms of massage and myofascial release techniques as well as acupuncture/pressure. The prognosis for this injury is varied, depending on the severity and chronicity of the problem. The time for recovery in an acute case is normally 6 to 10 weeks (4).
Treatment involved specific application of Trigenics® procedures administered to his lower leg and foot. He was also instructed on the proper use of cold applications for home use and initially was given gentle stretching exercises to perform. He was advised to refrain form weight bearing physical activities and to limit his walking until the swelling and pain subsided.
The Trigenics® techniques applied in this case involved the patient being positioned prone on a treatment table with the involved lower leg flexed at the knee. With the foot fully plantarflexed, the practitioner applies two variations of digital PDA (Proprioceptive Dynamic Acupressure) on the specific myopoints of the gastrocnemius and soleus muscles and along the medial and lateral margins of the Achilles tendon. This is done while the patient simultaneously exhales and dorsiflexes his foot using a specified amount of pressure to optimally engage the reciprocal innervation. The procedure is repeated up to three times on each Trigenics® myopoint and then the same positioning and procedure is performed on the plantar muscles of the involved foot. This is known as the strengthening procedure of the Trigenics® treatment protocols. With Achilles paratenonitis, this is then followed by the lengthening procedure, which uses another form of PDA in conjunction with stimulation of the inverse myotatic reflex. For the adjunctive lengthening procedure, upon exhalation the patient plantar-flexes their foot using a specific amount of pressure to optimally engage the inverse myotatic reflex. The lengthening technique is repeated three to five times with the patient holding the contraction for approximately six seconds. The same procedure is then repeated with the knee fully extended to work more specifically on the gastrocnemius muscles.
Immediately after the first treatment the patient reported that his leg felt considerably looser and for the first time, he could walk easily with less pain. After only three visits over approximately on e week he was able to run relatively pain-free. Having received 6 treatmens over two weeks the patient was discharged from care. His pain and inflammation had subsided completely. Frankly, I was amazed. I have treated many cases of Achilles tendonitis and paratenonitis in my 25 years as a sports chiropractor. This was the first time I used Trigenics® on such a case and cannot recall ever getting such quick results. I had not expected this patient to achieve this level of improvement so rapidly. Normally, with any other treatments, such a condition would sideline the runner for many more weeks (5). (It should be noted that my experience of using Trigenics® in the treatment of a variety of other soft tissue injuries has been similarly positive).
As a Fellow in the College of Chiropractic Sports Sciences, I treat a good number of athletes at all levels of competition. I have long recognized the need to attend to the soft tissue components of injuries and subluxations and have kept up to date on the latest and most effective modalities and techniques. The neurological model and theory behind Trigenics® makes great sense and has been long overdue. After observing the benefits of Trigenics, when modalities and myofascial release techniques could often only provide partial or temporary relief, I realized that Trigenics® represents a breakthrough in soft tissue and performance enhancement treatment. I strongly encourage any chiropractors interested in providing superlative care, to investigate this innovative procedure.
Reid DC., Sports Injury Assessment and Rehabilitation, Churchill Livingstone, New York, Edinburgh, London, Melbourne, Tokyo, 1992.
Khan KM., Cook JL., Taunton JE., Bonar F., Overuse tendinosis, not tendonitis. Part 1: A new paradigm for a difficult clinical problem. The physician and Sports Medicine, Vol 28-No5 , May 2000
Alfredson H., Pietilal T., Johnson P., Lorentzon., heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J. Sports Med, 1998 May 26 (3): 360-366