Combined osteopathy and exercise management of Achilles tendinopathy in an athlete:

a case report

Georgia Ross1Chris Macfarlane1Brett Vaughan1,2,*

1 College of Health & Biomedicine, Victoria University, Melbourne, Australia

2 Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia

*Corresponding Author

Brett Vaughan
Lecturer, Osteopathy
College of Health and Biomedicine
Victoria University
PO Box 14428
Melbourne VIC 8001
Australia
P. 61 3 9919 1210
F. 61 3 9919 1030
E. brett.vaughan@vu.edu.au

2

Abstract

Mid-portion Achilles tendinopathy is a common injury in sporting populations. There is

conflicting evidence about the best approach to conservative management. This report focuses

on the rehabilitation of an Achilles tendinopathy utilising osteopathic manual therapy (OMT)

and a structured exercise program in a semi-professional volleyballer. The patient presented

with a 4-month history of right mid-portion Achilles tendon pain that begun after a lateral

inversion sprain of the right ankle. The primary complaint was pain impacting the patients

vertical jump performance. The patient complained of pain that was greatest in the morning

and at the beginning of a training session prior to warming up. The inventory therapy was a

combination of OMT. The manual therapy was complemented with a rehabilitation program.

Outcomes were assessed with the Victorian Institute of Sport Assessment- Achilles (VISA-A),

visual analogue scales (VAS), painful arc, London Hospital Test, soleus lunge test and

maximum vertical jump. This case presented many challenging management options including

a resolving right ankle lateral inversion sprain, a past history of contralateral Achilles

tendinopathy and a high training load. The case demonstrated the importance of patient-

centred practice. It was integral that the patient’s role as a semi-professional athlete on the

volleyball court was analyzed closely in order to replicate different facets of his game, so that

the rehabilitation program could support a return to performance at the highest level. Once the

initial deficits in mobility and strength were addressed, the rehabilitation program focus moved

to injury prevention.

Keywords:
Osteopathic manipulative therapy; rehabilitation; exercise; mobilisation; outcome measure

3

Introduction

Achilles tendon injuries are commonly associated with physical activity1 and sports,2, 3 with a

reported incidence of 7-9% in a sporting population and in the general adult population 2.35 per

1000.4 The Achilles tendon is the most commonly ruptured tendon,2 the most commonly

treated by orthopaedic surgeons, and viewed as a ‘weekend warrior’ injury to those involved in

sports like volleyball requiring agility and speed.5 Although the sports population seem a likely

group for Achilles injuries, de Jonge and colleagues reported that only 35% of the cases in their

study were related to sporting activity.4 Rehabilitation treatment protocols for Achilles pain and

injury are well established3 with 71-100% returning to previous activity1 and those that do not

respond to conservative approaches may utilise surgery. The rate for surgery ranges from 29%

in one 8 year follow up to 24%-49% in another retrospective review.1 Surgery comes with a

range of complications5 and athletes tend not to return to the same level as performance as

prior to the injury in either treatment approach.2 There is still a need to explore treatment

options for patients with Achilles tendon injuries2 including implementing a multimodal

approach. The current report considers the use of a rehabilitation program in concert with

osteopathic manual therapy (OMT) to manage the pain, restore functional movement changes

in the ankle and foot, and reduce potential predisposing and/or maintaining factors to Achilles

tendinopathy in a high level athlete.

Presenting Concerns

The current report considers a 23-year old male professional volleyballer who presented with

right Achilles pain that was worse in the morning and before warming up. The pain impacted

his activities of daily living, particularly walking up and down stairs. Most significantly, the pain

4

impeded his ability on the volleyball court. At the time of presentation, in addition to the mid-

portion right Achilles pain, the patient also complained of medial ankle pain with overuse

injuries in the ankle common in the athletic population.6 Changes to ankle biomechanics

predispose athletes and others1 who are highly active to Achilles tendon injuries. Both

symptoms were recorded as 5/10 (moderate pain7) on the visual analogue pain scale (VAS).

The patient had been unable to continue his normal strength and conditioning program due to a

right ankle lateral inversion sprain sustained 4-months prior during a volleyball match overseas.

The inversion sprain was immediately treated by the team physiotherapist including manual

therapy, preventative ankle bracing, active range of motion exercises and a modified training

schedule. No outcome measures had been utilised at the time. The patient also self-reported

increased levels of post-match fatigue and generalized muscle soreness from reduced strength

and conditioning.

Clinical Findings

The patient was not on any medications and the past medical history was unremarkable. The

patient had previously been diagnosed with left Achilles tendinopathy in the previous year

(Table 1). A right talocrural lateral inversion injury had occurred 4 months prior to this

presentation of right mid-portion Achilles pain. There were no other notable predisposing

factors elicited in the history.

INSERT Table 1 here

The initial examination included active range of movement (AROM), passive range of

movement (PROM), as well as palpating the Achilles tendon for heat, Haglund’s deformity,

5

thickening or asymmetry of tendon size. During examination it was important to be cognizant

that this patient had experienced tendinopathy in his contralateral Achilles thus making

comparison potentially unreliable. It was intended that the patient undergo ultrasound bilaterally

to support a more definitive evaluation of tendon quality, however due to lack of availability it

was unable to be performed. Palpation of the tendon was followed by functional testing that

included walking on toes and heels, the lunge test, squatting, and maximum vertical jump

testing all with patient feedback regarding pain levels. The osteopathic examination was

supplemented by testing for a painful arc sign to distinguish between tendon and paratendon

lesions and the Royal London Hospital Test,1 which was positive.

Diagnostic Focus and Assessment

Potential differential diagnoses considered in this case were tibialis posterior tendinopathy,

retrocalcaneal bursitis, posterior impingement syndrome and a gastrocnemius muscle strain.1 A

diagnosis of mid-portion Achilles tendinopathy was supported by the past history of lateral

inversion sprain as a predisposing factor, site of maximal tenderness (mid-portion 4

centimetres proximal to the Achilles insertion), a positive Royal London Hospital Test,1 positive

palpatory findings, and an inability to load the Achilles tendon in all functional testing measures.

This diagnosis was underpinned by numerous historical factors including morning stiffness,

pain on activity3 and in addition to being a common injury for this age group and activity type.8

Measures to monitor the patient progress in addition to examination findings and patient

feedback included the Victorian Institute of Sport Assessment – Achilles (VISA-A), visual

analogue scale, patient jump height and soleus lunge test. The VISA-A is a reliable outcome

measure in both non-surgical and surgical Achilles tendinopathy cases.9 It involves eight

6

questions designed to evaluate pain and function which in the present case report, guided the

rehabilitation plan. On initial presentation the VISA-A score was 52/100 and 5/10 for the VAS.

The next measure was the patient’s vertical jump ability, which at initial presentation was zero

due to the pain levels. The patient reported their pre-injury vertical jump was 82cm. The final

measure was the soleus lunge test used to evaluate ankle dorsiflexion range. The initial test

measured 10cm from wall to great toe for the asymptomatic leg and 0cm for the symptomatic

side, as he could not flex his knee toward the wall. This demonstrated the significant

asymmetry between both sides.

Therapeutic Focus and Assessment

There were several specific challenges in treating this athlete that were incorporated into the

treatment goals. The patient was unemployed between volleyball seasons whilst in Australia.

As a result the costs associated with treatment, diagnostic imaging and adjunct therapies were

a consideration. The patients’ busy coaching and training schedule meant planning to keep him

training as much as possible, balanced with time for treatment and rehabilitation. Planning was

also required to allow for his rehabilitation and treatment to occur under alternate supervision

when he returned to play in Sweden later in the year. Finally, specific considerations were

made for his role in volleyball as a ‘setter’, which is discussed later. The patient had a busy

schedule, training four times per week whilst in Australia and six days per week whilst in

Europe and Canada. The patients’ role as a semi-professional athlete required a quick

recovery, so osteopathic manual therapy (OMT) and an exercise and rehabilitation program

were prescribed.

Osteopathic Manual Therapy

7

The patient and practitioner agreed to the main treatment goal of being able to jump without

pain. OMT comprised a group of techniques to address ankle and foot joint restrictions and

muscle hypertonia resultant from the initial trauma10 and the subsequent compensatory

movement patterns.11 The initial stage of treatment utilized an indirect technique - counterstain

(CST) to the right Achilles tendon.12 This technique can be useful when the area is painful and

low intensity techniques are required. CST requires the clinician to locate the most tender

point, then the clinician positions the body part to comfort, in this case the foot, to reduce the

tender point significantly (70% - 100%). The clinician then maintains the position for 90

seconds before repositioning the body part and retesting the tender point.13 Subsequent

techniques to address passive motion restrictions included anterior-posterior gliding articulation

(low amplitude repetitive motion) of the talocrural joint8, 14 and superior tibiofibular joint,15 as

well as subtalar springing.16 Muscle energy technique (MET) was used to address internal

rotation of the right tibia8 and muscular hypertonicity in the right gastrocnemius muscle belly.

Muscle Energy Technique (MET) and soft tissue therapy (cross, longitudinal fibre stretch and

inhibition) were used to treat the plantar fascia bilaterally and decrease hypertonicity in both the

popliteus and gastrocnemius muscles.17 To reduce tension in the musculature of the lower leg

and to assist in decompressing the Achilles tendon18 a heel lift was prescribed for both the left

and right sports shoes.

Rehabilitation

At the time of presentation the patient was using self-prescribed two ibuprofen tablets (non-

steroidal anti-inflammatory drug - NSAID) 30 minutes prior to a game for the previous four

weeks until the initial pain subsided - this provided pain relief for approximately the first hour of

8

activity. The patient was advised to begin his rehabilitation program and reduce his reliance on

the NSAIDs, given the potential effects of long-term use. Moreover, given the absence of

inflammatory infiltrates in tendinopathy NSAIDs tend to be of limited benefit.19 The program

contained an element to manage the pain including OMT and modified activity.12

A rehabilitation program (Table 2) was developed with several foci to accommodate the

individual circumstances of the athlete and informed by the literature.3, 20 Eccentric loading is

supported as the basis of the rehabilitation approach.21 Stresses placed on the Achilles tendon

need to be set according to the rehabilitation plan. The initial focus was to target to the

volleyballer’s role as a ‘setter’. The ‘setting’ role requires the setter to jump to position the

volleyball for another player to ‘spike’ or strike hard into the opponent’s side of the court. The

training program involved single leg stance activity as setters often have to chase the ball and

do not have sufficient time to realign themselves to perform a set with both feet firmly planted in

the ground. Training this aspect became even more pivotal as one legged-setting was how the

patient sustained his right lateral talocrual inversion sprain four months previously. Volleyball

involves a large amount of short high-intensity sprints especially given the player’s position of

setter, thus agility work was implemented into the rehabilitation plan from week five.

The second focus of the rehabilitation plan was to address both the Achilles injury and the

residual deficits from the right lateral inversion ankle sprain as predisposing elements to the

Achilles injury. It was suspected that the associated hypomobility of the talocrural joint was

placing increased stress through the Achilles tendon. Limited ankle dorsiflexion has been

identified as a potential risk factor for the development of mid-portion Achilles tendinopathy.22

The third focus was to include cross training to maintain cardiovascular fitness and minimize

prolonged stress placed on the Achilles tendon. Activities utilized included cycling, rowing and

9

swimming exercises. The patient was very compliant with all prescribed rehabilitation. Having

both the time and inclination to return to peak performance, particularly as it was his main

source of income contributed to the compliance.

Follow-up and Outcomes

At three weeks the patient reported no medial ankle pain and their mid-portion Achilles pain

had diminished from an initial VAS score of 5/10 to 3/10, indicating a clinically significant

change.7 At the completion of the rehabilitation program the tendon pain and swelling levels

were re-assessed with the Royal London Hospital Test and Painful Arc sign, and both were

negative. The VISA-A outcome scores improved from an initial 52/100 to a 64/100 over this

time. Although there is no clinically significant level of change established for the VISA-A, the

higher the score the lower the level of symptoms, with a score of 90 or above suggesting full

recovery.23 At this time point the patients’ vertical jump was 68cm with moderate pain, a

clinically relevant change from the zero jump height at initial presentation.

Patient Perspective

The patient gave informed consent for their information to be used in this case report. His

perspective of treatment was highly valued and after each treatment patient response to

treatment was gathered. During the initial few weeks of treatment the patient felt significant

gains in range of motion and decrease in his overall pain levels. As treatment progressed he

continued to feel improvements in his daily function but found that these improvements were

not at as fast a rate as they had been initially.

10

Discussion

Rehabilitation

Rehabilitation protocols for the management of Achilles tendinopathies are described in the

literature although the details are still in some debate.19-21, 24 The rehabilitation program

described in the current report was individualised to return this patient to volleyball with little

skill deficit whilst restoring muscular strength and balance. The initial use of concentric moving

to eccentric contraction was undertaken to help manage the patients symptoms, support

training and keep him active.20 Notably, the rehabilitation protocol incorporated single leg

exercises and biases to the regular weight training regime to support the probability of a poor

pass on the net or into the centre of the court leading to the requirement to utilise a single leg

jump in order to set the ball. The patients’ average number of jumps per training session

provided a useful indication of fatigue levels, and hence the level required to restore function in

order to return to professional sport performance. The patient reported averaging 2 jumps per

point (1 jump to ‘set’ and 1 jump serve or block) at 2 sets per session at an average of 100

points this indicates 200 jumps per training session. In training drills it was likely the patient

would set at least 4 balls per minute in quick succession over the hour amounting to 250 extra

jumps. The speed that these jumps were performed at played a pivotal role in ensuring his

rehabilitation had sufficient plyometric work, and was game specific manipulating both the

speed and volume of the exercises to emulate match play. Intervention adherence and

tolerability was monitored with a training diary with only moderate pain (less than 5/10) to be

experienced. If progression to the next stage of the plan was too difficult it was returned to the

previous level.

11

The majority of existing research regarding exercise guidelines in Achilles tendinopathy

pertains to eccentric exercise prescription.3, 21 Malliaris et al. outline four popular loading

regimes, however the mechanism by which these produce an outcome is not fully understood

with at least six proposed mechanisms.20, 21 Beyer et al.24 demonstrated that heavy slow

resistance (HSR) with the use of calf raises in a Smith machine, weighted calf raise, and calf

raises in leg press machine are equally as effective as a standard eccentric loading program

(ELP) of 3 sets of 12 unilateral eccentric heel raises every day for 12 weeks. Additionally the

HSR protocol demonstrated higher patient satisfaction over the 12 weeks. Both the HSR and

ELP had clinically significant improvements of greater than 10 VISA-A points.24

Initial eccentric loading research had 100% success, however there are lower success rates

with the inclusion of non-athlete groups.21 It is estimated that up to 45% of Achilles

tendinopathies do not respond to eccentric exercises, which is considered to be due to

practitioners’ lack of knowledge about load magnitude and frequency.24 A systematic review by

Malliaris et al.20 concluded that it is not the type of loading that is pivotal in successful

outcomes, but the magnitude and frequency of it. It may also be dependent on the patient

type. The patient in the current report is a young, healthy athlete whom the literature suggests

may respond better to higher load, particularly in the latter stages,20 as displayed in Table 2.

There is some suggestion that the duration of the loading program is of importance given that

some individuals continue to have neuromuscular and jump performance deficits 12 months

and even five years post-injury.20 Table 2 shows the initial 12 weeks of the program but it is

important to remember that rehabilitation is a means of injury prevention that continues well

beyond return to sport. Further research into the rehabilitation exercise guidelines for Achilles

tendinopathy could consider other individual characteristics such as physical activity levels,

12

age, gender etc. in order to allow clinicians to focus their management plans based on patient

subgroups.

There is some debate as to whether there is more benefit with the calf exercise staying at floor

level or progressing the heel-lowering phase to below the level of the step. Wiegerinck and

colleagues25 suggested that floor level maybe preferential to below the step achieving a VAS of

3.900 as opposed to 2.016. Their small sample size study also demonstrated the potential

benefit of electro-corporeal shockwave therapy (ESWT) as this demonstrated the largest VAS

decrease of 5.116. Despite the benefits of ESWT, alternate or more invasive therapies were

not a viable option in this case due to financial considerations. Subsequently, conservative

exercise management and manual therapy were used.

Osteopathic manual therapy

The patient also received four treatments of osteopathic manual therapy (OMT) primarily to the

talocrural joint, which involved articulation, high velocity low amplitude manipulation (HVLA),

counterstain technique (CST) and soft tissue stretching. HVLA was utilised to improve joint

range of motion. CST was used as it is low intensity and could help to reduce the patients’

symptoms. CST has been demonstrated to reduce the stretch reflex amplitude in the calf

muscles.26 As such it was thought that CST applied to the calf would reduce the symptoms

and assist healing by reducing the muscular tension supporting low pressure drainage and

more ‘normal’ muscular function. In addition Howell and colleagues26 also demonstrated

anecdotal reductions in soreness, stiffness and swelling in their Achilles ‘tendonitis’ cohort.

13

OMT techniques, such as CST, support a patient-centred approach, as there is a selection of

techniques to choose from to best suit the patient’s unique situation. In this case CST allows

for a pain-relief approach to treatment that potentially reduces the risk of further tearing or

rupture. CST requires the tension in the connective tissues to be reduced, or in a position that

places the client in ease, thus not aggravating the pain. Articulatory or passive range low

velocity mobilization techniques are used to improve biomechanical factors and the passive

ranges of joint motion,27 such as those that might be present after an ankle sprain. The

restoration of optimal function is aimed at supporting functions such as proprioception and is

also supported by CST.28

Discussion

The patient in this case report responded well with continual increases in his soleus lunge test,

which was complemented by the dorsiflexion rockers in the rehabilitation protocol. OMT acted

as an important adjunct to his rehabilitation regime by increasing range of motion and

decreasing surrounding muscular hypertonicity, which contributed to beneficial alterations in

the biomechanics of the concerned joints. This case highlights the importance of incorporating

the patient’s goals into rehabilitation protocol. A series of small goals were set throughout the

treatment process. These provided markers for progression and kept morale high despite not

being able to train at a pre-injury level. Interestingly, there is currently insufficient evidence to

suggest that there are harmful effects or any detriment to treatment outcomes if patients

continue pain-monitored Achilles tendon loading activities.3 This was particularly important in

the present case study given the patient was unable to rest from activity as volleyball provided

his income and that he was often unable to stay below pain levels of greater than 5/10 whilst

competing.

14

The most notable limitations in this case were was the patient missing two consecutive weeks

of treatment. It would have been advantageous to have had access to ultrasonography,

particularly given the patients past history of contralateral Achilles tendinopathy. This would

have allowed detection of the characteristics of a pathological tendon including hyperaemia,

thickening and calcification all contributing to poorer tendon integrity. This has implications for

the accessibility of ultrasonography and further training for osteopaths as a way of achieving

accurate diagnoses.

The findings of this case report illustrate the necessity for large-scale randomised-controlled

trials that examine a broad range of patient types i.e. athletes and non-athletes, to determine

the most appropriate loading doses and being able to evaluate whether the individual’s

tendinopathy is reactive or degenerative. Ongoing Achilles tendon injuries have a significant

impact on the performance of athletes. Additional evidence that helps to further specialise or

focus a rehabilitation program will allow clinicians to prescribe and support the patient through

highly individualised programs potentially leading to improved patient outcomes.

Conclusion

It is the intention of this case report to highlight the mix of a manual treatment approach (OMT)

combined with an exercise and rehabilitation program, as a representative treatment model for

osteopathic practice. This is especially so for the subset of acute ankle injuries identified by

Whitman10 that don’t respond to the conventional treatment approach. Utilising OMT to manage

physical findings that may restrict or impact on the daily activities of the patient, as well as

15

supporting and enhancing a program aimed at restoring function and supporting independence

from treatment is a potential strategy to suit a variety of clinical situations.

References

1. Carcia CR, Martin RL, Houck J, Wukich DK, Orthopaedic Section of the American

Physical Therapy A. Achilles pain, stiffness, and muscle power deficits: achilles

tendinitis. J Orthop Sports Phys Ther 2010;40:A1-26.

2. Holm C, Kjaer M, Eliasson P. Achilles tendon rupture--treatment and complications: a

systematic review. Scand J Med Sci Sports 2015;25:e1-10.

3. Silbernagel KG, Crossley KM. A proposed return-to-sport program for patients With

midportion Achilles tendinopathy: rationale and implementation. J Orthop Sports Phys

Ther 2015;45:876-886.

4. de Jonge S, van den Berg C, de Vos RJ, van der Heide HJ, Weir A, Verhaar JA et al.

Incidence of midportion Achilles tendinopathy in the general population. Br J Sports

Med 2011;45:1026-1028.

5. Erickson BJ, Cvetanovich GL, Nwachukwu BU, Villarroel LD, Lin JL, Bach BR, Jr. et al.

Trends in the management of Achilles tendon ruptures in the United States medicare

population, 2005-2011. Ortho J Sports Med 2014;2:2325967114549948.

6. Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse

injuries in sports: A systematic review. Scand J Med Sci Sports 2013;23:669-686.

7. Kelly A-M. The minimum clinically significant difference in visual analogue scale pain

score does not differ with severity of pain. Emerg Med J 2001;18:205-207.

8. So V, Pollard H. Management of Achilles tendon disorders. Australasian Chiropractic &

Osteopathy 1997;6:58-62.

16

9. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N et al. The VISA-A

questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy.

Br J Sports Med 2001;35:335-341.

10. Whitman JM, Childs JD, Walker V. The use of manipulation in a patient with an ankle

sprain injury not responding to conventional management: a case report. Man Ther

2005;10:224-231.

11. Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle

sprains. Man Ther 2008;13:63-67.

12. Saini SS, Reb CW, Chapter M, Daniel JN. Achilles tendon disorders. Journal of the

American Osteopathic Association 2015;115:670-676.

13. Wong CK. Strain counterstrain: current concepts and clinical evidence. Man Ther

2012;17:2-8.

14. Krueger B, Becker L, Leemkuil G, Durall C. Does talocrural joint thrust manipulation

improve outcomes after inversion ankle sprain? J Sport Rehabil 2015;24:315-321.

15. Fujii M, Suzuki D, Uchiyama E, Muraki T, Teramoto A, Aoki M et al. Does distal

tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? Man Ther

2010;15:117-121.

16. DiGiovanna EL, Schiowitz S, Dowling DJ. An osteopathic approach to diagnosis and

treatment: Lippincott Williams & Wilkins; 2005.

17. Grieve R, Clark J, Pearson E, Bullock S, Boyer C, Jarrett A. The immediate effect of

soleus trigger point pressure release on restricted ankle joint dorsiflexion: a pilot

randomised controlled trial. J Bodywork Movement Thera 2011;15:42-49.

18. Scott LA, Munteanu SE, Menz HB. Effectiveness of orthotic devices in the treatment of

Achilles tendinopathy: a systematic review. Sports Med 2015;45:95-110.

17

19. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower

repetition-volume protocol for midportion Achilles tendinopathy: a randomized

controlled trial. J Orthop Sports Phys Ther 2014;44:59-67.

20. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy

loading programmes : a systematic review comparing clinical outcomes and identifying

potential mechanisms for effectiveness. Sports Med 2013;43:267-286.

21. O’Neill S, Watson PJ, Barry S. Why are eccentric exercises effective for Achilles

tendinopathy? Int J Sports Phys Thera 2015;10:552.

22. Rabin A, Kozol Z, Finestone AS. Limited ankle dorsiflexion increases the risk for mid-

portion Achilles tendinopathy in infantry recruits: a prospective cohort study. J Foot

Ankle Res 2014;7:1-7.

23. Iversen JV, Bartels EM, Langberg H. The Victorian Institute Of Sports Assessment -

Achilles Questionnaire (VISA-A) - A reliable tool for measuring Achilles tendinopathy.

Int J Sports Phys Thera 2012;7:76-84.

24. Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP.

Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy:

A randomized controlled trial. Am J Sports Med 2015;43:1704-1711.

25. Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN.

Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports

Traumatol Arthrosc 2013;21:1345-1355.

26. Howell JN, Cabell KS, Chila AG, Eland DC. Stretch reflex and Hoffmann reflex

responses to osteopathic manipulative treatment in subjects With Achilles tendinitis.

Journal of the American Osteopathic Association 2006;106:537-545.

18

27. Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial Changes in Posterior Talar

Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals

With Recurrent Ankle Sprain. J Orthop Sports Phys Ther 2006;36:464-471.

28. Collins CK, Masaracchio M, Cleland JA. The effectiveness of strain counterstrain in the

treatment of patients with chronic ankle instability: A randomized clinical trial. J Man

Manip Ther 2014;22:119-128.

19

Table 1. Injury timeline.

February 2014 Diagnosed with left Achilles tendinopathy

March 2015 Right ankle inversion sprain
April 2015 Right Achilles pain and discomfort
June 2015 Provisional diagnosis of right Achilles tendinopathy

 
 

Table 2. Rehabilitation plan for each stage of the patients’ management.

Stage Strength Mobility & Proprioception Flexibility Agility/ CV

Fitness/
Sport
Specific
Initial (weeks 1-3) Isometric standing ABCs Gentle soleus and Bike
Pain management heel raise hold for dorsiflexion rocker gastrocnemius stretch (introduces
40-60 seconds 5 (knee to wall) dorsiflexion
repeats three times without
per day weight
bearing) 30
minutes 3
times per
week
Resisted ankle Proprioceptive single Self administered plantar Swim
(Theraband®) leg bias with toe touch fascia inhibition with a golf (breaststroke)
plantar and dorsi hold for 30 seconds ball freestyle
flexion exercises23 repeat 5 times 700m
10 repeats 3 sets submaximal
From week 3 effort
From Week 3
Standing
volleyball
sets (as
many reps as
required)

 
 

Stage Strength Mobility & Proprioception Flexibility Agility/ CV

Fitness/
Sport
Specific
Intermediate (weeks Isotonic heel raise Resisted ankle (Theraband®) Dorsiflexion rocker Continue with Figure 8
4-6) (knee straight and 15 repeats 3 sets gastrocnemius and soleus running
knee bent) one set Proprioceptive single leg balance stretching (option: seated exercises
to fatigue, no load with Theraband® use or Zigzag
eccentric-concentric. downward walking dog sprints 3m
Progress to single stance) line to
leg by week 6 baseline 10
repeats + add
3 block jumps
when reach
the net
Resisted ankle Golf ball plantar fascia Continue with
(Theraband®) inhibition standing
plantar and dorsi volleyball
flexion exercises 10 sets (around
repeats 3 sets the world with
basketball/
netball ring)

 
 

 
Advanced (weeks 7-9) Isotonic heel raise 3 x 15 on Proprioceptive single leg Continue with gastrocnemius Figure 8 with introduction of
step double leg, from week 9 balance on Bosu ball:24 with and soleus stretching ball and block jumps
progress to single leg added forward reach and hip
extension of contralateral leg
Single leg hops 10 repeats 3 Jumps from prone to standing
sets per leg in sagittal and on baseline with sprint and
frontal plane pass
Weeks 9-12 Isotonic heel raise 8 repeats 3 Commence plyometric double Continue with gastrocnemius Return to peak performance
sets double leg on step with 4 leg box jumps 10 repeats 3 and soleus stretching
kg KB/ backpack/ Smith sets
Machine/ loaded seated calf Lateral box jumps 10 repeats 3
raise progress to single leg sets
Progress load or add step into Progress to
Smith Machine single leg box jumps within
pain limits
Note: Patient continued with pain-modified training and game time throughout the 12 week rehabilitation plan