We talk a lot about how to treat chronic tendinopathy, but what should we do different with an acute first-time episode?
We discuss in this week’s podcast about acute Achilles tendonitis.
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#AskMikeReinold Episode 255: Treating Acute Achilles Tendonitis
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Show Notes
Transcript
Student:
So Tanya from Colorado Springs. How do you manage moderate to severe pain with acute Achilles tendinitis with no reported history of Achilles tendinopathy? The physician ordered oral steroids and a walking boot and no physical therapy for three to four weeks.
Lenny Macrina:
I would inject the tendon with steroids.
Mike Reinold:
Did they do it? No, it’s oral. They did oral. All right. Moderate to severe pain, acute Achilles tendonitis, no history of, this is the first episode.
Lenny Macrina:
Is this Dan Pope? Is there a name? Is there a [crosstalk 00:01:45].
Mike Reinold:
Is it weird that the first thing that went through my head is it’s gout. Dan, you want to give your case study of yourself and maybe talk about this a little bit?
Dan Pope:
I don’t know. I’ve seen this a few times too from some docs, and it makes me scratch my head a little bit. So if someone’s Achilles is hurting them a lot, and I think generally these folks have tried a few things. They’re not getting better and the doctor just suggests using a boot. So I don’t know if that’s what’s going on with your patient, but for most cases of tendinopathy, reactive tendinopathy, tendonitis, whatever you want to call it, generally, you’d like to have more of an active approach. Maybe they’re just so irritated that they’re not able to get through their regular life without flaring things up. Generally we want to keep people as active as we possibly can, but I think maybe in these cases the doc is figuring we just need to calm this down as much as possible. They keep flaring it up. Yeah, I don’t know what the question is, is the doctor making the right decision or what do you do in this instance?
Mike Reinold:
I think it’s more of what we do, right? I hate when you get these blanket statements. So you go on an oral steroid. It’s probably a five day dose pack, right? And then you say, go in a boot and no physical therapy for three to four weeks. Well, if the steroids work, you should be pretty dang close day six, day seven. What if you’re feeling great? We’re really going to literally do nothing for three more weeks and have nobody even monitor that, nobody even check on that, right? I don’t know. I’d say, Dan, from there, why don’t we ignore the no PT for three to four weeks part and just talk about how we would handle it. But acute to moderate Achilles tendonitis with no history, right? They’re in a boot for now. There’s nothing we can do. Let’s assume, now they just come to you for the first time a few weeks out of the boot. What’s your thought process on how they should present and what our next steps should be?
Dan Pope:
Yeah, I think that’s a little tough. Hopefully their pain levels are down, first and foremost, right? So let’s assume that they’re feeling pretty good at this point. They just got really weak. You just had them in a boot and nothing was working for a long period of time. So I think you have to be really careful for these folks. I’m guessing they’ve had a long history. They’re probably freaked out to move. I’m working with someone right now who had the same situation. A lot of foot pain, boot for a long period of time. Came out, they’re afraid to move whatsoever because at this point they haven’t and every time they tried to move it hurt in the past. So I think you have to, A, instill a little bit of confidence in that person, but B, also be really cautious.
Dan Pope:
For a lot of these folks I’m recommending a pedometer just because we have to make sure they’re not walking too much throughout the course of the day. And you see all sorts of people. Some people are way too afraid to move and other people don’t care and they do way too much. So I think you have to get a feeling of what type of person that is. And then once you get that idea, we have to very slowly start strength training them with really basic and easy stuff. So calf raise variations. Probably do really well with a seated calf raise variation because you don’t even have to use your full body weight. Probably start with some double leg calf raises and slowly progress over the course of time.
Dan Pope:
Very careful monitoring of symptoms, seeing if they’re flaring up. Being okay with a little bit of pain, but if it really starts flaring up to the point where it was before you probably have to back down quite a bit. And then just ride that rollercoaster of the course of time and give more when they need it and back off when they need. And progress back to your goals slowly over time.
Mike Reinold:
What level of discomfort would you be satisfied with during this progression? Because it’s probably going to be pretty unrealistic that there’s zero out of 10, right? This is your biggest tendon in the body for a reason because you’re putting so much stress on it throughout the day. What’s acceptable for you?
Dan Pope:
Yeah. There’s a lot of answers in the literature for different tendons in the body. I think the biggest one is probably pain the following day, and that’s mostly in the patellar tendon research. You’ll also see what’s tolerable being another one that’s in research, and the rotator cuff. In general, I like to keep pain minimal. So I tell people, let’s say keep it at a three out of 10 or less if you’re able to. And some folks just aren’t. So you’re probably going to have to dabble in something a little bit higher. And the next day we want to make sure their pain levels are back to their baseline. But if someone hasn’t moved in months, there’s a chance it’s going to be pretty sore. And we expect that. It might not be a bad thing. What I tell people is that the pain levels are important, but the bigger thing is that are you making progress from week to week and month to month?
Dan Pope:
And I also tell them, it’s kind of like losing weight. If you’re trying to lose weight and you look at the scale every single day, you’re probably going to be frustrated. But if you weigh yourself every two weeks, every month, you’ll see that change. And that probably gives us good feedback of whether or not we’re doing things appropriately. So if you’re having minimal pain or moderate pain, but over the course of time you’re getting stronger, pain levels are going down with activities that used to hurt. We’re moving in the right direction. I’m not even that concerned about pain at that point because I know we’re moving in the right way.
Mike Reinold:
I like it. So some big tidbits right there is you have to do a gradual progression of load, right? So that goes from seated calf raises, standing, double, single. Then we start getting more dynamic with load. Then we get more dynamic with movement and speed of movement. And then jumping. There’s a huge progression what we need to do. Make sure that you’re starting in the right spot. And then in order to go to that next step, like Dan said, maybe three out of 10 discomfort at most during, right? You could argue if you’re zero out of 10, that your Achilles could handle more, right? And you should be maybe going to the next exercise on your progression, right? So think of it that way. But then to see how you handled today’s workload is how well you recovered the next day.
Mike Reinold:
I think that’s the key for us is map out your progression of non, not non-weight, but walking in a boot and doing no PT to running and jumping. And fill in the gap with every exercise in between. And just say like, what’s my criteria to keep going through that progression? I think that was awesome. Can I also jump in here too before, because I know Dave’s got some too, but I just want to say that that pedometer thing was amazing, right? And that is one of those things a lot of people don’t think about and don’t put a lot of emphasis on. And even Dan, you even do this as like yeah, yeah, hand a pedometer and kept going. But that is huge. If you really want to work and see somebody’s progression is use a pedometer or use an app on your phone or watch or whatever you may have and actually see that and monitor it over time.
Mike Reinold:
What if you did your exercise progression, but then they went to the mall that night, right, or something like that. And you had no idea. And the next day they’re sore. You’re like, wow, it must have been from those seated calf raise as we did, right? And you’re like, no. So putting that all together with a pedometer is gold. And I think that’s a lot of things that we don’t do is PT is just an hour out of the week or whatever, right? It’s not all those other minutes. So huge advice, Dan, I like that. Dave, did you have something too?
Dave Tilley:
Yeah, I just wanted to give some more thoughts too because I think a lot of people, especially working with any athlete really who has an Achilles issue. So I unfortunately see a lot of Sever’s disease in younger athletes, but also older Achilles [inaudible 00:09:08] and also tears as well. But I think that the progression out of the boot is sometimes such a struggle. It’s similar to how doc’s sometimes are like, all right, no lunges ever, no squats ever, but you can run on three months, right? [crosstalk 00:09:18].
Mike Reinold:
Right.
Dave Tilley:
It’s like wear the boot for four weeks and, yeah, go for it. Try to do some jogging. And I think that lack of guidance around the blue transition really makes a lot of people frustrated because they can’t get back to daily life. And it just came to my mind because I literally had someone last night who, she had a talar dome issue, but was instructed to come out of the boot and she’s really struggling a lot just to walk normally and not have any pain.
Dave Tilley:
So I think using one, a heel wedge for these people is really important. Is to give them, usually you get them at like CVS or someone, but there’s like three layers you can rip away, like a half centimeter, I’m sorry, a half inch every time. If they go from the boot, the boot is so rigid. They have zero dorsiflexion and it gets really, really stiff in the calf and really stiff in their Achilles. So especially with insertional tendinopathies, they don’t really like that deep compression dorsiflexion. If you’re going upstairs and you just get your toes on the stairs and stoop down, it triggers pain for a lot of people.
Dave Tilley:
So if you can use the heel wedge, maybe you use, okay, we’re going to come out of the boot for, when you’re walking at school, I want you to use the boot because it’s a long distance. But then when you’re at home, let’s take the boot off and wear a sneaker with a heel wedge. And then you can go down to a half and then three quarter and then down to the final one over the course of maybe two weeks. And people, as they get their mobility back and start to load, like Dan said, if they could monitor their activity to do that, it really helps a lot with the transition. And so I’m educating a lot of people like, yes, I know you’re clear of the boot, but let’s give it two weeks to slowly get you back because you probably walk eight miles a day between all the stuff that you do. And I found that very, very helpful for people who kind of struggled to kind of get that [crosstalk 00:10:39].
Mike Reinold:
I would imagine coming out of a boot feels terrible. I’ve never been in a boot for four weeks. I can imagine. That seems aggressive. And again too, why can’t we be doing some general range of motion exercises and stuff during that. It’s like, come on docs. We got to get better with that so that way when we can start putting weight through the tendon, it’s not both a mobility and a loading restriction now, right? Crazy.
Dave Tilley:
Yeah.
Mike Reinold:
Mike, what’s up, Mike? What do you think?
Mike Scaduto:
Yeah, I was just thinking, and Dave just touched on this a little bit, but from a diagnostic specificity standpoint, I think, especially with an acute tendonitis, you probably want to be pretty specific with your diagnosis if it’s more insertional or if it’s mid-substance because I think that does help guide the exercise selection. Maybe more of an insertional down by the calcaneus really flared up. When you’re working on your calf raises, you may just have them go to neutral at the beginning and not go past into dorsiflexion because that will recreate some of their compressive issues if you think they’re having issues with compression of the tendon around the calcaneus. Versus more of a mid-substance, maybe you can work into a deeper dorsiflexion range when you’re doing your calf raises and your seated calf raises. They may be able to tolerate that pretty well. So I think it does guide the exercise selection, especially early on when you’re trying to calm down the area, but also generate a little bit of capacity in the calf. I think that can be fairly helpful for people.
Mike Reinold:
Yeah. To me, this seems like a fun one, right? Think about what Mike and Dan just talked about. We get to think of this huge exercise loading progression, which I think that’s what we think is fun in our world, right? It’s like, how do you get from point A to point Z, right, and all those things in between? And that’s great tidbits on variations on how you would do it. This is actually a fun one for me in my mind because this is PT to the tee, right? It’s workload progressions, exercise selections, and just gradual building them up over time. This is a perfect one.
Mike Reinold:
Awesome, good stuff. Well, hopefully that helps Tanya. Never fun to deal with somebody in that much pain, especially with an Achilles. Achilles are tough. You don’t want that thing to progress, and that’s probably what the physician was thinking there when they got so conservative on her, but something to keep in mind. But awesome stuff. Good luck with that. If you have questions like that, again, head to MikeReinold.com, click on that podcast link, and you can fill out the form to ask away. But be sure to subscribe, rate, and review us on iTunes and Spotify. And we’ll see you on the next episode. Thanks again.
