A Case Study for Treating Chronic Achilles Tendinopathy

The patient was a 60-year old female who developed acute onset of pain related to Achilles (Calcaneal) tendinopathy on her right side.

She had a surgical repair of the left Achilles approximately 10 years ago, which was deemed successful, but necessitated a 6-month period of post-surgical rehabilitation with a complete arrest of all forms of physical activity.

She was asymptomatic and fully functional on her left side lower leg with full strength and full mobility.

She was a very healthy senior who continued to remain very physically active by participating in competitive level tennis and basketball. She opted for a more conservative approach to her current condition so that she could continue to participate in her sports and not require an extended period of rest and absence from her activities.

The patient presented to the clinic for an assessment approximately 1.5 months after the initial onset of the pain symptoms. Initially, she employed ice, rest, stretching, and OTC anti-inflammatories to manage the pain symptoms. As there was minimal improvement over a period of 3 weeks and there was ongoing and increasing pain with activity, she was referred for a consultation for manual therapy by her family physician.

Initial assessment of the patient revealed that she walked with a slight limp during her gait that was most evident on the toe off portion of her right step. She stated that the pain was worse with running.

Evaluation of her right Achilles tendon revealed a hardened nodule beginning approximately 3 cm superior to the attachment site of the calcaneus and measuring approximately 8 mm wider than her left surgically repaired Achilles tendon at the same location.

Physical examination revealed 4/5 pain on the VAS with palpation, 3.5/5 pain on single leg ipsilateral weight bearing plantar flexion test, 4/5 strength test on ipsilateral weight bearing plantar flexion test, and failed weight bearing lunge test for ankle/tendon mobility.

Diagnostic ultrasound was utilized to verify the size of the nodule and the results demonstrated altered homogeneity of the tendon with signs of localized edema around the nodule.

Treatment frequency consisted of 2 sessions per week with at least 2 days of rest in-between sessions for a period of 3 weeks, followed by 1 session per week for an additional 4 weeks for a total of 10 treatment sessions over a 7 week period. Each session consisted of 5 minutes of moist heat of the Achilles and gastroc/soleus, and 2-3 minutes of manual soft tissue therapy that included myofascial release and Proprioceptive Neuromuscular Facilitation (PNF).

Graston Technique® (GT) was performed with Graston® instruments 2, 3, 4, and 6 using sweeping, swiveling, strumming, and brushing strokes for approximately 3-4 minutes.

Sweeping and brushing are very light introductory strokes that are gentle and desensitizing for the patient.

Swiveling and strumming are more aggressive strokes that are therapeutic in nature and geared toward fascial restrictions.

The areas that were treated with Graston Technique® included the gastrocnemius, soleus, Achilles tendon (including the nodule), calcaneus, and plantar aponeurosis.

The patient was given home care that included both concentric and isometric exercises, eccentric unloading, and sustained posterior chain stretches.

Taping was also employed on an intermittent basis to assist in managing the post treatment soreness and any localized tissue swelling.

At visit #6 and onward, dynamic pin and stretch and pin and glide strokes were initiated, as well as progressions into resistance band eccentric unloading and closed chain half kneel dynamic strokes. This treatment approach targeted the tissue in positions of provocation, as well as addressing the posterior fascial chain. GT instruments 2 and 4 were utilized during the pin and stretch and pin and glide therapy sessions.

Currently, the patient has been discharged with instructions to maintain her home care exercises. A follow up appointment has been booked in approximately 1 month to reassess the nodule of the tendon, determine the patient’s function, and to make further recommendations if required. The patient has been given approval to continue her sporting activities, but was instructed to monitor her pain symptoms during and after activity.

At her last visit, the following post treatment reassessment results were found:

• At least a 90% reduction in pain symptoms on palpation.
• Complete absence of pain reported on plantar flexion and dorsiflexion when weight bearing with 1 legged and 2-legged functional tests.
• 2.3 cm gain in the half knee weight bearing lunge test.
• Marked reduction in the size of the nodular tissue on the Achilles on palpation and measurement.

Graston Technique® (GT) therapy incorporates a sequential protocol; assessment, treatment, exercise, reassessment.

A recent systematic review demonstrated moderate evidence for the GT protocol in the treatment of tendinopathies(1). It is impossible to ascertain exactly which of the treatment approaches provided the most therapeutic benefit to the patient’s condition of chronic Achilles tendinopathy. She reported that all the treatment therapies seemed to help and make her “feel better.” From a functional perspective, the patient demonstrated the most progress when treated with GT in dynamic and functional movements. As it is with most treatment approaches for musculoskeletal conditions, each clinical case may be slightly different, and as this is only one case study of Achilles tendinopathy in a senior athlete, a combination of therapies and techniques were utilized to treat and manage the condition.

Thus, based on this case study, there seems to be a strong indication that the Graston Technique® (GT), when used as a manual technique in conjunction with other manual therapies, may be beneficial to the management of chronic Achilles tendinopathy.

This is especially evident when adhering to the GT therapy protocol and GT treatment progressions. Finally, the results also indicated that ice, rest, and OTC medications alone are of little benefit and perhaps may even delay the recovery process.

1. Thompson JA, Crowder L, Le D, Roethele AJ, Efficacy of instrument-assisted soft tissue mobilization for the treatment of musculotendinous injuries: a systematic review. Journal of Orthopedic & Sports Physical Therapy, 2018;48(1).

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