When Achilles Tendonitis Is Not Caused By A Tight Achilles
A patient comes into the office with an aching sensation in the posterior aspect of the right leg. He notes the pain has been increasing in the past two to three months and has gotten worse since he began to exercise. Specifically, in the past three weeks, the patient says he has had tightness in the Achilles tendon region. During that specific time period, the patient notes that he began a walking program on a slight hill by his house. He notes the hill provides a slight exertion that has been excellent for his stamina. The patient says he has only had the pain after a long climb and when he works out more than two times per week. He has tried over-the-counter orthotics, physical therapy for Achilles tendonitis as per his internist and a course of non-steroidal antiinflammatory medication as well. What Does The Examination Reveal? The patient is a healthy 24-year-old male who is slim and muscular in nature. Upon doing a clinical examination, we found that the patient has excellent muscle strength and only notes pain in the watershed region or distal midsubstance of the Achilles tendon. We did note callus formation of the forefoot, plantar to metatarsal heads one through four. The fifth metatarsal head is slightly callused. While there is no pain in the forefoot, the patient does have mild extensor tightness of the toes with mild hammering of all the toes. The hammering is flexible and reduces with patient ambulation and plantar pressure on the metatarsal heads. Dorsiflexion of the foot causes some extensor use. The patient’s rearfoot is well positioned with adequate motion of calcaneus and ankle. There is an equinus of the ankle with full dorsiflexion, which is soft in nature. There is no alteration in the equinus with the knee bent or straight. Upon doing a lateral inspection of the foot, we noted a cavus foot, which does not reduce with dorsal forefoot pressure. The patient has tightness of the plantar foot musculature and the plantar fascia. On a lateral plane, the forefoot lays below the level of the rearfoot with increased plantar position of the first metatarsal in comparison to the lateral metatarsals. Radiographs reveal a cavus foot with an increase in the calcaneal inclination angle and a plantarflexed forefoot position. The high point of the foot is in the midfoot at the region of the naviculocuneiform joint. Gait analysis reveals a normal gait pattern with a slight lateral heel position and an early heel off with ambulation. The patient inverts when standing and stays in a supinated position during the entire gait cycle. When we question this patient further as to walking patterns, he reveals that he has had mild midfoot pain and slight anterior ankle pain with ambulation. These problems have also been increasing in severity in the past three months. What Is The Diagnosis? 1. Primary Achilles tendonitis secondary to Achilles equinus 2. Gait changes due to arthritis of the foot 3. A supinated gait pattern causing Achilles tendonitis 4. A cavus deformity causing Achilles tendonitis. The correct answer is a cavus deformity causing Achilles tendonitis. However, this is a very simplistic answer to a very difficult problem. In order to provide effective treatment, one has to determine if the patient has a global cavus, a forefoot cavus, a rearfoot cavus or a combination cavus. Diagnostic Answers In order to understand cavus deformity, you need to consider the foot as a tripod. If the first metatarsal sits below the level of the lateral metatarsals, the foot or tripod will tilt laterally. If the heel is in varus position, the foot or tripod tilts laterally. If the entire forefoot sits below the level of the heel, the foot may not tilt medially or laterally, but may require additional dorsiflexion to get to a rectus position. This additional dorsiflexion may place a strain on the posterior ankle tendons and cause impingement on the anterior ankle region. There may also be strain on the high point of the foot with a global forefoot cavus. The best test of cavus feet is to perform a Coleman block test. Do this by placing the forefoot on the block and allow the heel and first metatarsal to hang off the block. If the heel position goes from varus without use of the block to rectus with use of the block, the heel varus is secondary to the first metatarsal being plantarflexed and is not due to the actual heel position. If there is no change, then there is a possible heel varus and a plantarflexed first metatarsal.