Chiropractic + Naturopathic Doctor • October 2019 • Technique toolbox

The patient was a 60-year old female that developed acute onset of pain related to Achilles (Calcaneal) tendinopathy on her right side. She had surgical repair of the left Achilles approximately 10 years ago that was deemed successful, but necessitated a six-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. As 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 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. She was referred for a consultation for manual therapy by her family physician when there was minimal improvement over a period of three weeks and ongoing and increasing pain with activity.

Initial assessment of the patient revealed 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 is worse with running. Evaluation of her right Achilles tendon revealed a hardened nodule beginning approximately three cm superior to the attachment site of the calcaneus and measuring approximately eight 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, 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 two sessions per week with at least two days of rest in-between sessions for a period of three weeks, followed by one session per week for an additional four weeks. That’s a total of 10 treatment sessions over a seven-week period. Each session consisted of five minutes of moist heat of the Achilles and gastroc/soleus. It also included two to three 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 towards fascial restrictions.

The areas that were treated with GT 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 number six and onwards, 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 one 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.

• Complete absence of pain reported on plantar flexion and dorsiflexion when weight bearing with one-legged and two-legged functional tests

• Marked reduction of size of the nodular tissue on the Achilles on palpation and measurement

Graston Technique therapy incorporates a sequential protocol; assessment, treatment, exercise, reassessment. A recent systematic review demonstrated moderate evidence for the GT protocol in the treatment of tendinopathies1. 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 seem 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. Provocation with dynamic movements, the histology of the tendon structure changes and thus treatment responses change. 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, 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.

Dr. John Dang, DC, GTS, MSc (Cand) has over 19 years of clinical expertise and is the director of Columbia Integrated Health Centre in New Westminster, BC. He is an adjunctive professor at The Vancouver College of Massage Therapy and is a lead instructor for Graston Technique, LLC. While currently working towards his Masters in Anatomy and Physiology Instruction with New York Chiropractic College, his clinical case load involves specializations in advanced soft tissue mobilization and functional rehabilitation.

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).