Effects of heel support banding using an elastic band on chronic pain at the achilles tendon in a mountaineer.

[Purpose] This study developed heel support banding (HSB) using an elastic band for flexible heel support and investigated its effect on chronic Achilles tendon pain of a mountaineer. [Subject] A 40-year-old male mountaineer with chronic Achilles tendon pain [Methods] Ankle dorsiflexion and plantar flexion angles, VISA-A questionnaire, load-induced pain, total pain threshold and tenderness at 3 kg of pressure were measured before and after applying HSB.
[Results] After one month of applying HSB, the dorsiflexion and plantar flexion angles increased; the VISA-A questionnaire score increased; the load-induced pain assessment score decreased; the pain threshold increased; and tenderness at 3 kg decreased.
[Conclusion] These results indicate that HSB use improves ankle range of motion, decreases pressure and pain, and could provide a new approach for effective intervention and management of chronic Achilles tendon pain.

INTRODUCTION

The Achilles tendon attaches the plantaris, gastrocnemius, and soleus muscles to the heel1). Excessive stress or tight or fatigued gastrocnemius and soleus muscles can result in microtrauma, degeneration, or inflammation of the tendon—a condition called Achilles tendonitis/tendinosis1). This condition can occur in the general population2) and is exacerbated by prolonged walking, excessive running, jumping, or walking hills. Mountaineering and mountain-related activities are associated with significant risk of injury in the ankle joint and Achilles tendon3). The nomenclature for disorders of the Achilles tendon is important, as the treatment is dependent on the underlying tendon pathology4) Achilles tendon conditions such as tendinosis are often chronic and non-inflammatory, although the area can be painful to touch. The condition is characterized by tendon degeneration2). Based on the etiology, Achilles tendinosis can be caused by a combination of factors such as failure of the normal healing mechanisms and repeated trauma5). The Achilles tendon serves to attach the plantaris, gastrocnemius, and soleus muscles to the calcaneus (heel) bone1).This study developed heel support banding (HSB) using an elastic band for flexible heel support and investigated its effect on chronic Achilles tendon pain of a mountaineer.

SUBJECT AND METHODS

A 40-year-old male mountaineer with chronic Achilles tendon pain participated in this study. The purpose and methods of the study were explained to the participant and informed consent was obtained according to the principles of the Declaration of Helsinki. The patient complained of chronic pain in the Achilles tendon of the right leg. He developed severe pain during active plantar flexion and palpation of the pre-insertion area of the Achilles tendon after mountain climbing, which he does three times per week. Active dorsiflexion and active plantar flexion, measured with a goniometer, were 13° (population normal angle, 20°) and 28° (population normal angle, 45°), respectively, due to pain. The VISA-A questionnaire is a reliable and valid instrument for the evaluation of pain intensity and levels of function in patients with Achilles tendon disorders. Scores on this eight-item questionnaire ranged from 0 to 100. A score of 100 indicates no pain and complete function6). The VISA-A questionnaire score was 56 (normal population range >95), and the load-induced pain, assessed on a numeric rating scale from 0 to 10, was 7. The pressure-pain threshold, assessed with an algometer (Pain Test-Model FPK; Wagner Instruments, Greenwich, CT), was 2.0 kg. Rompe et al.6) defined tenderness using a numeric rating scale following the application of 3 kg of pressure to the most tender area of the Achilles tendon. The tenderness at 3 kg, assessed on a numeric rating scale from 0 to 10, was 8. HSB is an elastic band (about 250 cm long), divided into four sections with the center piece binding together to form a figure X. To apply the band, the center of the band was placed above the knee approximately 5 cm from the patella. The thigh was tied with 2 pieces of the elastic band. Second, the other two pieces were placed longitudinally along the lower leg, while the third section of the band wraps around the lower leg, approximately 5 to 7 cm below the knee, and was bound to itself laterally. The fourth piece was tied to the transverse band. The third and fourth pieces of the band crossed each other at half of the distance between the foot and patella. Finally, these pieces of the band were placed around the foot and support the heel and foot arch. An elastic band of proper strength for the patient was selected by a therapist for maximum support of the heel and foot arch. The range of elastic bands includes black, silver, blue, green, red, and yellow. The patient in the study applied a level silver band prior to mountain climbing and proceeded to climb three times a week for one month. When climbing a mountain, he applied the HHSB.

RESULTS

After one month of applying the HSB, the dorsiflexion and plantar flexion angles increased to 18° and 37°, respectively, compared to the initial 13° and 28°. The VISA-A questionnaire score increased to 79 compared to the initial 56. The load-induced pain assessment decreased to 4 compared to the initial 7. The pain threshold increased to 5.2 kg compared to the initial 2.0 kg and tenderness at 3 kg, assessed on a numeric rating scale, decreased to 3 compared to the initial 8.

DISCUSSION

The function of this musculotendinous unit is to serve as the chief plantar flexor of the ankle joint during walking and running, providing the primary dynamic force for locomotion and jumping5, 7). Based on the etiology, the Achilles tendinosis was caused by a combination of failure of the normal healing mechanisms and repeated trauma5). The severe pain may have occurred gradually as repetitive microtrauma was imposed on the Achilles tendon. For this, this study developed HSB using an elastic band and investigated its effect on chronic Achilles tendon pain of a mountaineer. The result showed that after one month after applying HSB, the dorsiflexion and plantar flexion angles increased, the VISA-A questionnaire increased, the load-induced pain assessment decreased, the pain threshold increased and tenderness at 3 kg, assessed on a numeric rating scale, decreased. The tension of HSB created by increased stimulation during active ankle movement may have also created tension in the soft tissue structures. Increased tension may facilitate a pain inhibitory mechanism by providing an afferent stimulus to large-diameter nerve fibers to mitigate nociception. As the patient’s pain level reduced, the fear of pain during ankle movement might have reduced by proper sensory feedback, thus improving ankle range of motion. A Thera-Band, which provides varied resistance through the range of movement, has been used for rehabilitation in combination with therapeutic exercise8). It is light and portable, has low resistance, and can be adjusted to accommodate various situations9). In conclusion, one month of HSB for flexible heel support improved range of motion in the ankle and reduced pain. Therefore, the HSB could provide a new approach for effective intervention and management of chronic Achilles tendon pain.