medicina

Case Report
Pain and Function in the Runner a Ten (din) uous Link
Peter Francis 1,2, * , Isobel Thornley 2 , Ashley Jones 2 and Mark I. Johnson 2,3
1 Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland
2 Musculoskeletal Health Research Group, Leeds Beckett University, Leeds LS13HE, UK;
[email protected] (I.T.); [email protected] (A.J.);
[email protected] (M.I.J.)
3 Centre for Pain for Research, Leeds Beckett University, Leeds LS13HE, UK
* Correspondence: [email protected]; Tel.: +353-59917-5000




Received: 28 November 2019; Accepted: 27 December 2019; Published: 7 January 2020


Abstract: A male runner (30 years old; 10-km time: 33 min, 46 s) had been running with suspected
insertional Achilles tendinopathy (AT) for ~2 years when the pain reached a threshold that prevented
running. Diagnostic ultrasound (US), prior to a high-volume stripping injection, confirmed right-sided
medial insertional AT. The athlete failed to respond to injection therapy and ceased running for a
period of 5 weeks. At the beginning of this period, the runner completed the Victoria institute of
sports assessment–Achilles questionnaire (VISA-A), the foot and ankle disability index (FADI), and
FADI sport prior to undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle
architecture (muscle thickness (MT) and pennation angle (PA); US), muscle contractile properties
(maximal muscle displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and
calf endurance (40 raises/min). VISA-A and FADI scores were 59%/100% and 102/136 respectively.
Compared to the left leg, the right GM had a lower MT (1.60 cm vs. 1.74 cm), a similar PA (22.0◦ vs.
21.0◦ ), a lower Dm (1.2 mm vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in
the right leg compared to the left (48 vs. 43 raises). The athlete began a metronome-guided (15 BPM),
12-week progressive eccentric training protocol using a weighted vest (1.5 kg increments per week),
while receiving six sessions of shockwave therapy concurrently (within 5 weeks). On returning to
running, the athlete kept daily pain (Numeric Rating Scale; NRS) and running scores (miles*rate of
perceived exertion (RPE)). Foot and ankle function improved according to scores recorded on the
VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Improvements in MT (1.60 cm vs. 1.76 cm) and PA
(22.0◦ vs. 24.8◦ ) were recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms
vs. 15.4 ms) were recorded via TMG. Calf endurance was lower in both legs and the asymmetry
between legs remained (L: 31, R: 34). Pain intensity (mean weekly NRS scores) decreased between
week 1 and week 12 (6.6 vs. 2.9), while running scores increased (20 vs. 38) during the same period.
The program was maintained up to week 16 at which point mean weekly NRS was 2.2 and running
score was 47.

Keywords: chronic pain; pain management; Achilles; tendon; running

1. Introduction
Achilles tendinopathy (AT) is the 2nd most common running injury [1,2]. It is primarily located
in the mid-portion of the tendon or at the insertion with the calcaneus (insertional tendinopathy) [3].
The stages of tendinopathy have been characterized as reactive (a non-inflammatory cellular response
to acute loading that results in tendon thickening), dysrepair (failed healing that demonstrates greater
matrix breakdown and the separation of collagen) and degenerative (increased cell death, matrix
breakdown, neuronal and capillary in growth) [4]. Pain can be present or absent at any stage of the

Medicina 2020, 56, 21; doi:10.3390/medicina56010021 www.mdpi.com/journal/medicina

Medicina 2020, 56, 21 2 of 10

tendon pathology continuum. Furthermore, tendons can have discrete regions at different stages of the
pathology-continuum at the same time [4,5]. Pathological findings as a result of imaging the tendon do
not always correlate with patient symptoms [6].
The majority of running injuries are characterized by repetitive overuse and are usually to tissues
ill-equipped for load absorption (i.e., non-contractile) [1]. The insidious onset of pain at a threshold
(e.g., <5/10 on a Numeric Rating Scale; NRS) [7] below that experienced during traumatic insults
often allows the runner to continue to run. In other words, there is a dissociation between pain and
function in chronic injuries [8]. There are several pharmacological (e.g., NSAID’s, injection therapy)
and non-pharmacological (e.g., heavy isometric loading, shock-wave therapy, cross-training) aids
that produce short-term analgesic effects in tendinopathy [9–13]. However, chronic pain can reach a
threshold whereby it is more akin to that experienced in traumatic pain (>5/10 on an NRS). This can
force the athlete to stop running and seek longer-term resolutions.
The strongest evidence for the long-term resolution for Achilles tendon pain comes from exercise
protocols [14]. Variations of the Alfredsson protocol (straight and bent knee eccentric exercise on
the edge of a step) [15,16] appear to be most effective in patients with mid-portion tendinopathy.
Excessive dorsi-flexion on the edge of a step is thought to increase the compressive load at the tendon
insertion and therefore, straight leg exercises on a flat surface appear to be more effective for those with
insertional tendinopathy [17]. These protocols have been further enhanced by a greater understanding
of the other neuromuscular deficits that occur as a result of Achilles tendon injury. For example,
externally paced eccentric exercise using a metronome standardizes the time the muscle is under
tension and enhances neural plasticity [18].
The reasons pain and function respond positively to this form of training are multi-factorial [19].
To the best of the authors’ knowledge, there are no scientific reports which capture self-reported
function (Victoria institute of sports assessment–Achilles questionnaire; VISA-A, the foot and ankle
disability index FADI, and FADI Sport) [20–22], muscle architecture (Ultrasonography; US), muscle
contractile properties (Tensiomyography; TMG), muscle endurance (Calf Endurance Test) and pain
(Numeric Rating Scale; NRS) pre and post conservative Achilles tendon management.

2. Case Report

2.1. Case History

The patient provided written informed consent for the publication of this case report. A male
runner (30 years, 10-km time: 33 min 46 s) had been running with suspected insertional AT for
110 weeks (~2 years) having had the symptoms for the previous 5 years. The average miles per week
for the 2-year period was 30. The average miles per week during phases of race preparation was ~40
and the maximum miles per week was 50. During this period, pain (~≤5/10; NRS) and or stiffness
was present every morning during the first steps on walking. Pain usually subsided as running
progressed and returned after periods of prolonged rest. The runner used a 4-day-per-week running
schedule and a 3-day-per-week cross-training schedule to manage running loads applied to the tendon
and to lower the risk of other injury. Occasionally, pain increased (≥5/10; NRS) and was relieved
using heavy double-legged isometric exercise (~85 kg) and reducing running from four days to three.
No structured Achilles tendon rehabilitation was undertaken other than calf raise exercises on days the
runner attended the gym (maximum 2*per week). The above summarises the training and pain status
of the runner for much of the 2 years prior to cessation. This period included personal bests over 5 km
(16:10), 10 km (33:46) and half-marathon (78:00).
Nine weeks before cessation (week 101/110), the runner began to increase the volume and
sometimes intensity of one weekly run in an attempt to train for a marathon. This elevated daily
pain to 7/10 and to a point where conservative self-management (as above) was no longer effective.
The runner attended a sports medicine physician for an ultrasound guided high-volume stripping
injection as prescribed in Humphreys et al. [10]. The diagnosis of right-sided medial insertional AT
Medicina 2020, 56, 21 3 of 10

was made by a qualified medical doctor using ultrasonography. The doctor had ~20-years’ experience
Medicina 2019, 55, x FOR PEER REVIEW 3 of 10
in the diagnosis of musculoskeletal conditions, diagnostic ultrasound and steroid injection therapy.
Medicina 2019, 55, x FOR PEER REVIEW 3 of 10
The doctor was a member of the British Association of Sports and Exercise Medicine. Diagnosis was
The doctor was a member of the British Association of Sports and Exercise Medicine. Diagnosis was
obtained
The doctorby palpating the painful
of the site on the medial calcaneus
Sportsand using ultrasonography to imagewas
the
obtained by was a member
palpating the painful British
site onAssociation
the medialofcalcaneusand
andExercise Medicine. Diagnosis
using ultrasonography to image
same area
obtained (Figure 1).
by palpating Over the
theOver course
painful of 1 week (no running), the runner failed to respond to injection
the same area (Figure 1). thesite on the
course of medial
1 weekcalcaneus and using
(no running), ultrasonography
the runner to imageto
failed to respond
therapy and
the sametherapyceased
area (Figurerunning.
1). Over the course of 1 week (no running), the runner failed to respond to
injection and ceased running.
injection therapy and ceased running.

Figure 1. Identification of right-sided medial insertional tendinopathy.

Figure1.1. Identification
Figure Identification of right-sided medial insertional
insertional tendinopathy.
tendinopathy.

2.2. Assessment
2.2. Assessment
The
Therunner reported
runnerreported
reportedto tothe
to thelaboratory
the laboratory(Figure
laboratory (Figure2)
(Figure 2)2)at at
at Leeds
Leeds
Leeds Beckett
Beckett
Beckett University
University
University andand
and completed
completed
completed the
the
the Victoria
Victoria institute
Victoriainstitute
instituteof of
ofsports sports assessment-Achilles
sportsassessment-Achilles
assessment-Achilles questionnaire questionnaire (Victoria
(Victoria institute
questionnaire (Victoria instituteof institute
ofsports of sports
sportsassessment-
assessment-
assessment-Achilles
Achilles questionnaire;
questionnaire; VISA-A), VISA-A),
the foot andthe foot
ankle and ankle
disability disability
index (FADIindex
and(FADI
FADI
Achilles questionnaire; VISA-A), the foot and ankle disability index (FADI and FADI Sport), prior and FADI
Sport), Sport),
priortoto
prior to
undergoingundergoing
an an
assessment assessment
of of
bi-lateralbi-lateral gastrocnemius
gastrocnemius medialis medialis
(GM) (GM)
muscle
undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle architecture (muscle muscle architecture
architecture (muscle
(muscle
thickness
thicknessthickness
(MT)
(MT) and (MT)
and and pennation
pennation
pennation angle angleUS),
angle (PA);
(PA); (PA);
US), US), muscle
muscle
muscle contractile
contractile
contractile properties
properties
properties (maximal
(maximal (maximal
muscle
muscle
muscle displacement
displacement (Dm) (Dm)
and and contraction
contraction time time
(Tc); (Tc); Tensiomyography
Tensiomyography (TMG)) (TMG))
displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and calf endurance (40 and and
calf calf endurance
endurance (40
(40 raises/min).
raises/min).
raises/min).

(a)
(a) (b) (c)
(c)
Figure2.
Figure 2.2.The
Theuse
The useof
use ofultrasonography
of ultrasonography(US),
ultrasonography (US),
(US),tensiomyography
tensiomyography (TMG)
(TMG)
(TMG) and
and thethe
and calfcalf
the endurance
endurance
calf testtest
endurance inin
in the
test
the assessment
assessment of of
(a) (a)
musclemuscle architecture,
architecture, (b)
the assessment of (a) muscle architecture, (b) (b) contractile
contractile properties,
properties, and and
(c) (c) endurance.
endurance.
properties, and (c) endurance.

VISA-A
VISA-Aand
VISA-A andFADI
and FADIscores
FADI scoreswere
scores were
were 59%/100%
59%/100%
59%/100% and 102/136,
and respectively.
102/136, respectively.
respectively.Compared
Compared
Compared to to
the leftleft
tothe
the leg,leg,
left the
leg,
right GMGM had ahad
lower MT MT
(1.60 cm vs. ◦ ◦
theright
the right GMhad aalower
lower MT(1.60
(1.60 cm 1.74
cm cm),cm),
vs. 1.74
vs. 1.74 a similar PA PA
a similar (22.0 vs. vs.
(22.0°
(22.0° 21.021.0°),
vs. ), a lower
21.0°), aalowerDm
lower Dm(1.2
Dm mm
(1.2
(1.2 mm
mmvs.
2.0
vs.mm)
2.0 and
mm) Tc (16.5
and Tc ms vs.
(16.5 17.7
ms ms).
vs. Calf
17.7 endurance
ms). Calf was higher
endurance in
was the injured
higher in leg
the
vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in the injured leg (right) (right)
injured compared
leg to
(right)
the left
compared(48 vs.
to 43
the raises).
left (48 vs. 43 raises).
compared to the left (48 vs. 43 raises).

2.3.Intervention
2.3. Intervention
Theathlete
The athlete ceased
ceased running
running for
for 55 weeks
weeks and
and began
began aa metronome
metronome guided
guided (15-BPM),
(15-BPM), 12-week
12-week
progressive eccentric training protocol (3 sets, 12 reps, 2*day) on a flat surface, using a weighted-vest
progressive eccentric training protocol (3 sets, 12 reps, 2*day) on a flat surface, using a weighted-vest
 Medicina 2020, 56, 21 4 of 10

2.3. Intervention
The
Medicina 2019,athlete ceased
55, x FOR running
PEER REVIEW for 5 weeks and began a metronome guided (15-BPM),4 12-week of 10
progressive eccentric training
Medicina 2019, 55, x FOR PEER REVIEW protocol (3 sets, 12 reps, 2*day) on a flat surface, using a weighted-vest
4 of 10
(1.5
(1.5kg
kgincrements
incrementsper perweek).
week).The Theexercise
exercise waswas performed
performed by bybilaterally
bilaterally plantar flexing
plantar bothboth
flexing legslegs
andand
lowering
(1.5 unilaterally
kg increments on
per the affected
week). The leg
exercise to a
was count of
performed 4 s (15
by BPM).
bilaterally The athlete
plantar
lowering unilaterally on the affected leg to a count of 4 s (15 BPM). The athlete also received six sessions also
flexing received
both legs and six
sessions of
of shockwave shockwave
lowering unilaterally therapy
therapy (2000 on the (2000
affected
shocks shocks
perleg per session
to a count
session at a pressure
of 4 s (15and
at a pressure BPM). and frequency
The athlete
frequency of 1.8–2.2
also received
of 1.8–2.2 bar and bar
six10 Hz,
and 10sessions
Hz, respectively)
of shockwave concurrently
therapy (2000 within
shocks theper
first 5 weeks.
session at aThe athlete
pressure andrecorded
frequency daily pain scores
of 1.8–2.2 bar
respectively) concurrently within the first 5 weeks. The athlete recorded daily pain scores (NRS) [23]
(NRS)and[23]10throughout the intervention
Hz, respectively) concurrently(Figure within the 3). first
On 5return
weeks.toThe running
athlete(after 5 weeks),
recorded thescores
daily pain athlete
throughout the intervention (Figure 3). On return to running (after 5 weeks), the athlete also recorded
(NRS) [23]
also recorded throughout
a score composed the intervention
of miles * rate (Figure 3). On return
of perceived to running
exertion (RPE)(after
[24].5Running
weeks), the athlete
miles* rate
a score composeda of
also recorded
miles
score
* rate of
composed
perceived
of miles *in rate
exertion
of perceived
(RPE) [24]. (RPE)
exertion
Running miles* rate
[24]. Running
of perceived
miles* rate
of perceived exertion (RPE) was recorded order to provide a crude estimate of running load.
exertion (RPE) was
of perceived recorded
exertion (RPE) in order
was to provide
recorded a crude
in on
order to estimate
provide aofcrude
running load. ofRunning
estimate running began
load. with
Running began with a 2.5-mile jog, barefoot and a hard grass surface (British Summer Time). This
a 2.5-mile jog,
Running began barefoot
with and on
a 2.5-mile a hard grass
jog,athlete surface
barefootcould and on (British
a hard Summer
grassthree
surface Time). This
(British was
Summer progressed
Time). (week
was progressed (week 6–13) until the run 8 miles, times per week at an RPEThis of 11
6–13)was
until the athlete
progressed (week could
6–13) run 8 miles,
until threecould
the athlete times runper week three
8 miles, at antimes
RPE perof 11 (light).
week at anThe
RPElaboratory
of 11
(light). The laboratory measures were re-assessed at the 12-week point. The athlete continued to
(light).were
measures The re-assessed
laboratory measures were re-assessed
at the 12-week point. The at the 12-week
athlete continued point. The athlete
to perform the continued to
eccentric training
perform the eccentric training protocol and record pain and running load data up to week 16 (Figure
perform
protocol and the eccentric
record pain training
and protocol
running anddata
load record
up pain
to and running
week 16 (Figure load data
3). up to week
Between week 1613(Figure
and 16, the
3). Between week 13 and 16, the three 8-mile runs were replaced with an 8-mile run over an
3). Between
three 8-milesurface week
runs were 13 and
replaced 16, the
with three
an 8-mile 8-mile runs
runthat
over were replaced
an undulating with an
surface 8-mile run over an
undulating
undulating surface (shod; RPE:
(shod; 13),
RPE: a track
13), a tracksession
session thatbegan
beganwithwith44×× 400 400 m and(shod;
m and
RPE: 13),
progressed
progressed
a track
toto1616× ×
session
400 m400 that
(shod; began
RPE RPE with
15) and 4 ×
a long 400 m
runrun and
thatthat progressed
progressed to
toto 16 ×
1212miles 400 m (shod; RPE 15) and a long run
RPEthat
m (shod; 15) and a long progressed miles(barefoot
(barefoot and occasionallyshod;
and occasionally shod;RPE
progressed
11). to 12 miles (barefoot and occasionally shod; RPE 11).
11).

Figure 3. The
Figure intervention
3. The interventionfor
forthe
the management
management ofofmedial
medial insertional
insertional Achilles
Achilles tendinopathy.
tendinopathy.
Figure 3. The intervention for the management of medial insertional Achilles tendinopathy.
2.4. Outcomes
2.4. Outcomes
The The
athlete
2.4. Outcomes had had
athlete a compliance of 80.4%
a compliance (135/168
of 80.4% possible
(135/168 sessions)
possible to the
sessions) to 12-week eccentric
the 12-week training
eccentric
protocol. At
training the 12-week
protocol. point, foot and ankle function improved according to scores recorded
scoreson the
The athlete had aAt the 12-week
compliance of point,
80.4%foot and ankle
(135/168 function
possible improved
sessions) to theaccording
12-weektoeccentric
VISA-A (59% on
recorded vs.the
97%) and FADI
(59% (102 vs. 127/136). Figure 4 127/136).
displaysFigure
pre and post left–right differences
training protocol. AtVISA-A
the 12-week vs.point,
97%) and
footFADI
and (102
anklevs.function improved 4 displays pre and
according post
to scores
in gastrocnemius muscle
left–right differences inarchitecture
gastrocnemiusand contractile
muscle properties.
architecture and contractile properties.
recorded on the VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Figure 4 displays pre and post
left–right differences in gastrocnemius muscle architecture and contractile properties.

(a) (b)

Figure 4. Cont.
(a) (b)
Medicina 2019, 55, x FOR PEER REVIEW 5 of 10

Medicina
Medicina 2020,2019,
56, 2155, x FOR PEER REVIEW 5 of 10 5 of 10

(c) (d)
Figure 4. Changes in gastrocnemius muscle architecture ((a) muscle thickness and (b) pennation
(c)
angle) and contractile properties ((c) muscle displacement and (d) contraction(d) time) pre and post
intervention.
Figure
Figure 4. Changes
4. Changes in gastrocnemius
in gastrocnemius muscle
muscle architecture
architecture ((a)((a) muscle
muscle thicknessand
thickness and(b)(b) pennationangle)
pennation
angle) and properties
and contractile contractile ((c)
properties
muscle((c) muscle displacement
displacement and (d) contraction
and (d) contraction time) pretime) pre and
and post post
intervention.
In the intervention.
injured leg, improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were
recorded via injured
In the US. Improvements in Dmin(1.15
leg, improvements mmcm
MT (1.60 vs.vs.
1.69 mm)
1.76 cm)and (16.5◦ ms
Tc (22.0
and PA vs. vs. ◦ ) were
24.815.4 ms)recorded
were
In the injured leg, improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were
recorded
via US.via TMG. Calf endurance
Improvements in Dm (1.15 wasmmlower
vs. in both
1.69 mm)legs and
and Tcthe asymmetry
(16.5 ms vs. 15.4between legsrecorded
ms) were remainedvia
recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms vs. 15.4 ms) were
(L:TMG.
31, R:Calf34).endurance
Pain intensity
was (mean
lower inweekly NRSand
both legs scores) decreased between
the asymmetry between week 1 and week
legs remained 12 (6.6
(L: 31, R: 34).
recorded via TMG. Calf endurance was lower in both legs and the asymmetry between legs remained
vs.Pain
2.9),(L:
while
intensity running scores increased (20 vs. 38) during the same period. The program
31, R: 34). Pain intensity (mean weekly NRS scores) decreased between week 1 and week 12 (6.6while
(mean weekly NRS scores) decreased between week 1 and week 12 (6.6 vs. 2.9),was
maintained
running up to
scores
vs. 2.9), week
while 16 at(20
increased
running which point
vs. 38)
scores mean
during
increased theweekly
(20 same NRS
period.
vs. 38) was
during The2.2program
the and
samerunning score was 47up
was maintained
period. The program (Figure
to week
was
5).16 at maintained
which point upmean
to weekweekly NRS point
16 at which was 2.2
meanand running
weekly NRSscore
was 2.2wasand47running
(Figurescore
5). was 47 (Figure
5).

Figure
Figure 5. Weekly
5. Weekly painpain (numericrating
(numeric rating scale;
scale; NRS)
NRS)andandfunction
function (miles*rate of perceived
(miles*rate exertion;
of perceived exertion;
Figure RPE)
5. Weekly pain
response to (numeric rating
intervention. scale;
Weekly NRS)
mileage and
totals function
began with (miles*rate
9.5 on week 5 of perceived
and ended withexertion;
26 on26 on
RPE) response to intervention. Weekly mileage totals began with 9.5 on week 5 and ended with
RPE) response
week 16.to intervention. Weekly mileage totals began with 9.5 on week 5 and ended with 26 on
week 16.
week 16.
3. Discussion
3. Discussion
3. Discussion
The The runner in this case report ran for ~2 years with persistent pain and achieved several personal
runner in this case report ran for ~2 years with persistent pain and achieved several personal
bests.
TheThis This
runner demonstrates,
in this case reportin this athlete atyears
least, that
withpain can be managed andinachieved
a way thatseveral
allows personal
a high
bests. demonstrates, in this ran for ~2
athlete at least, that persistent
pain can bepain
managed in a way that allows a high
bests. level
This of athletic
demonstrates, function.
in this This underscores
athlete at least, the
that title
pain of
canthis
be paper which
managed in suggests
a way that
that pain
allows and
a high
level function
of athletic
arefunction. This linked
not as closely underscores the title
in chronic pain ofas this
theypaper
may be which suggests
in pain thatfrom
resulting paintraumatic
and function
level
are of
not athletic
as function.
closely linked This
in underscores
chronic pain as the may
they title beof in
this
painpaper which
resulting fromsuggests
traumatic thatinsult.
pain Inand
fact,
insult. In fact, baseline results of the calf endurance test appear to demonstrate a compensatory
function
baseline are not as
results of closely linked
the calfcalfendurancein chronic pain as they may be in pain resulting from traumatic
mechanism whereby endurancetest appear
in the to demonstrate
injured leg was highera than
compensatory mechanism[25].
that of the non-injured whereby
insult. In fact,
calf endurance
Calf baseline
in theand
endurance, results
injured of was
leg
to a lesser the calf
extent PA,endurance
higher thanhave
may test
thathelped
of theappear to demonstrate
non-injured
to compensate [25]. Calf
for the a compensatory
endurance,
asymmetry and to a
in MT
mechanism
lesserand Dmwhereby
extent reported.
PA, may calfhave
endurance
helped to in compensate
the injured leg for was higher thaninthat
the asymmetry MTof theDm
and non-injured
reported. [25].
Calf endurance,
This athleteanddidto anot
lesser
respondextenttoPA, may have helped
a high-volume to compensate
stripping for themay
injection, which asymmetry
suggest in MT
that this
and Dm reported.
type of intervention is not as effective in insertional tendinopathy as it appeared to be for mid-portion
tendinopathy [10]. It may also reflect intra-individual responses to injection therapy. Overall, pain and
function appeared to respond positively as a result of the combined shockwave therapy and eccentric
Medicina 2020, 56, 21 6 of 10

loading protocol administered over the 16-week period. It is difficult to know from a case report
whether the effects demonstrated were due to one or both interventions. It should be noted that
pain did not begin to lower on a consistent basis until week 7, and all shockwave therapy had been
administered by week 5. These findings, combined with the rise in function and fall in pain from ~week
10, suggest that the eccentric loading protocol was the dominant factor in recovery. This suggestion is
underpinned by the substantial improvements in neuromuscular function reported.
In the injured leg (right), there were improvements in gastrocnemius medialis MT (~10%) and
PA (~12.7%), as measured by US, which appeared to be reflected by the relative improvement in Dm
(~47%) and, to a lesser extent, Tc (~6.7%). These findings were expected, as they mirror improvements
in muscle size and function in response to resistance exercise [25]. Strength increases prior to changes in
muscle size and is usually proportionally greater, i.e., modest gains in muscle size are usually associated
with 3–4 times the relative strength gains [26,27]. In the early stages of resistance training, this is
suggested to be as a result of an increase in the neural drive to muscle [28]. Häkkinen and colleagues
reported the largest motor units to be recruited within the first 7 weeks of resistance training [29].
The force output of a muscle increases in response to the number of sarcomeres in parallel. An increase
in PA facilitates more sarcomeres in parallel, i.e., an increase in physiological cross-sectional area (CSA)
without a change in anatomical CSA [30]. It is likely that the increase in PA and the overall increase
in contractile mass (MT) contributed to the increase in Dm reported in this athlete. However, Dm is
not a measure of force but of stiffness and therefore, it is likely to be heavily influenced by the tendon
aponeurosis complex and intramuscular connective tissue. These are the structures which transfer
muscle force to the bone. Increases in musculotendinous stiffness have previously been reported in
response to resistance training [31,32] and likely contribute to changes reported in Dm. These changes
in connective tissue stiffness are thought to be primarily driven by an increase in type I collagen
synthesis [33].
This interpretation of an increase in Dm representing an increase in stiffness is somewhat at
odds with researchers in the field who suggest a lower Dm to be associated with a greater muscle
stiffness [34]. These interpretations are based primarily on cross-sectional studies comparing power
and endurance athletes [35] and founded on what remains a limited understanding of the physiology
that underpins measures obtained from Tensiomyography. In our laboratory, we are still optimizing
the standard operating procedures [36,37] in order to obtain stable measurements prior to a more
in-depth interpretation of what the data might indicate physiologically. Our experience from this case
report and on-going investigations in our laboratory suggest that differences in Dm are dependent on
the context in which they are reported. We suggest that in the case of cross-sectional comparisons, as
mentioned above, lower Dm is indeed indicative of higher muscle stiffness. However, in the case of
training or detraining we suggest that the increase or decrease in contractile mass and PA can lead to
an increase in or decrease in Dm. We advise caution in the interpretation of these findings and others,
as interpretation of the data obtained from Tensiomyography remains in its infancy.
The modest reduction in Tc might be expected from an intervention that did not challenge the
speed of muscle contraction. The improvements reported are likely due to an increase in the number
of sarcomeres in series [38] and the increase in PA, which would allow sarcomeres to operate closer
to their optimum length [25]. Calf endurance appeared to decline during the 12-week period, which
we suggest is due to the initial 5 weeks without running and the gradual buildup of running up to
week 12. It is likely that the removal of a stimulus that had been there for ~2 years led to this reduction.
The asymmetry between legs remained, suggesting that some of the adaptations which occurred in the
painful leg over time remained.
There are several limitations we would like to acknowledge related to the interpretation of this
case report. Firstly, although tendon structural abnormalities are present on ultrasound, this cannot be
inferred to represent pathology [39]. In fact, the link between findings on imaging and pain in runners
is weak for several musculoskeletal conditions [40–42]. That being said, the presence of loading specific
pain and pain on palpation suggest an accurate diagnosis was received. Secondly, although we suggest
Medicina 2020, 56, 21 7 of 10

the eccentric exercise protocol was the primary driver behind improvements demonstrated in this case,
the influence of the injection and the shockwave therapy cannot be ruled out. Recent evidence suggests
that high-volume image-guided injections, as used in this case, demonstrate improvements in pain and
function with or without steroid in mid-portion AT [43]. This did not appear to be the case in this report.
Although pain did not decrease on a consistent basis until week 7, a significant dose of shockwave
therapy was administered during the first 5 weeks. Furthermore, there are promising results in terms
of medium and long-term follow-up in mid-portion AT following shockwave therapy [44]. There are
several mechanisms by which shockwave is speculated to have an effect on pain and tissue healing.
The short-term effects on pain are thought to occur due to hyper stimulation analgesia [45]. In the
medium term, it has been suggested that a sharp rise in substance P release and a subsequent long
decrease may lead to longer lasting relief from pain [46]. Tendon repair is speculated to be promoted
post shockwave therapy via an increase in tenocyte proliferation and an induction of growth factors [47].
Finally, tendinopathy is a condition associated with chronic pain. Disability levels associated with
chronic musculoskeletal pain are more closely associated with cognitive and behavioral aspects of pain
than sensory and biomedical ones. Positive outcomes are associated with changes in psychological
distress, fear avoidance beliefs, self-efficacy in controlling pain and coping strategies [48]. Therefore,
in this case, the break from running, and the knowledge of a combined shockwave therapy and exercise
intervention coupled with an expected timeline of improvement may have had just as big an impact as
the intervention itself.

4. Conclusions
This athlete ran at a high level for 2 years with persistent Achilles pain. Even after an evidence-based
rehabilitation programme and a gradual return to running, this athlete was never entirely pain-free.
The findings in this runner appear to underscore the need for greater awareness among clinicians about
the dissociation between pain and function in Achilles tendinopathy. Pain education and limiting
fear avoidance may be as important as physical rehabilitation. The neuromuscular adaptations in this
study were substantial and the physiology which underpins them is multifactorial. To what extent
these neuromuscular adaptations contribute to the reduction in pain and increase in running specific
function is unknown and it will perhaps always be an almost impossible research question to answer.
However, it is likely that the combination of neuromuscular adaptations and structural adaptations
within the tendon itself help to better balance stress on biological tissue preventing overload of a
specific portion of tendon.

Author Contributions: Conceptualization, P.F.; methodology, I.T. and A.J.; formal analysis, I.T. and A.J.;
writing—original draft preparation, P.F.; writing—review and editing, M.I.J. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: The authors would like to acknowledge the institutions of Leeds Beckett University and
Institute of Technology Carlow for providing the facilities and support in writing the full manuscript respectively.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to
publish the results.

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