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Achilles tendinitis, knee pain, wants to take ibuprofen, orthotics, wants to do MRI, X-Ray. Treatment ?

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Orthopaedic Surgeon
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Female, age: 22, ht: 5'4".
I've spent 8 weeks in PT for severe peroneal/achilles tendonitis; the pain has lessened considerably and I've been able to walk about, even run once or twice. My physical therapist suggested orthotics for over-pronation & high-arches, which I received last week.
Now I'm back to the level of pain I was experiencing before: pain in the peroneal brevis and longus where it wraps around the medial/lateral malleolus, in the gastrocnemius, and a bit below, presumably in or under the achilles tendon. All this plus the recurrence of pretty severe knee issues (pain above and below the patella, very sharp pain on the medial side of knee, muscle spasms in my quads).
I can't pinpoint a singular, acute injury to explain it's onset. Could this a bio-mechanical problem? I can only speculate on what the knee issue is, but what are the chances of having tendonitis in more than one joint; surely it's not a coincidence if this is the case? I'm going next week for adjustments to the orthotics--
What I don't understand is why, with weeks of PT, has one week caused such a HUGE reversal? Is tendonitis not reversible? Should I request an MRI or X-ray? I leave for Marine boot camp in about 2 months and need help or suggestions.

Additionally, if this helps, both knees have a burning sensation, amongst a not-inconsiderable amount of pain, are inflammed- very hot but not visibly swollen, click/pop (w/ pain) when my knee is extended. I've begun reactive solutions: exercises to strengthen the vastus medialis in case the problem is muscle imbalance, glute exercises, in addition to the continuing PT for peroneal tendonitis. The GP I saw very helpfully suggested writing a prescription for Ibuprofen. Hopefully, you can provide some insight.
Posted Fri, 20 Apr 2012 in Bones, Muscles and Joints
Answered by Dr. Atul Wankhede 9 hours later
Thanks for posting your query.

As I perceive you had relief with the physiotherapy but the condition worsened after you happen to use the orthotics. However I believe your body by now must have adjusted to function without need for any orthotics. A biomechanical imbalance, which is very likely in your case, could be present in your hips, knees or below ankle like in flat foot. In any case you are most likely to face muscle fatigue and occasional spasm or even tendonitis.

Most of these symptoms are self limiting and can be controlled by temporary medication, physio and eventually orthotics. Many a times orthotics are not useful unless they are recommended at an early age so that body acclimatises to an artificial mechanical support. But in adults one may not always expect favorable result.

In my opinion you most likely have a flexible loss of medial foot arch, that manifest in these problems. But using arch support is definitely not helping, so consider discontinuing its use. The only long lasting solution to this is strengthening exercises. These will prevent future relapses. You may take mild analgesics and carry on physio for a few weeks more. In addition you may ask your physician to do blood tests to rule out anaemia or decreased calcium and other minerals in your blood. And dont worry it is completely curable. You just need some rest before you start off the exercises.

The problem in your knee seems more or less related to same issue and will be sorted out by quadriceps strengthening exercises. The burning sensation may be due to a variety of reasons like neurological involvement from spine, arthritis like in gout or an intraarticular infection. Dont worry about the sound, its completely normal.

If the symptom persists go for the aforesaid investigations along with a preliminary Xray.

This I hope shall help for now. If you need any more information I'm available for follow up.

Above answer was peer-reviewed by
Follow-up: Achilles tendinitis, knee pain, wants to take ibuprofen, orthotics, wants to do MRI, X-Ray. Treatment ? 10 hours later
1. As I have already been through several weeks of PT & have had these issues for months- would I benefit from a cortisone injection in the feet and knees?

2. Also, I have been performing exercises to strengthen the glutes and vastus medialis for 4 weeks to date. If anything I’m experiencing more pain than previously. Is this normal? The knee pains whether standing or sitting- and has even affected my sleep. Can you suggest any exercises?

3. Who could best tell me if the problem is biomechanical? My podiatrist or an orthopedic specialist?

4. The podiatrist ordered orthotics because of a falling arch & over-pronation, but the orthotic doesn’t begin to touch my arch. I mentioned this initially but he suggested I wear it for two weeks to see. So should I bother having it mended or forgo the orthotics?

Answered by Dr. Atul Wankhede 1 hour later

Thanks for writing again.

I shall answer you categorically.

1. You will benifit from further physiotherpy. That shall be in the form of local ultrasonics, passive ROM (Range of Motion) and muscle strengthening exercises. But you should avoid steroid injection if you can. It does not improve the reason for the pain, but merely subsides it and you carry on spoiling an already worsened knee and ankle.

2. It is a prerequisite for exercises that you should be painfree. If you have persistent pain, take adequate rest, medications and local ultrasonics, wait for it to completely subside and then gradually start exercises. I'll suggest quadriceps strengthening, gastroc-soleus strengthening.

3. Your orthopaedician will tell you if you have biomechanical imbalance.

4. I'm not sure what you mean by "it does not touch the arch", but it certainly does not seem comfortable. In any case before you carry on using it or get it mended, get a second opinion from your orthopaedician.

I hope, I've answered your queries. If you need more help feel free to ask.

Wish you speedy recovery.


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