ankylosing spondylitis and achilles pain

[helz001]

Just looking to see if anyone has any experience regarding this. I am currently treating a 57 year old gentleman with bilateral TA pain. He has chronic thickening around the TA region and is most aggravated by 'rubbing shoes' when walking which is a problem as he has to wear special safety shoes in his job. Symptoms have mostly settled unilaterally with an eccentric loading programme (straight and bent knee), stretches for gastroc and soleus and DTF/US Rx though one side remains an issue. From reading around I have found that there are links between ankylosing spondylitis (the gentleman has been diagnosed with this 20 years ago) and achilles tendinitis. Does anyone have any advice re: alternative treatment (he has not tried GTN patches at this stage) and to whether the ankylosing spondylitis affects the response time to rehab?
Thanks

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[ginger]

AS is an ongoing spinal condition that will cause protective spinal behaviour, including at the site most likely to give rise to altered neural events within the achilles area, L5. Attempts to mobilise L5S1 may be thwarted by the state of thickening and calcification around the lower spine and pelvis. Gentle mobs there may still be of value. Worth a try though.

[physiojlb]

AS can also have a more direct impact on the achilles. The reason many people with AS get TA pain is due to enthesitis which is inflammation of the area where soft tissure attatches to bone, (the tendon insertion), and may not only be related to the calcification around the spine. The enthesitis also causes the muscles to become 'stiff' so a stretching programme may also be appropriate.

I think joint mobilisation should be approached cautiously in the case of AS and should be avoided in patients suffering from extreme cases of AS. If the patient is not greatly affected then joint mobs may be appropriate but personally this would be one of the last stages of treatment and not first port of call. But it all depends on the patient! And only if indicated. Of course manipulations are contraindicated in AS patients.

[ginger]

As any experienced physio will know , there are too many variables that impact on the choices of treatment too permit forums like these and respondents , no matter how attentive, to provide anything but general guidance. With the prospect of "enthesitis " , I would make this point, this is one of those diagnoses popular with medical practitioners. MD's who have a pathology first mind set , whose ideas on cause are almost always with an alert to the painful structure first.
I most often find this diagnosis to be a euphemism for " I don't know , maybe the physio will ". In almost every occasion I can recall , the answer was to be found in the irritation of nerves associated with the enthesis, rather than the structure itself. These irritations are most likely to be at the nerve root, as a chemical effect related to an inflammatory response . These responses are natural , non pathological contributor to a large list of similar euphemisms, including achilles pain, swelling etc. By a gentle first order consideration of L5 , you will have the means to go forward, knowing with some certainty, wether this common cause of pain in a sciatic distribution, is involved in this case , or not. There is no other effective way , without the use of spinal injections , to assert this. You may like to try ten minutes of low dose ultrasound at L5S1 first, then retest the ankle. I do not share physiobob's concerns with mobs ,particularly using a CM protocol, in cases like the one you posted, where AS is the pathological feature driving protective behaviour.