Achilles Tendinitis Case Studies

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DOI: 6/10/2014. Patient is a 63-year-old female assistant store manager who sustained injury when she twisted her right ankle while coming out of the back room. As per OMNI notes, she was initially diagnosed with right ankle sprain.
MRI of the right ankle done on 1/19/16 showed chronic Achilles tendinitis without evidence of tear and without evidence of posterior tibial tendon tear.
Per IME report dated 4/15/2016 by Dr. Shankman, the patient has not reached maximum medical improvement. The examiner notes that the patient has a torn Achilles tendon, which has not united and operative intervention is indicated to prevent further injury. Recommendations include repair of the Achilles tendon, cast for a few weeks after the surgery and then two
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Patient noted immediate partial improvement in right anterior foot/ankle pain with passive and active dorsiflexion and weight-bearing.
Based on the medical report dated 09/21/16, the patient presents with right ankle pain, posteriorly. She states that she occasionally feels a pulling sensation medially after certain activities, such as when she climbs a ladder. She did receive an injection in her ankle with minimal relief. Symptoms are mildly alleviated by PT.

On examination of the right ankle, there is a significantly resolved deformity and a mass posteriorly of the right ankle over Achilles.

There is palpable swelling of the posterior aspect and Achilles tendon. Visible swelling of the Achilles tendon is seen. There is tenderness over the Achilles tendon and plantar fascia, but there is no tenderness on the right over the anterior aspect, calcaneus, lateral malleolus, medial malleolus or posterior tibial tendon.

Plantar flexors strength is 5/5 on the left, diminished and with pain on the right.

Ankle range of motion is full with dorsiflexion and plantar flexion. Tightness is noted with inversion and

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