Introduction

The second leading cause of years lost to disability globally is musculoskeletal problems.1 Back, knee, and hip disorders have garnered the most attention and have been well reported. Ankle and foot complaints are known to be substantially prevalent in older adults with reported pain, second only to knee problems.2 Ankle injuries in physically active individuals are the most common lower extremity injury, with ankle sprains being the most common in athletics.3,4 Achilles tendinopathy is also one of the most common injuries for people participating in physical exercise, especially athletes involved in long term or repetitive training.5,6

Golf is a sport played by persons of all ages and abilities globally and is associated with numerous positive health and well-being benefits.7 Despite the health benefits, athletes can still develop injuries related to golf participation. Tendinopathy is the 2nd most common type of injury amongst golfers, with the most common cause of tendinopathies arising from repetitive practice and suboptimal biomechanics.8,9

Like many athletic movements, a golf swing involves a sequence of complex multi-segmental movements.10 Assessment tools that incorporate whole-body functional movements may help to uncover important underlying dysfunctions not isolated to the injured joint or tissue. Regional interdependence refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patient’s primary complaint.11 This concept is a key principle in a Selective Functional Movement Assessment (SFMA). Growing interest in the regional interdependence model is not without controversy regarding its relevance within musculoskeletal examination and practice, which warrants further scientific investigation.11

This case report describes a short-term favorable therapeutic outcome using manual therapy and long-term guided therapeutic exercise using a regional interdependence approach for an avid golfer with chronic Achilles tendinosis.

Case Report

History

A 51-year-old male sought evaluation of medial, posterior, and lateral left ankle pain at a physical therapy clinic in the fall of 2022. He reported symptoms during his golf swing that progressed throughout the summer golf season to pain while walking, eventually progressing to include all weight-bearing activities. Treatment consisted of manual therapy throughout posterior soft tissue, active dorsiflexion exercises, and a brace to limit supination of lateral ankle during golf activity. Symptoms reduced after “about 3 treatments over 3 weeks,” and he discontinued care with the physical therapist.

He visited a chiropractic clinic in early spring of 2023 following an increase in golf activity. He stated that the left ankle pain had returned at a 6/10 with golf activity, 4/10 while walking, and 3/10 at rest on a Visual Analog Scale (VAS). The Lower Extremity Functional Scale (LEFS) indicated an initial 46% of maximal function. Pain was located inferior to the lateral malleolus and posterior, into Achilles tendon. Pain was described as sharp and stabbing with activity and achy at rest. Aggravating factors included golfing, walking, using stairs, and standing for longer than 1 hour. Alleviating factors included rest, medication (NSAIDS), and self-directed mobility exercises for short-term relief. Pain was worse in the morning upon rising, relieved with ankle mobility regimen, and worsened as the day progressed with golf activity and walking. He was unable to walk 18 holes of golf due to pain but could tolerate the pain with the use of a golf cart multiple times per week.

Assessment

Examination exhibited normal vitals, except for a BMI of 34.43. His lower extremities appeared normal and symmetrical upon inspection. Lower extremity deep tendon reflexes, sensation to light touch, and motor strength testing were unremarkable. Orthopedic testing of the ankle included talar tilt test, anterior drawer, and high ankle squeeze test, resulting in negative findings for instability at the ankle.

SFMA top-tier testing revealed dysfunctional and nonpainful movement patterns for multi-segmental rotation bilaterally, and dysfunctional and painful movement patterns included left single-leg stance and arms-down deep squat. SFMA breakout assessments determined mobility dysfunctions for bilateral ankles, limited in inversion, eversion, and dorsiflexion with the knees flexed to 30° and completely extended. Additionally, mobility dysfunctions were found for bilateral hips, limited in internal rotation while flexed to 90° and also at 0° of extension. Local biomechanical exam of bilateral ankles showed reduced dorsiflexion, eversion, and inversion with hard end-feel and loss of fluid motion in the left talocrural and subtalar joints compared to a soft end-feel with normal fluid motion on the right. Local biomechanical exam of both hips found reduced internal rotation with normal fluid motion and soft end feel bilaterally. Primary diagnoses rendered were Achilles tendinosis with left ankle joint fixations.

Treatment

Initial treatment consisted of long-axis traction high-velocity low-amplitude (HVLA) manipulative therapy of the left talocrural and subtalar joints, instrument-assisted soft tissue mobilization (IASTM) of the left Achilles tendon, and instructions to continue self-directed mobility exercise regimen at home. After 4 visits over 2 weeks, his pain had reduced to 3/10 while golfing, 1/10 casually walking, and no pain at rest. Eccentric loading was introduced after performing IASTM of the Achilles tendon by standing with forefoot on a step and slowly lowering his heel down to a stretch. Eccentric loading was implemented for another 4 visits over 4 weeks, which further reduced pain to 2/10 with golf activity and 1/10 pain when walking, if walking more than 30 minutes. For the next 4 months, he sought care for the ankle pain with 1 visit every 2 weeks. During that interval, he improved to 84% of maximal function, according to the LEFS. After his golf season concluded, he continued care for 3 months for a shoulder complaint and reported no symptoms in his ankle or Achilles tendon.

In early 2024, his ankle pain returned after starting some off-season golf-swing speed training. His pain and outcome assessment was similar to his original initiation of care, with 7/10 pain while training, 2/10 with walking, 1/10 at rest, and 50% function LEFS score. Observation of his golf swing exhibited a slide towards the target and inversion of his left ankle during the follow through of the motion, reproducing and increasing pain. When directed to keep pressure on the left head of the first metatarsal, pain reduced to resting pain value (1/10), but he was unable to perform without clinician-mediated stabilization. Long-sitting split-leg hip windshield wipers, supine bilateral hip drops, and a Comerford hip complex were performed for 1 set of 10 reps bilaterally. After the exercises, he was able to perform the directed left foot stabilization without assistance, rating the perceived exertion (RPE) at a 9/10 to complete the motion. He was instructed to perform the 3 exercises 3 times per day for 3 sets of 10 repetitions bilaterally. On the next visit, 1 week later, there was reduction in ankle and Achilles pain to 2/10 during swing speed training, and no symptoms outside of that activity. At follow up 3 months later, he reported no pain with golf activity when focus is on stabilization of left forefoot, which he rated a 3/10 RPE after completing his hip mobility regimen. He could now walk 18 golf holes, observing his son’s golf meet without pain. His LEFS scored at 90% of maximal function and the patient provided consent for the case report to be published.

Discussion

The etiology behind Achilles tendinopathy can be unclear but research has clarified the difference between Achilles tendinitis and Achilles tendinosis. Achilles tendinitis occurs when there is an inflammatory process seen clinically with pain and swelling. On the other hand, Achilles tendinosis refers to a degenerative process of the tendon without clinical signs of intra-tendonous inflammation.5,12 Leadbetter describes tendinosis as a failure of the extracellular matrix to replace lost or damaged tissue due to repetitive trauma causing an imbalance towards degeneration over synthesis of the matrix.12 This case fits the tissue response definition of Achilles tendinosis due to the repetition of golf-swing practice and play.

The initial treatment using manipulation for the joint fixations and IASTM were chosen due to the findings at the anatomical source of pain. The rationale for these treatments were the success achieved with the patient at physical therapy, previous practitioner clinical success with similar presentations, and current research concepts showing the promotion of tissue healing from neovascularization from microtrauma.5 The ankle mobility assessment in the SFMA evaluates dorsiflexion and plantar flexion in knee extended and bent knee postures along with a qualitative eversion and inversion. The multidirectional ankle mobility dysfunction was treated using an eccentric loading strategy applied post-therapy, which is suggested to promote structural tendon length changes.13,14 Recurrence of ankle pain after a symptom-free period prompted us to investigate the primary activity producing the pain by evaluating his golf swing. His swing biomechanics showed the sliding toward target instead of rotation around the lead leg. The lead hip in the golf swing has been shown to use almost the entire physiological range of motion for external rotation in the backswing, and internal rotation during the downswing.10 The SFMA finding of his hip mobility dysfunctions for rotation suggested improving mobility of his hips by guided therapeutic exercises.

The ankle and tendinosis manual therapy seemed to be appropriate therapy for the tissue at the site of pain based on the reduction of symptoms, but we believe the lack of hip mobility during golf activities was creating the tendinosis. The quick response in symptom reduction with the therapeutic exercises was similar to the manual therapy benefit, but the relief was maintained longer with the guided hip mobility than with the manual therapy. The ankle and hip are not common areas for golf injuries,9,15 but the left (lead) ankle does have a greater prevalence of injury compared to the lead hip.9 This may be due to the ankle having less stability in terms of ligamentous integrity compared to the hip, leading to greater reliance on the muscles and tendons of the ankle to support extrinsic stress. Impairments associated with musculoskeletal injuries are not often isolated to the injured joints or tissues, and dysfunctions can persist if the impairments are not addressed.

Limitations

This case report contains several limitations. First, the confirmation of the diagnosis can benefit from imaging modalities such as x-ray, diagnostic ultrasound, or MRI to exclude comorbidities such as degenerative changes, congenital anomalies, or other soft tissue anomalies. Second, the tendinosis may have resolved spontaneously through natural progression of the disorder. Finally, the coaching of the golf swing and foot position may have reduced the repetitive stress on the ankle and tendon without the therapeutic exercises, even though the golfer was not able to initially achieve the foot stability without performing the exercises.

Conclusion

This report presents a golfing athlete complaining of lead side ankle and Achilles tendon pain, with lead ankle and hip mobility dysfunctions. The primary complaint responded positively to treatment directed at the area of pain, with short-term relief reported during his golf season. When the complaint had a recurrence of symptoms, he also responded positively to therapeutic intervention and activity modification for longer-term symptom relief during golf activity. The results suggest an example of regional interdependence where the impairment of hip mobility during golfing activity was creating repetitive stress at the ankle, which also showed a mobility deficit. The results of this case support the importance of clinical examination and treatment of regional impairments beyond the site of presenting complaint, especially when engaging in complex movement patterns seen in sports.