Hoy os expongo otro caso clínico en el que un tratamiento avanzado ha conseguido solucionar un dolor de larga evolución. Se trata de una paciente que acudió a consulta con dolor en la región posterior del talón, predominantemente derecho, de cinco años de evolución. Ha sido tratada por su médico de familia con antiinflamatorios en ciclos de cuatro semanas muy espaciados entre sí y con 7 sesiones de fisioterapia hace 12 meses que abandonó por no sentir mejoría.
En la exploración física encuentro dolor a la palpación en ambos tendones aquíleos. La paciente refiere sintomatología durante todo el día pero empeoramiento durante los primeros pasos de la mañana, acompañado de sensación de rigidez.
Le realicé un estudio biomecánico en que objetivé Silverskiöld +, soleo corto, gemelos algo más cortos. En dinámica observé una marcha con apoyo inicial ligero varo que durante el apoyo medio comienza el momento muy levemente pronador menor en el pie del hemicuerpo más largo (miembro inferior derecho) de la articulación subastragalina, con marcada apertura de la marcha derecha y despegue a 90º.
También realicé una ecografía que informé así:
“Se realiza estudio bilateral con transductor lineal de 7 – 12 MHz y ecógrafo ALPINION ECUBE 9 DIAMOND:
Se aprecia heterogeneidad fibrilar en la entesis de ambas fascias plantares, con engrosamiento en su inserción, sin grandes zonas de fasciosis. PD-.
Ambos tendones aquíleos con zonas hipoecoicas en su inserción compatible con tendinopatía insercional leve y zona anecoica en el tercio medio (derecho 0,29 cm2) (izquierdo 0,28 cm2) que parece corresponder con tendinosis / paratendinosis del cuerpo medio. Estructura fibrilar normal. PD -. No neovascularización tendinosa.”
Aquí están las fotos:
La conclusión diagnóstica fue:
- Tendinosis / paratendinosis tercio medio aquíleo bilateral (derecho 0,29 cm2) (izquierdo 0,28 cm2).
- Gastrocnemios cortos.
Y el tratamiento:
- Electrolisis percutánea intratisular ecoguiada en zona de tendinosis (3 -4 sesiones).
- Ejercicio excéntrico de tríceps sural (12 semanas).
- Estiramiento riguroso y cuidadoso del músculo gastrocnemio y sóleo.
- Valoración de puntos gatillo de sóleo y gemelos.
- Ortesis plantares según mejoría con tratamiento invasivo.
Por si os lo estáis preguntando…¡¡mejoró!! Y mucho. No dejéis que un dolor os atormente cinco años. Ni siquiera un mes.
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