Achilles tendinopathy - presentation, management, classification
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Tendinosis
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Tendinitis
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- Degenerative Change in tendon's structure and sheath - more vunerable to breakage
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- Acute Inflammatory process from trauma, excessive use, lack of training
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- Chronic inflammation promotes neovascularisation - makes it more likely to rupture tendon
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Can be insertional or non-insertional
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Insertional: damage to tendon fibres at their insertion - Haglund deformity
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Non-insertional: 2-6cm proximal to insertion (hypovascularity)
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Haglund deformity: bony exotosis - enlargement of posterior calcaneus
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Often affects middle aged males in 3rd/4th decade
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Likely to occur again in the contralateral side
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Runners are most commonly affected - especially those with midfoot/forefoot strike pattern
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Women wearing high heeled shoes - shortens gastrocnemius/soleus
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Can be Extrinsic/Intrinsic
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Extrinsic: improper warm up, overtraining, cold weather, running on hard surfaces, excessive stair/hill climbing, improper arch support/footwear, poor conditioning, returning to activity after inactivity, mechanical overload, obesity, medication (steroids, fluroquinolones), direct trauma
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Intrinsic: age, sex, lateral instability of the ankleprior lower limb f#, hyperpronation, pes planus/cavus, gastroc-soleus inflexability/weakness, limited ankle dorsiflexion, limited subtalar motion
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Systemic: Diabetes, hypertension, inflammatory arthropathy, gout, corticosteroids/quinolones
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Obesity
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Pain/Tenderness in the tendon/heel that intensifies with activity (walking/running)
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Difficulty standing on toes or walking downstairs
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Morning pain/stiffness
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Warmth and swelling increasing throughout the day
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Palpation in the 2-6cm from insertion or insertion to determine insertional from non-insertional
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Fusiform swelling/bony enlargement = chronic
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ROM - passive dorsiflexion + resisted plantarflexion affected
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+ve calf squeeze test (for achilles rupture)
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- Plantaris can be involved - tenderness on medial mid tendon
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- If plantaris is involved, US or MRI can be considered
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- Assess for functional deficits in the kinetic chain (ankle, knee, hip, lx spine, glut meds)
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- Overhead squat, Trendelenberg, single leg squat (glut med)
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- Hallux limitus functional exam: Place thumb under patients metatarsal head
force patients foot into dorsiflexion and pronation pinch patient's great toe with opposite hand and passively moves it into dorsiflexion jamming/locking on dorsiflexion or lack of metatarsal PF = Hallux limitus |
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Only should be considered if:
Plantaris involvement siginificant trauma + altered gait rule out other pathology - Calcaneal epiphysitis/avulsion |
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- Ultrasound
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- MRI (lower sensitivity than US)
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- CT - rules out trabecular stuctural alterations at the insertion
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- VISA -A (Victoria Institute of Sports Assessment) - post treatment follow up pain and function scale
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F#
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Avulsion
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Neoplasm
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Infection
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Ankle Sprain (Ottawa Ankle rules)
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Retrocalcaneal Bursitis
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Posterior Ankle impingement
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Os-Trigonum syndrome
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Tenosynovitis
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Tendon dislocation
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Tennis leg
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Sural Neuroma/ Nerve entrapment
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Systemic inflammatory disease
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Calcaneal apophysitis
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Plantar Fasciitis
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Haglund deformity
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Sever Disease
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Heel Pad syndrome (deep pain in the middle heel - feels like a bruise)
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Erdheim Chester Disease (abnormal multiplication of Histiocytes)
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- Rest, NSAIDs,eccentric rehab, correction of mechanical faults
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- Crutches/brace
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- Runners can be switched to swimming/cycling
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- Avoidance of shoes with heels
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- Single leg eccentric heel drop offs (slow and knee straight and bent) 3 sets of 15 twice per day for 12 weeks
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- Slow and progressive loading is more effective (10% per week)
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- Increase of patient's night pain = excessive load
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- Soft tissue work, myofascial release and stretching recommended
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- Manipulation of ankle, knee and hip (kinematic chain)
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- Athletes should perform a warm up routine before exercise and introduce new activities slowly and avoid increasing activity - runners should begin on smooth surfaces
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- Avoid compression socks
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- Return to play criteria (triple 5)
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- Shockwave if not responsive to initial management
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- SUrgery if not better within 6 months
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- Ankle dorsiflexion <5 degrees on the uninjured side
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- Calf circumference <5mm of uninjured side
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- Patient able to perform 5 sets of 25 single leg heel raises
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- Good with early management
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- Surgical care is mostly successful (80%)
risk of complications: Ruptured tendon, DVT, reflex dystrophy, persistent neuralgia, deep infections, wound problems, discomfort, hypertrophy |
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- As number of risk factors increases, failure of non-operative treatment increases
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