Achilles Pain
Achilles pain is common in athletes but also the sedentary Current concept review of Achilles tendinopathy – PMC with an overall estimated incidence rate 1.85 cases per 1000 patients. Risk factors include but are not limited to, high sporting demand, improper training regimes in athletes, increasing age, high BMI, underlying metabolic disease due to chronic systemic inflammation and certain medications (fluoroquinolones antibiotics).
There are multiple differential diagnoses including, mid portion and insertional tendinosis +/- retrocalcaneal bursitis. This may be associated with a Haglund’s deformity and enthesopathy. Paratenonitis (inflammation of the paratenon surrounding the Achilles), traumatic cases include partial and complete ruptures and manifest after sudden forced plantarflexion of the foot.
In tendinopathy the Achilles tendon goes through the same pathophysiological changes as any other tendon in the body ‘degeneration within the tendon itself with disorganisation of the collagen fibres and an increase in the microvasculature and sensory nerve innervation’ Tendinopathy – PubMed. This ultimately leads to pain and subsequent loss of performance for the individual.
What are the signs and symptoms?
In tendinosis, patients will complain of an insidious onset of posterior ankle pain, with symptoms localised to Achilles itself. Pain can be felt at the attachment onto the calcaneus (insertional), within the mid portion or a combination of both. The tendon can appear diffusely swollen, and morning stiffness is common. In the early stages pain typically occurs at the beginning and at the end of training sessions/exercise. As the disease process progresses, pain may occur during exercise, and in severe cases, it can interfere with activities of daily living. Achilles tendinopathy: aetiology and management – PMC
In traumatic cases, there is a sudden onset of posterior ankle pain. 75% of Achilles ruptures occur in males between the 3rd and 5th decade of life. Chronic Achilles Tendon Rupture – PubMed. Pain is often associated with an audible ‘pop’ with a sensation of being kicked in the lower leg. Achilles Tendon Rupture – PubMed.
In full-thickness tears there is a loss of ankle function with an inability to rise onto the toes. Palpation may reveal a tendon discontinuity with bruising around the posterior ankle. The Thompson test will often be positive; with the patient positioned prone, the calf is squeezed, observing the presence and degree of plantarflexion of the foot and ankle. In Achilles ruptures this action will be absent. The test has been shown to have a strong sensitivity and specificity in diagnosing Achilles ruptures. DIAGNOSTIC ACCURACY OF PHYSICAL EXAMINATION TESTS OF THE ANKLE/FOOT COMPLEX: A SYSTEMATIC REVIEW – PMC
How is it diagnosed?
The diagnosis will be made from a combination of your clinical history, examination findings and, commonly, an ultrasound scan. The patients will have the signs and symptoms as discussed previously. Ultrasound will be used to confirm the diagnosis in insidious and traumatic cases.
In insidious cases, ultrasound will be able to assess for tendinosis with clear visualisation of the enthesis attachment, along with concurrent pathology including retrocalcaneal bursitis, both deep and superficial, enthesophytes (bony projections at the attachment site) and degenerative tears. Similar pathological changes can be seen on ultrasound in the mid portion along with vascularisation as new nerve endings and blood vessels grow into the tendon from the underlying Kager’s fat pad. This is widely considered to be the main pain driver factor in mid-portion Achilles tendinopathy. Ultrasound Doppler Flow in Patients With Chronic Midportion Achilles Tendinopathy: Is Surface Area Quantification a Reliable Method? – PubMed
In traumatic cases, ultrasound has a key role in assessing the Achilles tendon and has been shown to have a strong sensitivity and specificity guiding treatment options Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis – ScienceDirect. The most common rupture site is at the mid tendon, roughly 4-6cm proximal to its insertion. Ultrasound is useful in differentiating between partial and complete tears. Partial tendon tears tend to be related to tendon degeneration and are more commonly located in the dorsal aspect of the tendon affecting the sub tendon from the medial head of the gastrocnemius or appear as longitudinal, intrasubstance tears Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap – PMC.
In the case of complete tears, the proximal and distal ends of the tendon will not appear continuous. The dynamic nature of ultrasound allows the assessment of the tendon ‘gap’ which is an important consideration when deciding surgical or conservative treatment. With a tendon gap of over 10mm and especially those over 15mm when the foot is placed in maximum tolerated plantarflexion orthopaedic review with consideration of repair is likely to be needed Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap – PMC as these tears have an increased re-rupture rate due to lack of natural healing with equinus splinting alone.
How is it treated?
Treatment options are divided into conservative and surgical.
Conservative options: (For none-traumatic cases)
- In the first-line management, it aims at addressing any modifiable risk factors, advice regarding training load and a progressive rehab plan to improve the tolerance and capacity of the tendon. There are slight differences in the rehab strategies between mid-portion and insertional tendinosis. Mainly the avoidance of loaded end-of-range dorsiflexion exercises for patients with insertional Achilles pain. Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts – PubMed
- For patients with insertional Achilles pain, a simple heel raise can be beneficial to avoid the tendon being placed in a sustained lengthened position, which can have a drastic analgesic effect. Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy – PubMed
- Shockwave is a non-invasive treatment option which has also been shown to be helpful in patients with mid-portion Achilles tendinosis The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review – PubMed
- For refractory cases, an ultrasound-guided ‘high-volume’ injection can be utilised in the management of mid-portion Achilles tendinopathy. This process involves injecting local anaesthetic, saline and a small amount of steroid into the interface between the Achilles tendon and the underlying Kager’s fat pad to mechanically disrupt the neovascularisation. Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis – PMC. Despite being widely implemented, its efficacy remains in question. Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial – PubMed.
- Ultrasound-guided retrocalcaneal bursal injections are an injection option for patients with refractory insertional Achilles pain that are struggling to progress. Evidence does show a significant short-term decrease in pain. Complications can occur in the way of tendon rupture with risk of around 1.8%. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis – PubMed
- Platelet Rich Plasma (PRP) injections. For patients with Achilles tendinopathy +/- longitudinal split tears, a PRP injection may be discussed as an alternative to steroid-based interventions. By having a PRP injection, we are in effect concentrating a patient’s platelets from whole blood, rich in growth factors, and then injecting this directly into the tendon to stimulate the body’s natural healing process. PRP releases bioactive factors that promote cell growth and collagen production and reduce inflammation. Despite its attractive description as a regenerative option, its efficacy has yet to be fully established. The Efficacy of Platelet-Rich Plasma Injection Therapy in the Treatment of Patients with Achilles Tendinopathy: A Systematic Review and Meta-Analysis – PubMe
Surgical options: (For none-traumatic cases)
- Surgical intervention for Achilles tendinosis is usually a last resort. There are both open and endoscopic techniques which usually consist of tendon debridement/tenotomy of the diseased tissue +/- tendon repair. For insertional symptoms this may also include resection of a Haglund deformity or enthesophytes where present and may include the removal of the retrocalcaneal bursa. A treatment algorithm for managing Achilles tendinopathy: new treatment options – PMC.
Management of Traumatic Cases:
- Surgical V Conservative. Surgical repair of the Achilles tendon is usually reserved for the young, high-demand patient. While older patients with lower functional requirements and/or comorbidities are more likely to be managed conservatively with equinus splinting. This approach allows the tendon ends to approximate and natural healing to take place without surgery. Achilles Tendon Ruptures: Nonsurgical Versus Surgical Treatment – PubMed. Imaging factors such as the ‘tendon gap’ as discussed previously also help guide decision-making. Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap – PMC. Surgical intervention is linked with a lower risk of re-rupture rates with a quicker rehabilitation time but with a higher risk of complications. Surgical vs. nonoperative treatment for acute Achilles’ tendon rupture: a meta-analysis of randomized controlled trials – PubMed
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