Achilles tendonitis & rupture

Question 1

What is special about the Achilles’ tendon compared to other tendons?

Answer 1

It is the thickest and strongest tendon in the body

Question 2

What is tendinopathy?

Answer 2

Impaired tendon healing which is a combination of pain, swelling and impaired performance of the tendon

Question 3

What are the common sites for tendinopathy in general?

Answer 3

• Rotator cuff - supraspinatus tendon
• Wrist extensors - lateral epicondyle
• Wrist pronators - medial epicondyle
• Patellar
• Quadriceps
• Achilles’

Question 4

What are the most common sites of tendinopathy in athletes vs general population?

Answer 4

Athletes - Achilles’ and patellar

General - Achilles’ and lateral epicondyle

Question 5

What are the signs/symptoms of tendinopathy?

Answer 5

• Well-localised tenderness
• Insidious onset
• Pain during activity - may resolve after warm up
• Tendon thickening
• Tendon nodularity
• Crepitus - in acute phase of Achilles; tendinopathy

Question 6

Which medication increases risk of tendinopathy?

Answer 6

Fluoroquinolones e.g. ciprofloxacin - Achilles’ most affected but shoulder and hand can also be affected

Question 7

What are the risk factors for tendinopathy?

Answer 7

• Athletic training
• Unsuitable equipment e.g. worn-out shoes
• Hard and high-friction playing surface
• Older age

Question 8

What is shown?

Answer 8

Medial and lateral pressure applied anterior and superior to the Achilles’ insertion elicits pain

Question 9

“What causes tendinitis?”

Answer 9

Mainly repetitive mechanical loading on the tendons but risk increases with age, genetics, body weight, metabolism and in individuals prone to pro-inflammatory states (e.g. T2DM).

There is disruption of collagen within the tendons, problems with its healing and blood supply which can all contribute to pain.

Question 10

How common is Achilles’ tendinopathy?

Answer 10

10% of runners

Question 11

Where is the pain in Achilles’ tendinitis? What elicits the pain?

Answer 11

2-6cm above insertion of tendon into the calcaneus in the avascular zone

Elicited by resisted plantar flexion and passive dorsiflexion of the ankle

Question 12

What special test is used to check for Achilles’ rupture?

Answer 12

Thompson test: with the patient prone (face down), calf muscles are squeezed, which should intrinsically plantar flex the foot if the Achilles’ is intact.

Question 13

Which two areas does Achilles’ tendonitis occur?

Answer 13

Mid portion

Interstional

Question 14

How do you diagnose Achilles’ tendinopathy? What other tests can be done?

Answer 14

Clinical diagnosis

US, MRI and XR (rarley useful unless calcified) can also be done.

Question 15

What are some differentials for Achilles’ tendonitis?

Answer 15

• Bursitis - retrocalcaeneal
• Pain of other tendons around the Achilles’ tendon - e.g. plantaris
• Fractures calcaneus
• Tear of fasica
• Impingement of the posterior ankle
• Dislocation of peroneal/plantar flexor tendons
• Nerve pain - irritation or neuroma of sural nerve
• Fat pad irritation
• Haglund’s deformity
• Systemic inflammatory disease

Question 16

Which muscle fibres is the Achilles tendon composed of?

Answer 16

Soleus and gastrocnemius

Question 17

What is the management of Achilles tendon rupture?

Answer 17

Same day assessment by an orthopaedic specialist

Question 18

What is the stepwise management of Achilles’ tendonitis?

Answer 18

1. Recognise contributing factors and reduce these e.g. fluoroquinolones
   
   • Use cold packs or ice after acute injury
   • Simple analgesia for pain relief
   • Rest
2. If no improvement after 7-10 days –> refer to physiotherapy
3. If no response –> refer to sports physician or orthopaedics
   
   • Exercise programme
   • ESWT - extracorporeal shock-wae therapy
   • Surgery e.g. debridement or removal of diseased tendon

Question 19

What triad is used to exclude Achilles’ tendon rupture?

Answer 19

Simmonds triad - patient lies prone

• Angle of declincation - greater dorsiflexion of injured ankle
• Palpation - gap in the tendon
• Calf squeeze test - foot remains in neutral position when calf is sqeezed

USS is the modality of choice for diagnosis.

Question 20

What are the symptoms of Achille’s tendon rupture?

Answer 20

• Audible snap
• Feeling of being kicked or hit by raquet
• Aching, swelling, mild bruising of the calf
• Difficulty weight bearing

Question 21

What is shown?

Answer 21

Haglund’s deformity