Anatomy
- Achilles tendon contains type I collagen fibres
- Paratendon = contains an abundance of elastin , keeps collagen bundles together and allows movement
Tendinosis vs Tendinitis
Tendinosis |
Tendinitis |
- Degenerative Change in tendon's structure and sheath - more vunerable to breakage |
- Acute Inflammatory process from trauma, excessive use, lack of training |
- Chronic inflammation promotes neovascularisation - makes it more likely to rupture tendon |
Paratenonitis - inflammation of outer layers of the tendon - part of tenosynovitis and tenovaginitis
- Oedema + Exudate + inflammatory cells
Types
Can be insertional or non-insertional |
Insertional: damage to tendon fibres at their insertion - Haglund deformity |
Non-insertional: 2-6cm proximal to insertion (hypovascularity) |
Haglund deformity: bony exotosis - enlargement of posterior calcaneus |
Demographics
Often affects middle aged males in 3rd/4th decade |
Likely to occur again in the contralateral side |
Runners are most commonly affected - especially those with midfoot/forefoot strike pattern |
Women wearing high heeled shoes - shortens gastrocnemius/soleus |
Risk Factors
Can be Extrinsic/Intrinsic |
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 |
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 |
Systemic: Diabetes, hypertension, inflammatory arthropathy, gout, corticosteroids/quinolones |
Obesity |
Presentation
Pain/Tenderness in the tendon/heel that intensifies with activity (walking/running) |
Difficulty standing on toes or walking downstairs |
Morning pain/stiffness |
Warmth and swelling increasing throughout the day |
Palpation in the 2-6cm from insertion or insertion to determine insertional from non-insertional |
Fusiform swelling/bony enlargement = chronic |
ROM - passive dorsiflexion + resisted plantarflexion affected |
+ve calf squeeze test (for achilles rupture) |
Considerations
- Plantaris can be involved - tenderness on medial mid tendon |
- If plantaris is involved, US or MRI can be considered |
- Assess for functional deficits in the kinetic chain (ankle, knee, hip, lx spine, glut meds) |
- Overhead squat, Trendelenberg, single leg squat (glut med) |
- 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 |
Diagnostic Imaging
Only should be considered if:
Plantaris involvement
siginificant trauma + altered gait
rule out other pathology - Calcaneal epiphysitis/avulsion |
- Ultrasound |
- MRI (lower sensitivity than US) |
- CT - rules out trabecular stuctural alterations at the insertion |
- VISA -A (Victoria Institute of Sports Assessment) - post treatment follow up pain and function scale |
Ultrasound
Ultrasound can assess the injury
Left side shows achilles tendinopathy (increased thickness of tendon + hyperemia + hypervascularity - Assess using the Doppler)
Right = normal
DDx
F# |
Avulsion |
Neoplasm |
Infection |
Ankle Sprain (Ottawa Ankle rules) |
Retrocalcaneal Bursitis |
Posterior Ankle impingement |
Os-Trigonum syndrome |
Tenosynovitis |
Tendon dislocation |
Tennis leg |
Sural Neuroma/ Nerve entrapment |
Systemic inflammatory disease |
Calcaneal apophysitis |
Plantar Fasciitis |
Haglund deformity |
Sever Disease |
Heel Pad syndrome (deep pain in the middle heel - feels like a bruise) |
Erdheim Chester Disease (abnormal multiplication of Histiocytes) |
Management
- Rest, NSAIDs,eccentric rehab, correction of mechanical faults |
- Crutches/brace |
- Runners can be switched to swimming/cycling |
- Avoidance of shoes with heels |
- Single leg eccentric heel drop offs (slow and knee straight and bent) 3 sets of 15 twice per day for 12 weeks |
- Slow and progressive loading is more effective (10% per week) |
- Increase of patient's night pain = excessive load |
- Soft tissue work, myofascial release and stretching recommended |
- Manipulation of ankle, knee and hip (kinematic chain) |
- Athletes should perform a warm up routine before exercise and introduce new activities slowly and avoid increasing activity - runners should begin on smooth surfaces |
- Avoid compression socks |
- Return to play criteria (triple 5) |
- Shockwave if not responsive to initial management |
- SUrgery if not better within 6 months |
- Patient should use non-injured leg to return to heel up start position (avoids concentric contractions)
- Moderate pain is common, but if patient has excessive pain, patient should assist downward motion with non-injured leg
Triple 5
- Ankle dorsiflexion <5 degrees on the uninjured side |
- Calf circumference <5mm of uninjured side |
- Patient able to perform 5 sets of 25 single leg heel raises |
Prognosis
- Good with early management |
- Surgical care is mostly successful (80%)
risk of complications: Ruptured tendon, DVT, reflex dystrophy, persistent neuralgia, deep infections, wound problems, discomfort, hypertrophy |
- As number of risk factors increases, failure of non-operative treatment increases |
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