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Achilles tendinopathy Cheat Sheet by

Achilles tendinopathy - presentation, management, classification

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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