Achilles tendon

Question 1

What is the most common cause of posterior heel pain?

Answer 1

Achilles tendon disorders
= tendinopathy, partial tear, rupture

Question 2

What are the typical symptoms of Achilles tendinopathy?

Answer 2

Gradual onset of posterior heel pain, worse after activity, with morning pain and stiffness

Question 3

Name two key risk factors for Achilles tendon disorders

Answer 3

1. Quinolone antibiotic use
   = ciprofloxacin
2. hypercholesterolaemia

Question 3

What region of the Achilles tendon is most affected by tendinopathy and why?

Answer 3

The hypovascular region 2–6 cm above the calcaneal insertion, making it vulnerable to poor healing

Question 4

What is Achilles Tendonitis?

Answer 4

Inflammation of the Achilles tendon

Question 4

What is the pathophysiology of Achilles tendinopathy?

Answer 4

Repetitive microtrauma and failure of collagen repair, leading to disorganised fibre structure

Question 5

What physical activity change is usually recommended in Achilles tendinopathy?

Answer 5

Reduction or modification of precipitating activities (e.g. running)

Question 6

What physiotherapy approach is commonly used in Achilles tendinopathy?

Answer 6

Eccentric calf muscle exercises

Question 7

What is the role of NSAIDs in Achilles tendinopathy management?

Answer 7

To help with pain and inflammation

Question 8

Why should corticosteroid injections be avoided around the Achilles tendon?

Answer 8

They increase the risk of tendon rupture

Question 9

What device can be used to reduce stress on the Achilles tendon?

Answer 9

A heel raise or splint/boot to offload the tendon

Question 10

What serious complication can Achilles tendinopathy lead to?

Answer 10

Achilles tendon rupture

Question 11

What is the classic conical presentation of Achilles tendonitis?

Answer 11

1. Pain of the Achilles tendon or at its insertion in the calcaneus
2. Morning stiffness
3. Pain and stiffness ease with walking

Question 11

When should an urgent referral to orthopaedics be considered for Achilles disorders?

Answer 11

If Achilles tendon rupture is suspected – same-day referral/ admission

Question 12

What is a common age group affected by Achilles tendon rupture?

Answer 12

People over 40, due to age-related tendon degeneration

Question 13

What is a classic symptom reported in Achilles tendon rupture?

Answer 13

1. A sudden sharp pain
2. Often described as feeling like being kicked in the back of the leg
3. Followed by difficulty in weight-bearing

Question 14

What type of event often leads to Achilles tendon rupture?

Answer 14

Sudden deceleration with resisted calf contraction, such as lunging in sports (e.g. squash)

Question 15

What are the key signs of Achilles tendon rupture on examination?

Answer 15

1. Plantarflexion Weakness
2. Inability to tiptoe stand
3. Palpable tendon gap.

Question 16

What clinical test is used to confirm an Achilles tendon rupture?

Answer 16

The Simmonds (Thompson) test

= no plantarflexion when the calf is squeezed in a prone patient with feet over the bed edge

Question 17

What imaging modality is preferred initially for suspected Achilles tendon rupture?

Answer 17

Ultrasound

Question 18

What are three risk factors for Achilles tendon rupture?

Answer 18

Diabetes, rheumatoid arthritis, and corticosteroid use

Question 18

What does Simmond’s triad include?

Answer 18

1. Increased dorsiflexion compared to the opposite side
2. A palpable tendon gap
3. Absent plantarflexion on calf squeeze

Question 19

What are the two main treatment options for Achilles tendon rupture?

Answer 19

1. Conservative management
   = serial casting
2. Surgical repair

Question 20

What is the conservative treatment approach for Achilles tendon rupture?

Answer 20

Casting with the foot in plantarflexion (equinus position) for around 8 weeks to approximate the tendon ends

Question 21

When should an orthopaedic referral be made for Achilles tendon rupture?

Answer 21

Immediately or same-day if rupture is suspected

Question 21

What complication is associated with surgical management of Achilles rupture?

Answer 21

Wound healing problems

Question 22

A 32-year-old basketball player presents difficulty mobilising after an injury while playing in a match. He reports hearing a 'popping' sound when the incident occurred and experiencing a sudden onset of severe pain in the back of his left leg. Clinical examination showed swelling of the left calf and no movement of his left foot whilst squeezing the corresponding calf, whilst lying face down on the examining bench. What is the best initial investigation to request for this patient?

Answer 22

Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture

Question 23

A 34-year-old man attends following an injury that occurred while playing football. He reports sudden pain in his right calf that started with a snapping sound while running. You suspect an Achilles tendon rupture and examine for the signs present using Simmonds' Triad. What does this examination involve?

Answer 23

1. Calf squeeze test 2. Observation of the angle of declination 3. Palpation of the tendon

Question 24

A 52-year-old man has an Achilles tendon rupture while playing tennis. He has no past medical history and has had no previous musculoskeletal problems. During the preceding week, he was commenced on antibiotic therapy for an infection and has been taking it for the past seven days. Which antibiotic was he likely to have started?

Answer 24

Ciprofloxacin

Question 25

A 23-year-old man attends the emergency department having developed severe pain in his left heel while playing football. He says he was tackled from behind by an opposition player, heard a loud 'snap', and then felt sudden and severe pain in the affected heel. Since the injury he has been unable to walk on the affected foot. On examination he is unable to plantarflex the left foot, and left calf squeeze test is negative. His neuro-vascular examination is normal in the affected leg. Which is the most appropriate test to confirm the diagnosis?

Answer 25

ultrasound

Question 26

A 32-year-old man presents to the emergency department with right ankle pain that started suddenly while playing football. Initially sharp, the pain has since become dull and is accompanied by swelling around his calf and ankle. On examination, his gait is antalgic. The right ankle and lower calf are swollen with bruising. Active plantar flexion is reduced, while other movements remain intact. Squeezing of the calf reveals an absence of plantar flexion. What is the best next initial investigation?

Answer 26

Ultrasound of the ankle

Question 27

A 25-year-old man reports that he experienced a sharp pain in the back of his calf while he was playing football and had to go offside following this as he was struggling to walk. He is seen by his team doctor who examines him and remarks that he has a positive Simmond's sign. What injury is he likely to have sustained?

Answer 27

Achilles tendon rupture