Achilles Tendonitis

Question 1

What is Achille’s tendonitis?

Answer 1

Inflammation of the calcaneal (achilles) tendon

Question 2

What is Achilles tendon rupture?

Answer 2

Tendon rupture resulting in complete loss of function of ipsilateral calf muscle.

Question 3

What factor puts patients at the highest risk for Achilles tendonitis or rupture?

Answer 3

High intensity activities (e.g. running / jumping)

Question 4

What muscles does the achilles tendon unite?

Answer 4

• Gastrocnemius
• Soleus
• Plantaris

Question 5

Into what bone does the achilles tendon insert?

Answer 5

Calcaneus

Question 6

What movement does the calcaneal tendon facilitate?

Answer 6

Plantarflexion of the ankle

Question 7

What is the pathophysiology of Achilles tendonitis?

Answer 7

Repetitive action of the tendon results in microtears leading to localised inflammation, leading to the tendon becoming thickened, fibrotic and less elastic with repeated episodes.

Question 8

What is the pathophysiology of achilles tendon rupture?

Answer 8

Substantial sudden force (such as sudden jump or rapid change in direction) applied across the tendon (usually with existing Achilles tendonitis)

Question 9

What are the risk factors for achilles tendonitis / achilles rupture?

Answer 9

• Unfit individual with sudden increase in exercise frequency
• Poor footwear choices
• Male gender
• Obesity
• Fluoroquinoquinolones use (for tendon rupture)
  
  • e.g Ciprofloxacin

Question 10

What are the symptoms and signs of achilles tendonitis?

Answer 10

Symptoms

• Pain & stiffness in posterior ankle
  
  • Gradual onset
  • Worse with movement
  • Improved with mild exercise or heat application

Signs

• Tenderness over tendon on palpation
  
  • Usually worse 2-6cm above insertion

Question 11

What are the symptoms and signs of achilles rupture?

Answer 11

Symptoms

• Pain in posterior calf
  
  • Sudden onset
  • Severe
• Audible popping sound
• Feeling that something “went”

Signs

• Loss of power of ankle plantarflexion
• +ve Simmond’s Test
• Palpable step in Achilles tendon

Question 12

Why is plantarflexion still present, but weakened after achilles tendon rupture?

Answer 12

The peroneal tendons contribute to plantarflexion so movement remails but is significantly weakened.

Question 13

What is Simmond’s test?

Answer 13

A special test to assess for potential Achilles tendon rupture

Patient kneels on a chair & with affected ankle hanging off the edge of a chair, squeeze the affected calf.

+ve Simmond’s sign = Plantarflexion is absent in tendon rupture.

Question 14

What are the main differentials for achilles tendonitis?

Answer 14

• Ankle sprain
• Stress fractures (tibial / calcaneal)
• Osteoarthritis

Question 15

What are the main differentials for achilles tendon rupture?

Answer 15

• Ankle fracture
• Ankle sprain

Question 16

What investigations are used to diagnose Achilles tendonitis / Achilles tendon rupture?

Answer 16

Usually a clinical diagnosis

When there is clinical uncertainty, an US scan may be required

Question 17

What is the management of achilles tendonitis?

Answer 17

Acute tendonitis

1. Supportive measures

• Stop precipitating exercise
• Ice the area
• NSAID regularly

Chronic tendonitis

1. Rehabilitation & physiotherapy

Question 18

What is the management of achilles tendon rupture?

Answer 18

1. Analgesia
2. Immobilisation in equinus cast

• Ankle splinted in a cast in plantarflexion for 2 weeks, then semi-equinus for 4 weeks, then neutral for 4 weeks.
• Provided with crutches & not allowed to weight bear

3. Surgical fixation with an end-end repair
   * For delayed presentations (>2 weeks) or cases of re-rupture