Achilles Tendonitis

Question 1

What is achilles tendonitis?

Answer 1

Inflammation of the calcaneal tendon.

Question 2

Epidemiology

Answer 2

Affects around 2 per 1000 adults

More common in high-intensity activities which chronically overload the tendon like running and jumping.

Also common in middle-aged unfit men who start doing sports again.

Question 3

Sequelae of achilles tendonitis

Answer 3

Achilles tendon rupture resulting in complete loss of function of the calf muscle.

Approx 80% of all ruptures occur during athletic activity.

Question 4

Pathophysiology of achilles tendonitis

Answer 4

Unites gastrocnemius, soleus and plantaris muscles.

Inserts in to the calcaneus and produces plantarflexion of the ankle.

Repetitive action of the tendon results in microtears leading to localised inflammation.

The tendon will then become thickened, fibrotic and loses elasticity with repeated episodes.

Question 5

Pathophysiology of achilles tendon rupture.

Answer 5

Substantial sudden force applied across tendon.

Can be in context of achilles tendonitis.

Movement such as sudden jump or rapid change in direction while running.

Question 6

Risk factors

Answer 6

Unfit individual who has a sudden increase in exercise frequency

Poor footwear choice

Male gender

Obesity

Recent fluoroquinolone use

Question 7

Clinical features of tendonitis.

Answer 7

Gradual onset of pain and stiffness in posterior ankle.

Worse with movement

It can be improved with mild exercise or heat application.

Question 8

Examination findings of tendonitis.

Answer 8

Tenderness over the tendon

Worse 2-6cm above its insertion site.

Question 9

Clinical features of rupture.

Answer 9

Sudden-onset of severe pain in posterior calf

Audible popping sound and a feeling of that something ‘went’.

Question 10

Examination findings

Answer 10

Marked loss of power of ankle plantarflexion.

Peroneal tendons can still contribute to plantarflexion so the movement is intact but severely weakened.

Question 11

Specific indicators of tendon rupture.

Answer 11

Simmonds’ test

Palpable step in the achilles tendon

Question 12

Explain Simmonds’ test

Answer 12

With patient kneeling on a chair with affected ankle hanging of the edge of the chair.

Squeeze the affected calf.

If the achilles tendon is intact the foot will plantarflex.

If the plantarflexion is absent the tendon is ruptured.

Question 13

Dx

Answer 13

Ankle sprain

Stress fractures tibial or calcaneal

OA

Ankle fracture

Ankle sprain

Question 14

Ix

Answer 14

Clinically diagnosed

USS can be useful if diagnosis is uncertain and also useful to differentiate between complete and partial tears.

Question 15

Management of tendonitis

Answer 15

Supportive measures

Stop precipitating exercise
Ice the area

Anti-inflammatory medication.

Rehab and physio might be done in chronic tendonitis.

Question 16

Initial management of acute tendon rupture (< 2 weeks)

Answer 16

Regardless of partial or full-thickness it needs analgesia and immobilisation.

Ankle splinted in a plaster in full equinus (ankle and toes maximally pointed)

Provide crutches and tell patient not to weight bear.

Question 17

What is done after initial management?

Answer 17

Position is held for 2 weeks.

After 2 weeks ankle is brought to semi-equinus.
This is held for 4 weeks.

After this ankle is brought into neutral position.
This is held for 4 weeks.

Question 18

When is surgical intervention indicated?

Answer 18

Delayed presentation (>2 weeks)

Cases of re-rupture

Done by end-to-end tendon repair

Question 19

More and more units are now switching from plaster immobilisation to what?

Answer 19

Weight-bearing orthosis called a moonboot with a large heel raise.

Question 20

Pros of moonboot.

Answer 20

Achieves the same position as equinus.

The patient is allowed to fully weight bear immediately however.