Pain in the region of the Achilles tendon is an extremely frequent presenting symptom, especially among distance runners. The anatomy of this area is shown in Figure 28.1 and the conditions that can present with pain in this region are listed in Table 28.1.
Clinical perspective
The Achilles tendon, named after the legendary warrior and hero of Homer's Iliad, is the most common site of Achilles region pain. Acute tendon rupture causes sudden severe pain and inability to weight-bear on the affected leg. Overuse Achilles tendon injuries—tendinopathy— may arise after a particularly arduous training session or competition or may arise insidiously. The condition that was generally called ‘Achilles tendinitis' is not truly an inflammatory condition (1) and thus, is referred to as ‘Achilles tendinopathy'(2) throughout this book. Chapter 2 includes a detailed discussion of the pathology that underlies the common sports medicine tendinopathies.(3)
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Fig. 28.1 The Achilles region
(a) Surface anatomy)
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(b) Anatomy
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The main differential diagnoses of gradual onset Achilles region pain arise from neighboring anatomy. There are two bursae in this region, the retrocalcaneal bursa, which lies between the posterior aspect of the calcaneus and the insertion of the Achilles tendon, and the Achilles bursa, which lies between the insertion of the Achilles tendon and the skin (Fig. 28.1b). When inflamed, these may cause Achilles region pain with or without associated Achilles tendon conditions. The posterior process of the talus or a discrete anatomical variant, the ostrigonum, can each be involved in posterior impingement syndrome. This is most commonly seen in ballet dancers but occurs occasionally in sprinters and in football players.
In adolescents, it is important to consider the diagnosis of Sever's disease, a traction apophysitis at the insertion of the Achilles tendon into the calcaneus (Chapter 35). Referred pain is a rare cause of Achilles region pain but should always be considered. |
| History
The athlete with overuse tendinopathy or retrocalcaneal bursitis notices a gradual development of symptoms and typically complains of pain and stiffness immediately on rising in the morning. This pain diminishes with walking about or applying heat (e.g. a hot shower). Similarly, the athlete's pain diminishes during training, only to recur several hours afterwards.
The onset of pain is usually more sudden in a p a rtial tear of the Achilles tendon and this condition may be more disabling in the short term. As the histological abnormality in a partial tear and in overuse tendinopathy are identical (see below), we do not emphasize the distinction other than to suggest that time to recovery may be longer in cases of partial tear. A history of a sudden, severe pain in the Achilles region with marked disability suggests a complete rupture. The patient or a nearby colleague often reports hearing a ‘shot'.
Examination
As well as examining the painful area, it is important to determine possible predisposing factors, such as unilateral calf tightness, joint stiffness at the ankle or subtalar joints and abnormal lower limb biomechanics.
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Observation
(a) standing
(b) walking
(c) prone (Fig. 28.2a)
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Active movements
(a) plantarflexion
(b) dorsiflexion
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Passive movements
(a) plantarflexion
(b) plantarflexion with overpressure (Fig. 28.2b)
(c) dorsiflexion
(d) subtalar joint (Fig. 28.2c)
(e) muscle stretch
(i) gastrocnemius (Fig. 28.2d)
(ii) soleus (Fig. 28.2e)
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Resisted movements
(a) plantarflexion
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Functional tests
(a) calf raises
(b) hop
(c) eccentric drop (Fig. 28.2f)
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6. Palpation
(a) Achilles tendon (Fig. 28.2g)
(b) retrocalcaneal bursa
(c) posterior talus
(d) calf muscle
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Special test
(a) Simmond's calf squeeze test (Fig. 28.2h)
(b) biomechanical assessment (Chapter 4)
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Fig 28.2 Examination of the patient with pain in the Achilles region
(a) Observation - prone. Look for swelling of the tendon and wasting of the calf muscle
(b) Passive movement - plantarflexion. This will be painful if posterior impingement is present. Overpressure can be applied.
(c) Passive movement - subtalar join. Restricted subtalar joint movement is a potential cause of Achilles region pain and a contributory factor to abnormal biomechanics.
(d) Passive movement - muscle stretch (gastrocnemius). The patient stands so that body weight causes overpressure. The knee must remain extended and the hell remains in contact with the floor. The foot remains in neutral by keeping the patella in line with the third metatarsal. Compare the stretch on both sides.
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Clinical perspective part 1
