Chapter 28
Pain in the Achilles Region

Early treatment and long-term rehabilitation continued

Treatment of specific presentations of tendinopathy 

In addition to the general rehabilitation program for Achilles tendinopathy, we address the treatplace the muscle into dorsiflexion. This stabilizes the tendon as a rigid base against which the paratenon can be treated. Techniques include sliding the paratenon over the tendon longitudinally (Fig. 28.13a) and in a rotatory movement in the transverse plane (Fig. 28.13b).ment of three common clinical presentations— paratenonitis, focal tendon nodules and partial rupture. A summary of an integrated treatment regimen for Achilles tendinopathy is shown in the box on page 548. 

Tendon swelling and paratenonitis 

Some patients present with a clinical picture of paratenonitis and can benefit from soft tissue massage, particularly when symptoms have been present for some weeks. The therapist should place the muscle into dorsiflexion. This stabilizes the tendon as a rigid base against which the paratenon can be treated. Techniques include sliding the paratenon over the tendon longitudinally (Fig. 28.13a) and in a rotatory movement in the transverse plane (Fig. 28.13b).

Small, discrete, palpable tendon nodules represent lesions of tendinosis with or without calcification. These areas may cause significant pain and tenderness without much swelling. The lesions move as the tendon is moved through full range in contrast to lesions of the paratenon, which remain fixed as the tendon slides. In addition to the strengthening program outlined above, soft tissue massage with grade I transverse mobilization, longitudinal friction and trans-verse friction can be beneficial. In lesions that are less tender, grade III techniques can be used to reduce the amount of chronic scar tissue. The tendon should be placed in a position of pain-free stretch and iced for 10 minutes after treatment. 

Fig. 28.11 Sustained myofascial tension treatment of calf muscle thickening

Fig. 28.12 Subtalar joint mobilization to treat stiffness. The foot is placed in dorsiflexion and medial-to-lateral pressure is applied to the calcaneus

The patient who presents with acute onset of pain with localized tenderness and swelling and a focal sonographic abnormality may have suffered a partial tear (Fig. 28.6), although tendinosis and partial tears can be indistinguishable on ultrasound and MRI (and have identical histopathology).(1) This injury requires a lengthy period of rehabilitation that begins with several weeks to a month of rest from aggravating activities. Treatment is as for tendinopathy but with a more gradual progression of the strengthening program. 

Occasionally, conservative management of Achilles tendinopathy fails. This failure is more common in older male patients and those with longstanding symptoms, those who persist in full training despite symptoms or those who have uncorrected predisposing factors. In these cases, surgery may be indicated. It should be remembered, however, that the rehabilitation program, particularly for severe Achilles tendon injuries, is a slow, lengthy program. Surgery is only indicated when there is failure to progress in the rehabilitation program. Surgery should not be considered unless six months of appropriate conservative management has failed. 

Surgery of the patient with chronic Achilles tendon injury involves incision of the paratenon and release of adhesions,(19) removal of any areas of degenerative tissue and repair of any partial tears. Complications occur in about 10% of operations and include skin edge necrosis of the incision, superficial wound infections, nerve irritations and deep venous thrombosis.(21)

Surgery needs to be followed by a carefully monitored rehabilitation program involving eccentric strengthening as described for Achilles tendinopathy above. After surgery for Achilles tendinopathy, plantarflexion remains weak in the first six to nine months despite intense rehabilitation.(22) Clinical progress should determine return to sport but the practitioner and patient should be aware that it is not uncommon for patients to require around nine months to regain full function after this surgery.