Chapter 28
Pain in the Achilles Region

Complete rupture of the Achilles tendon classically occurs in athletes in their 30s or 40s while playing racquet sports. The condition appears to be increasing in prevalence.(23) The patient describes a sudden onset of acute pain in the Achilles region immediately followed by grossly diminished function. The patient will often describe a feeling ‘as if I was hit or kicked in the back of the leg'. A snap or tear may be audible. 

The patient will usually have an obvious limp but may have surprisingly good function through the use of compensatory muscles. On examination, Simmond's calf squeeze test is positive ( Fig.28.2h)(24) and there is often a palpable defect in the tendon. Treatment of the acutely ruptured Achilles tendon remains controversial.(25) As there is no agreed protocol, it is important that the treating practitioner explains the relative merits and potential complications to the patient. 

Surgical management 

Surgical repair of the Achilles tendon, with or without augmentation, is generally considered the most appropriate form of management for active individuals seeking the best functional result. Traditionally, this has been followed by rigid immobilization in a plaster cast for four to nine weeks. After that time the patient begins weight-bearing in a walking cast. Upon removal of the cast the repaired region will be scarred and extremely thickened. The muscle tendon complex is shortened as a result of the prolonged period of plantarflexion. 

Once the cast is removed, the athlete requires intense rehabilitation with electrotherapy and mobilization of the stiff ankle, subtalar and midtarsal joints. A strengthening program for the Achilles tendon is required and described below. At approximately eight weeks after surgery when the patient is walking, the scar surrounding the repair will be stable. Soft tissue techniques (e.g. longitudinal and transverse gliding) can then be used to enhance tissue healing and encourage appropriate alignment of the maturing collagen. Treatment results in improved range of ankle dorsiflexion and reduced stiffness at the site of the repair.

We note that since the early 1980s surgeons have considered the possibility of early motion after treatment of ruptured Achilles tendon. In 1999, Danish surgeons reported that early restricted motion in a below-knee cast for six weeks shortened the time needed for rehabilitation without any ill-effects on tendon healing.(26)

Complications of Achilles tendon repair include the complications of any surgical procedure, together with deep venous thrombosis, pulmonary embolism, wound infection, wound necrosis and re-rupture.(27) A prospective randomized trial of surgical versus conservative treatment in 111 patients found no difference in incidence of complications or re-ruptures in the two groups.(28)

Conservative management 

Conservative management of an Achilles tendon rupture may be indicated in older patients.(28) This involves cast immobilization, initially in a position of maximal plantarflexion to protect the tendon,(29) then after four weeks gradually reducing the amount of plantarflexion. Some, but not all, studies of this treatment method have reported residual lengthening of the Achilles tendon and a rather high re-rupture rate.(25)

Retrocalcaneal bursitis

Inflammation in the retrocalcaneal bursa, which lies between the Achilles tendon and the posterior border of the calcaneus, is common in athletes and often mistaken for Achilles tendinopathy. The main clinical feature that helps differentiate between the two conditions is the site of maximal tenderness (Fig. 28.1b). Retrocalcaneal bursitis may coexist with Achilles tendinopathy. This is known as Haglund's syndrome when it occurs in association with a retrocalcaneal exostosis or prominent posterior superior calcaneus (Haglund's deformity). Biomechanical abnormalities, joint stiffness and proximal soft tissue tightening are all predisposing factors that warrant correction if present. If conservative management fails in cases where a Haglund's deformity is present, surgery is indicated (Fig. 28.14). 

Retrocalcaneal bursitis should be treated with NSAIDs and relative rest from aggravating activities. Corticosteroid injection (0.5 mL of corticosteroid and 0.2 mL of local anesthetic agent) into the area between the Achilles tendon and the upper posterior border of the calcaneus may be helpful. Abolition of pain after local anesthesia helps confirm the diagnosis. Following injection, the patient should rest for 48 hours and then slowly resume activity, building up to full activity over a period of two to three weeks.