| Less common causes
Sever's disease
Sever's disease or calcaneal apophysitis occurs in adolescents where traction of the Achilles tendon causes inflammation of the apophysis of the calcaneus (Chapter 35).
Posterior impingement syndrome
Posterior impingement syndrome of the ankle is caused by impingement of the posterior talus by the adjacent aspect of the posterior aspect of the tibia in extremes of plantarflexion. An enlarged posterior tubercle of the talus (Fig. 28.15a) or an ostrigonum (Fig. 28.15b) may be present. This condition is commonly found in ballet dancers, gymnasts and footballers, all of whom maximally plantarflex their ankles. It is also seen secondary to ankle plantarflexion/inversion injuries.
The ostrigonum represents an unfused ossific center in the posterior process of the talus. This is a normal anatomic variant present in approximately 10% of the population. It was originally thought that the ostrigonum was painful simply because of its unfused condition. However, it is the space-occupying nature of the bone that causes the pain irrespective of whether the bone is fused or united.
The diagnosis of posterior impingement syndrome is suggested by pain and tenderness at the posterior aspect of the ankle and confirmed by a positive posterior impingement testpain is reproduced on passive plantarflexion of the ankle. If further confirmation is required, a small amount of a local anesthetic agent can be injected a round the posterior talus and the impingement test performed without pain.
Posterior impingement syndrome should be treated with relative rest, manual mobilization of the subtalar, talocrural and midfoot joints, NSAIDs and electrotherapeutic modalities. In ballet dancers, forcing turnout and/or sickling the foot can predispose to this condition, so technique assessment is essential. If the condition persists, a corticosteroid injection around the area of maximal tenderness may be effective in reducing pain and swelling. This is best done from the lateral side, as the medial aspect of the ankle contains the neurovascular bundle. Frequently, this condition does not respond to conservative management and requires surgical removal of the posterior process or the ostrigonum. Most rapid return to activity after this surgery occurs if there is little disruption of the fat pad that is encountered during dissection to the posterior process of the talus.
Other causes of pain in the Achilles region
Referred pain to this region from the lumbar spine or associated neural structures is unusual but must be considered. Achilles bursitis is generally caused by excessive friction, such as by heel tabs or wearing shoes that are too large. Treatment consists of NSAIDs and occasionally a corticosteroid injection.
RECOMMENDED READING
Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26: 3606.
Astrom M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop 1995; 316: 15164.
McCrory JL, Martin DF, Lowery RP, et al. Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exerc 1999; 31: 137481.
Niesen-Vertommen SL, Taunton JE, Clement DB, et al. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med 1992; 2: 10913.
Movin T, Gad A, Reinholt FP, et al. Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 1997; 68: 1705. Waterston SW, Maffulli N, Ewen SWB. Subcutaneous rupture of the Achilles tendon: basic science and some aspects of clinical practice. Br J Sports Med 1997; 31: 28998.
REFERENCES
1. Astrom M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop 1995; 316: 15164.
2. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions. Time to change a confusing terminology. Arthroscopy 1998; 14: 8403.
3. Khan KM, Cook JL, Bonar F, et al. Histopathology of common overuse tendon conditions: update and implications for clinical management. Sports Med 1999; 27: 393408.
4. Simmonds FA. The diagnosis of the ruptured Achilles tendon. The Practitioner 1957; 179: 568.
5. Astrom M, Gentz CF, Nilsson P, et al. Imaging in chronic Achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996; 25: 61520.
6. Movin T, Kristoffersen-Wiberg M, Shalabi A, et al. Intratendinous alterations as imaged by ultrasound and contrast medium enhanced magnetic resonance in chronic achillodynia. Foot Ankle Int 1998; 19: 31117.
7. Khan K, Kannus P. Use of imaging data for predicting clinical outcome (letter). Br J Sports Med 2000; 34: 73.
8. Soila K, Karjalainen PT, Aronen HJ, et al. High-resolution MR imaging of the asymptomatic Achilles tendon: new observations. Am J Roentgenol 1999; 173: 3238.
9. O'Brien M. Functional anatomy and physiology of tendons. Clin Sports Med 1992; 11: 50520.
10. Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis (jumper's knee): findings at histopathologic examination, US and MR imaging. Radiology 1996; 200: 8217.
11. Astrom M. On the nature and etiology of chronic Achilles tendinopathy [PhD]. Lund University, Sweden, 1997.
12. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis. Etiology and treatment. Am J Sports Med 1984; 12: 17984.
13. McCrory JL, Martin DF, Lowery RP, et al. Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exerc 1999; 31: 137481.
14. Niesen-Vertommen SL, Taunton JE, Clement DB, et al. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med 1992; 2: 10913.
15. Enwemeka CS. The effects of therapeutic ultrasound on tendon healing. A biomechanical study. Am J Phys Rehabil 1989; 68: 2837.
16. Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30: 118390.
17. Åstrom M, Westlin N. No effect of piroxicam on achilles tendinopathy. A randomized study of 70 patients. Acta Orthop Scand 1992; 63: 6314.
18. Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26: 3606.
19. Maffulli N, Testa V, Capasso G, et al. Results of percutaneous longitudinal tenotomy in Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 1997; 25: 83540.
20. Maffulli N, Binfield PM, Moore D, et al. Surgical decompression of chronic central core lesions of the Achilles tendon. Am J Sports Med 1999; 27: 74752.
21. Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med 2000; 28: 7782.
22. Alfredson H, Pietila T, Lorentzon R. Chronic Achilles tendinitis and calf muscle strength. Am J Sports Med 1996; 24: 82933.
23. Maffulli N, Waterston SW, Squair J, et al. Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med 1999; 9: 15760.
24. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. Am J Sports Med 1998; 26: 26670.
25. Waterston SW, Maffulli N, Ewen SWB. Subcutaneous rupture of the Achilles tendon: basic science and some aspects of clinical practice. Br J Sports Med 1997; 31: 28998.
26. Mortensen NHM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. J Bone Joint Surg 1999: 81A: 98390.
27. Soldatis JJ, Goodfellow DB, Wilber JH. End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 1997; 25: 905.
28. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993; 21: 7919.
29. Sekiya JK, Evansen KE, Jebson PJ, et al. The effect of knee and ankle position on displacement of Achilles tendon ruptures in a cadaveric model: implications for nonoperative management. Am J Sports Med 1999; 27: 6325.
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Less common causes
