Information
Achilles tendon ruptures.
The classic history of an achilles tendon rupture is straightforward and most commonly occurs playing sport. However often the history can be much less obvious, particularly in an elderly patient and may just present as a swollen ankle/calf.
The important clinical evaluation is the squeeze test (also known as Thompsons or Simmonds test). The patient must be kneeling and the other side should be compared. The resting position of the foot is assessed and when the calf is squeezed the foot should plantar flex. If it does not plantarflex then a rupture should be suspected.
In the majority of cases Achilles tendon ruptures are treated without surgery using a specific protocol in a walking boot.
Achilles tendinopathy
Previously known as Achilles tendonitis, this is a very common condition in which patients complain of pain in the Achilles tendon which is worse on activity.
Non-insertional Achilles tendinopathy
This is the most common type of Achilles tendinopathy and patients complain of swelling and pain in the midsubstance of the tendon. This often occurs after a period of increased activity, change in footwear but can also develop after a period of immobilisation. It is, like any other tendinopathy, a failure of the tendon to be able to perform the load that is asked of it.
In the majority of cases this will respond to strengthening and so physiotherapy is the first line of treatment. If this is not successful then there are other treatment options such as shockwave, injections and in a small number of cases surgical intervention.
Examination to exclude a rupture should be performed. If the squeeze test is normal then a referral to physiotherapy should be made.
Referral into the Foot & Ankle service is only appropriate if physiotherapy has failed or if there is a suspicion that there has been a rupture.
Insertional Achilles Tendinopathy or Haglunds Deformity
This condition is seen when the patient complains of pain and swelling where the Achilles tendon attaches onto the heel bone rather than in the middle of the tendon. There are a few variations, but this is a different condition that the typical non-insertional tendinopathy and generally does not respond to the same management – in particular heel drops or stretching can aggravate it.
Physiotherapy is the first line treatment.
If the patient does not respond to physiotherapy then an Xray will be helpful to look for calcification at the tendon attachment. If there is a significant amount of calcification then non-operative management may not be successful. Surgery is often required to remove any calcification and in some cases will also involve a tendon transfer.
Achilles tendon contractures
If the Achilles tendon is too short or a gastrocnemius muscle is tight then it may lead to pain in the foot – it can cause pain in the heel, plantar fasciitis or pain in the forefoot from altered biomechanics.
In the first instance stretching will be of benefit and a referral to physiotherapy helpful.
If the symptoms do not improve surgery can be performed to lengthen the tendon, so in these cases a referral would be appropriate.
M.A. & J. McK. 24-09-24
