Achilles tendinopathy

• Achilles tendon:

  • Thickest and strongest tendon in the body
  • Connects the calf muscles to the calcaneus (heel bone)
  • Achilles tendon unites the gastrocnemius, soleus and plantaris muscles (calf muscles)
  • Function: when calf muscles flex this pulls on the Achilles tendon causing plantar flexion of the ankle - foot moves down
• Achilles tendinopathy:

  • Pain, swelling, inflammation and impaired function of the Achilles tendon
  • Midpoint tendinopathy = 2-6cm above insertion point of tendon into calcaneus (most common)
  • Insertion tendinopathy = within 2cm of insertion point of tendon into calcaneus
• Risk factors:

  • Exercise that stresses the tendon
  • Inappropriate footwear
  • Inflammatory conditions e.g. RA and ankylosing spondylitis (AS causes enthesitis)
  • Diabetes - hyperglycaemia causes tendon inflammation
  • Raised cholesterol
  • Fluoroquinolone antibiotics e.g. ciprofloxacin and levofloxacin (warn patients when starting these meds)
• Presentation:

  • Gradual onset of pain/aching in Achilles or heel
  • Pain aggravated by activity or pressure
  • Stiffness - may be in morning or after period of prolonged rest
• Examination:

  • Tenderness, swelling, redness, thickening/nodularity on palpation
  • Examine range of motion: pain worsened with passive dorsiflexion of ankle (stretches tendon)
• Diagnosis:

  • Clinical - no investigations usually needed
  • If suspect underlying cause may arrange bloods e.g. HbA1c, lipid profile
• Management:

  • Manage any underlying cause e.g stop abx
  • Manage conservatively - ice, rest, paracetamol +/- NSAIDs (short term)
  • Do not inject with corticosteroids - risk of rupture
  • If pain no better in 7-10 days refer to physio
  • If no improvement refer to secondary care - exercise programmes, extracorporeal shock-wave therapy (increase blood flow), surgery (remove nodules and adhesions)
• Prognosis:

  • Most improve with conservative treatment - usually after 12 weeks on treatment
  • Some cases can persist for up to 2 years
• If someone presents with suspected Achilles tendinopathy, rupture of the Achilles tendon needs to be ruled out