HOW TO TREAT 17
Clinical presentation depends on the mode of overload , and several structures may be overloaded at the same time . The different sources of pain can be managed sequentially by first improving the Achilles tendinopathy with isometric exercises , then dealing with the other sources of pain .
A B
Achilles tendon rupture
Achilles rupture can present as sudden onset pain and dysfunction . The classic symptom is the sensation of being kicked in the calf , with the individual often reporting they had turned around to see what hit them . There may be minimal pain associated with the rupture .
The diagnosis can be missed as intact toe flexors and the plantaris tendon can still produce non-weight-bearing plantar flexion . Single-leg heel raise is impossible . There are several tests with a high sensitivity and specificity . In the Matles test , the patient lies prone with their knees bent . More dorsiflexion on the ruptured side is a positive test ( see figure 7A ). 22
In the Simmonds – Thompson test , the patient lies prone with their feet hanging over the edge of the couch . Squeezing the calf muscle fails to produce plantar flexion in the foot if the Achilles is ruptured ( see figure 7B ). 22
Insertional Achilles tendinopathy
This occurs on the superolateral aspect of the calcaneus just proximal to the tendon insertion on the distal part of the calcaneus ( see figure 8 ). It is at this point that , in dorsiflexion , the tendon is compressed against the superolateral aspect of the calcaneus and the retrocalcaneal bursa is compressed between the bone and the tendon . Pathology results in tendon thickening , and bursal swelling that may be a result of either fluid ( that may or may not be inflammatory ) or bursal wall thickening . The bursal swelling is not a diagnosis in isolation ; bursal involvement is associated with an insertional Achilles tendinopathy and must be treated holistically .
Management requires removal of compressive loads ; the easy option is to add a large heel lift . The best way to achieve this is with shoes that have a heel height of more than 3cm , although sometimes up to 5cm is required before the tendon becomes asymptomatic . Men can achieve this with elastic-sided boots or shoes with an inbuilt heel raise (‘ elevator ’ shoes ). Six to eight weeks of low compressive loads in high shoes supplemented by rehabilitation exercises can manage most cases of insertional Achilles pain .
Peritendon irritation
Peritendon irritation ( not confirmed as inflammation ) occurs when the ankle is repeatedly moved through a large range of movement outside of its usual activity . This creates friction between the tendon and the surrounding structures resulting in irritation of the peritendon structures . The peritendon posterior to the Achilles tendon contains a series of gliding membranes that accommodate the normal tendon movement against the surrounding tissues . The anterior structure ( Kager ’ s fat pad ) is not affected ( but may be abnormal on imaging in Achilles tendon pathology ).
Peritendon irritation can occur after direct blow , wearing tight socks or ankle tape ( the last two usually settle quickly on removal of provocative load ). Patients present with tendon
Figure 3 . Mild left-sided medial gastrocnemius and soleus wasting appreciated at rest in A and plantar flexion in B .
A
Figure 4 . Common strategies when calf strength is poor . A . Ankle inversion . B . Reduced calfraise height . C . Flexing through knee . D . ‘ Spider toes ’ or clawing .
B
C
D