Australian Doctor 3rd Dec 2021 | 页面 18

18 HOW TO TREAT : ACHILLES TENDINOPATHY

18 HOW TO TREAT : ACHILLES TENDINOPATHY

3 DECEMBER 2021 ausdoc . com . au pain on movement from plantar flexion to dorsiflexion with or without load ( that is , swimming or cycling ).
Crepitus may be palpable or audible and may be enhanced by placing a stethoscope over the tendon while the patient moves from plantar and dorsiflexion in prone .
Management requires removal of the provocative load , so it is important to identify either compression or repetitive low-load movements on history . A substantial heel lift can reduce movement of the tendon against the surrounding tissues and should settle the initial irritation .
The off-label use of heparin cream improves pain and function , and the combination of an anti-inflammatory cream and a heparin cream layered over the tendon overnight ( with cling wrap to protect the sheets ) can be bene ficial . This combination appears to be effective after about seven nights but may need to be spread out over more time if skin irritation occurs .
Plantaris tendon compression
The plantaris tendon can approximate the Achilles , causing compression and friction on the medial side of the Achilles tendon . 23 Compression of the Achilles may result in tendon pathology and tendinopathy . Suspected plantaris involvement is a reason to image an Achilles tendon ( either ultrasound or MRI ), as management strategies for plantaris tendon compression differ from that of a standard Achilles tendinopathy program .
Management of plantaris tendon compression emphasises reducing compression and friction ( heel lift and exercise away from dorsiflexion ). It can take several months for the symptoms to ease . A surgical opinion can be beneficial in athletes and those with persistent pain .
The plantaris may rupture spontaneously ( usually in athletes ). This can be managed conservatively with healing taking 6-8 weeks . During that time , the Achilles tendon can be loaded isometrically , progressing to isotonic loads . Institute a graduated program to return to high loads once the swelling and pain have settled .
Figure 5 . Ankle dorsiflexion range of movement via the knee-to-wall test .
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Figure 7A . Matles test position with demonstrable dorsiflexion of the ruptured side .
Figure 7B . Simmonds – Thompson test position .
Figure 6 . Test for posterior ankle impingement .
B
Pain from surrounding structures
Posterior ankle pain occurs after a sprain or persistent plantar flexion loads in sport ( such as ballet and fast bowling ). The imaging findings of an os trigonum or Stieda process are not linked to posterior ankle pain . 24
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B
The superficial bursa between the tendon and the skin may become irritated as it is highly innervated and thus sensitive to shoes with a hard heel counter ( see figure 9 ). It is often mistaken
for an insertional Achilles tendinopathy and can be differentiated on history ( aggravated by certain shoes , eased by bare feet ) and examination ( not load-dependent pain ). Padding , management of shoes and corticosteroid injection ( occasionally performed ) is the appropriate treatment .
The medial and lateral foot and ankle tendons can be a source of pain , somewhat determined by activity and age . Flexor hallucis tenosynovitis is mainly seen in dancers ; tibialis posterior tenosynovitis or tendon pathology occurs in older people ; and peroneal tendon issues ( tenosynovitis , retinacular disruption and tendon dislocation ) occur after ankle sprain ( see figure 10 ). The management of these
Figure 8A and B . Long-standing insertional Achilles pathology .
conditions depends on the structure and the onset .
RISK FACTORS
LIFESTYLE factors may influence the likelihood of tendinopathy , as sedentary behaviour is associated with
unloading , which decreases tendon stiffness , muscle and kinetic chain
25 , 26 strength , power and endurance . This has consequences for general health , but specific to the tendon , as it means any small increase in activity can trigger tendinopathy .
Obesity has been associated with tendinopathy . 27 The mechanical pathway ( heavier limb , body ) is not supported , rather the low-grade systemic inflammation is the likely driver . 28 There are no studies on change in obesity and tendinopathy .
Diabetes , especially persistent elevated blood glucose in type 2 diabetes , is clearly related to tendinopathy . 29 The mechanisms are unclear , but the increase in advanced glycation end products in collagen-rich tissues such as tendon can increase PAGE 20