Achilles Tendinopathy

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Clinical Features

In general, history and physical exam features are better at ruling in, rather than ruling out achilles tendinopathy. Self reported morning stiffness is the only feature with a moderate negative likelihood ratio.

Test	Sens.	Spec.	LR+	LR-	K
Palpation (tenderness)	64%	81%	3.15	0.48
Arc Sign	42%	88%	3.24	0.68
Royal London Hospital Test	54%	86%	3.84	0.54
Morning stiffness	89%	58%	2.12	0.19
Palpation thickening	59%	90%	5.9	0.46
Crepitus	3%	100%	inf	0.97
Stretch on passive dorsiflexion with knee joint in flexion	13%	87%	1.00	1.00
Single legged heel raise	22%	93%	3.14	0.95
Hop test	43%	87%	3.31	0.66
Thompson test (for rupture)

• Palpation: Palpate midportion and insertion
• Royal London Hospital Test: Pain on palpation disappears on maximal dorsiflexion compared to plantarflexion in achilles tendinopathy
• Arc test: palpate for thickened part/nodule, then have patient move ankle. In achilles tendinopathy the nodule should move, if it does not move then consider paratendonitis. Paratendonitis may show swelling.
• Modified straight leg raise for assessing sural nerve neuropathy: bring ankle into dorsiflexion and inverison, then flex the hip.
• Posterior impingement: passively hyperplantarflex the ankle looking for pain provocation.
• Plantaris tendinopathy: medial pain as the plantaris compresses against the medial achilles tendon
• Accessory/low soleus: can lead to compartment syndrome like symptoms e.g. symptoms settle quickly after the patient stops running

Diagnosis

Diagnosing achilles tendinopathy follows the same overarching assessment principles as other lower limb tendinopathies.

1. Epidemiological Data
   • Prevalent in all age groups especially runners
2. Highly localised pain at tendon enthesis
   • Only exception to the general lower limb tendinopathy rule, because can also get midportion achilles tendinopathy
3. Pain onset 24 hours after high and fast load activities
4. Proportional pain load relationship
   • Every stage perform a couple of repetitions and gauge pain.
   • Start with walking or running to assess the pain, double calf raises on the ground, double calf raises on a step, single leg calf raises, single leg knee bent calf raises, add load if required, add speed to calf raises with knee bent, hopping double leg, hopping single leg, hopping forward, backwards, sideways, jumps for maximal height with single leg.
5. Hallmark signs
   • Morning stiffness, this is the most sensitive sign.
   • Often have pain after arising from sitting.
6. Muscle Wasting.

Diffuse

• Ankle (Tibiotalar) Osteoarthritis
• Subtalar Osteoarthritis
• Inflammatory arthropathies - Rheumatoid Arthritis, septic arthritis, osteomyelitis, gout, Osteonecrosis.
• Sarcoid periarthritis
• Benign or malignant neoplasms, myelodysplastic and leukaemic disorders
• Plant-thorn synovitis
• CRPS

Ankle pain persistent following injury

• Fractures - anterior process calcaneus, lateral process talus, posterior process talus (or, rare, os trigonum fracture), osteochondral lesion, tibial plafond chondral lesion, base of fifth metatarsal
• Bony impingements - anterior, posterior, anterolateral
• Atypical sprains - chronic ligamentous instability, medial ligament sprain, syndesmosis sprain (AITFL sprain), subtalar joint sprain
• Tendon injuries - chronic peroneal tendon weakness, peroneal tendon subluxation/rupture, tibialis posterior tendon subluxation/rupture
• Other - inadequate rehabilitation, chronic synovitis, sinus tarsi syndrome

Lateral Ankle Pain

• Peroneal Tendinopathy or recurrent dislocation of peroneal tendons
• Sinus Tarsi Syndrome
• Impingement syndrome (anterolateral, posterior)
• Stress fractures (talus, distal fibula)
• Referred Pain (lumbar, peroneal nerve, superior tibiofibular joint)
• Cuboid Syndrome
• Os Peroneum
• Osteochondritis dissecans (anterior lateral talus)

Medial Ankle Pain

• Tibialis Posterior Tendinopathy
• Flexor Hallucis Longus Tendinopathy
• Medial Calcaneal Nerve Entrapment
• Stress fracture (calcaneal, talar, medial malleolar, navicular)
• Tarsal Tunnel Syndrome
• Posterior Ankle Impingement
• Referred Pain from the lumbar spine
• Complications of acute ankle injuries
• Os tibiale externum (accessory navicular)
• Osteochondritis dissecans (posterior medial talus)

Posterior Ankle Pain

• Midportion Achilles Tendinopathy
• Insertional Achilles Tendinopathy
• Retrocalcaneal bursitis
• Paratenon inflammation
• Posterior impingement syndrome
• Plantaris Tendinopathy
• Sever Disease (Calcaneal Apophysitis)
• Accessory or low soleus muscle
• Referred Pain (neural structures, lumbar spine), and sural neuropathy
• Achilles tendon rupture
• Achilles enthesopathy due to inflammatory arthropathies
• Osteochondritis dissecans (posterior medial talus)

Treatment

Physical Therapy

Graded loading programme