The patient’s unmet needs (PUNs)
Your next patient is clearly hobbling as she walks into the consulting room. She is a 34-year-old lady who attends rarely and has no relevant past medical history. ‘It’s my heel, doctor,’ she says. ‘It’s been going on for weeks. It hurts at the back and it’s murder when I get up in the morning or after I’ve been sitting down’. Examination reveals a swollen Achilles tendon, which is very tender. You explain the diagnosis. ‘What’s brought that on?’ she asks. ‘And can you recommend some exercises I can do to sort it out? I don’t really want to take any pills or go to hospital.’
The doctor’s educational needs (DENs)
What causes Achilles tendonitis? Is it ever a sign of any underlying disease?
The term ‘Achilles tendonitis’ is no longer correct, as studies demonstrate that little or no prostaglandin-mediated inflammation is present in people with Achilles disorders. Achilles tendinopathy is a more accurate term used to describe pain, swelling, weakness and stiffness of the tendon. Initially, reactive tendinopathy results in a non-inflammatory response to overload, which thickens the tendon, reduces stress and increases stiffness. If overload continues, this leads to tendon disrepair and disorganised tissue and, finally, degenerative tendinopathy.1
Acute ‘flare-ups’ can therefore be thought of as an exacerbation of a chronic underlying process where the tendon is unable to withstand any new mechanical load.
There are several biomechanical factors that put additional overload on the Achilles. They can be split into intrinsic and extrinsic factors. Some intrinsic factors, seen on examination, include overly pronated feet, tight or weak hamstrings, a pes cavus foot and lateral instability of the ankle. Extrinsic factors include sudden change in training pattern or technique, previous injury and environmental factors such as hard, slippery surfaces.
Other contributory factors include quinolone use, seronegative arthropathy, hyperlipidaemia, diabetes and hypertension. A positive family history raises the risk almost five-fold.
What is the differential diagnosis? What features confirm the diagnosis?
Other diagnoses that cause pain in and around the Achilles tendon include:
• Achilles tendon rupture.
• Retrocalcaneal bursitis (pain is reproduced with a pinch in front of the tendon).
• Haglunds deformity (a calcaneal ‘pump bump’ is seen, which can inflame).
• Ankle osteoarthritis.
• Posterior impingement of a bone or soft-tissue abnormality (this pain occurs on forced plantar flexion on examination or is brought on by jumping or kicking).
• Systemic inflammatory disease (especially if bilateral or other systemic features).
• Calcaneal pathology, including stress fractures, Sever’s disease (apophyseal injury seen in adolescents).
• Radicular pain from a nerve root pathology.
The history should assess for patterns of symptoms, predisposing intrinsic and extrinsic factors and the presence of risk factors.
Patients usually describe pain or stiffness in the Achilles 2-6cm above the calcaneal insertion. Local thickening also suggests tendinopathy. Morning stiffness may be present and the pain may settle with initial activity, but increase with prolonged activity. Less commonly, patients describe similar symptoms with point tenderness over the insertion.
How can the GP be sure this isn’t a partial or complete rupture of an Achilles tendon?
A significant partial tear or rupture of the Achilles is most common in men in their 30s and 40s, when degeneration has begun, but activity is still high. Incidence is seven in 100,000 in the general population.2 Suspect a rupture if the patient reports a sudden audible ‘pop’ and an impression of having been kicked in the calf. There is usually difficulty in walking. Examination features may include a palpable gap, weakness of ankle plantar flexion and a positive calf squeeze test. In this test, a rupture should be considered if the ankle remains still or with reduced plantar flexion, compared to the other side.
Drugs, such as quinolones or steroids, may also increase your suspicion, as they are associated with Achilles rupture in less active older adults.
What exercises and conservative measures should help?
The aims of treatment are load reduction and pain management. Cold packs and simple analgesia can be used for pain relief. Initial modified rest is recommended until pain subsides. A heel lift to effectively shorten the Achilles can also reduce load. Prolonged complete rest is counterproductive. Once pain has settled, the patient can restart exercise and increase as pain allows. Start with low loads, such as brisk walking, and increase gradually. If pain increases on return to activity then restart exercise at a level that causes only mild discomfort. Explain that this can take a few attempts over a three to six-month period.
A daily programme of calf stretches and strength training should be implemented. Strength training includes simple calf raises, as far as is comfortable. The movement should be slow and controlled – gradually increase the number of lifts and load by aiming to do single calf raises.
If simple measures are not effective, what should the GP consider? When should the patient be referred?
Failure of simple measures is usually due to not addressing causes. Insertional Achilles tendinopathy, as opposed to the more common mid-portion tendinopathy, responds less well to conservative measures. A referral to a sports medicine or musculoskeletal service should be considered.
The most effective physiotherapy treatment includes an eccentric exercise programme, which involves doing painful heel drops.3 A 12-week programme is recommended and continued for several months if there is a positive response.
A biomechanical, including orthotic, assessment can be carried out. Other non-surgical interventions, which have not yet been fully evaluated, include extracorporeal shock-wave therapy and novel injection therapies. Surgical interventions can be performed.
• Achilles tendinopathy is a more accurate term for these disorders as there is no inflammation.
• ‘Overload’ rather than inflammation is the main driver of pathology.
• Treatment should therefore aim to reduce load and address pain.
• Prolonged rest is counterproductive and a gradual return to activity is needed to allow the tendon to adapt to new stresses.
• A daily programme of calf stretches and heel raises should be advised.
• The condition can take as long as six months to settle.
• A referral to a sports medicine or musculoskeletal service should be made if conservative measures fail.
• Conservative measures usually fail because underlying issues have not been addressed (for instance, biomechanical factors).
• Physiotherapy treatment includes an eccentric exercise programme.
• Some patients may need to undergo novel therapies such as extracorporeal shock-wave therapy, injections (not steroid) or surgery.
Dr Ricky Shamji is a GP in Birmingham and a sports and exercise medicine registrar at Queen’s Medical Centre, Nottingham
1 Cook JL, Purdam CR. Is the tendon a continuum? A pathology model to explain the clinical presentation of load induced tendinopathy. Br J Sports Med, 2009;43:409-16
2 Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy, risk factors and injury prevention. Foot Ankle Spec, 2010;3:29-32
3 Van der Plas A, de Jonge S, de Vos RJ et al. A 5-year follow-up study of Alfredson’s heel drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med, 2012;46:214-18