Evaluation of Achilles Pain

Differential Diagnosis

Common

1. Achilles Tendinopathy (Tendinosis, paratendinitis, partial tears)

2. Retrocalcaneal Bursitis

Less Common

1. Posterior Impingement Syndrome

2. Sever's Disease (Traction Apophysitis at Achilles Insertion onto Calcaneous)

3. Achilles Bursitis

4. Referred pain from Neural Structures or Lumbar Spine

Not to be Missed

1. Achilles Tendon Rupture

2. Achilles Tendinopathy secondary to inflammatory arthropathies

History

• Sudden versus gradual onset of pain

• Snapping or 'shot'

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the knee to rule out knee injury or ligamentous disruption. Also examine the ankle, and Lumbar Spine (for referred pain)

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. Achilles Tendon

2. Retrocalcaneal bursa

3. Posterior Talus

4. Calf Muscle

Motion

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Special Tests

1. Thomson's Test for intact acchilles unit (also known as the Simmond's Calf Squeeze Test)

2. Arc Sign and Royal London Hospital Test for Achilles Tendinitis

Investigations

1. Plain Films: Rarely Useful in acute phase, however, if symptoms are longstanding Xray may reveal a Haglund's Deformity, a prominent superior projection of the calcaneous, posterior impingement, or calcification in the tendon.

2. Ultrasound: May reveal signs of tendinopathy.

3. MRI: Also may reveal signs of tendinopathy.

4. Doppler Ultrasound: If DVT is suspected.

Appendix

Muscular Movers of the Ankle

Index

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