Fig. 58 MRI of Achilles tendinopathy showing retrocalcaneal bursitis as a common cause
SYMPTOMS The athlete complains of gradual onset of diffuse exercise-induced pain or ache around the Achilles tendon. This is common in runners and in players during pre-season training in soccer, rugby and similar sports. AETIOLOGY 'Tendinopathy' is a broad definition, encompassing a number of ailments that cause pain in this region. From the anatomical and clinical point of view it is important to differentiate insertional problems from free tendon or paratendon ailments. CLINICAL FINDINGS There is local tenderness on palpation over the tendon or its insertion, which often is thicker, with or without localised nodules. Occasionally there are inflammatory signs with redness and increased temperature. Compare to the other side.
INVESTIGATIONS Ultrasound or MRI will differentiate between intra-and extra-tendinous ailments. TREATMENT Management and advice depend on underlying pathoanatomical diagnosis. Para-tendinous ailments are the most benign, usually
Fig. 58 MRI of Achilles tendinopathy showing retrocalcaneal bursitis as a common cause treatable with modification in training, correction of shoes and local anti-inflammatory medication. If they become chronic, surgery may be necessary to release constrictions and adhesions between the skin and tendon sheath. Temporary adaptation of training is usually required; Free tendon and insertion ailments (partial ruptures, tendinosis and tendonitis and bursitis) - see specific sections for detailed treatment. Cortisone injections should be administered only in rare cases, due to the high risk of later tendon rupture. Surgery, followed by a few weeks' partial immobilisation and rehabilitation before resuming sport, may be necessary if conservative treatment fails. Weight bearing is usually allowed early if the injury is protected by an ankle brace.
REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a three to six months' return programme.
EXERCISE PRESCRIPTION Cycling and swimming (when wound is healed) and closed chain strength exercises, are good alternatives to keep up general fitness.
Monitor clinical symptoms and signs. The tendon may remain thicker than normal after healing. Calf muscle strength should be similar to the other side. Objective tests with resisted toe raises are suggested. DIFFERENTIAL DIAGNOSES Tendinosis, ten-donitis, bursitis, para-tendinosis, para-tendinitis, posterior impingement, tarsal tunnel syndrome. PROGNOSIS Excellent-Good.
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