Achilles Tendinopathy Insertional

Subjective

Objective

Research

Why this and nothing else?

Differentials

Pathology

Treatment

Change in load profile often being cause can be a acute or chronic issue.

Common overuse injury occurring an the insertion site of Achilles.

Long term management. 3-6 months.

All about patient buy in and education, no chance without these.

Activity modification with slow progressive load management programme.

  • Emphasized the importance and reliance of loading as a treatment approach.
  • Treat the donut not the hole (hole is the pathology).
  • Local nociceptive issue not centrally sensitised.
  • State importance of tendon being able to manage fast loads. Mimic spring like function.
  • Critiqued eccentric and heavy slow resistance programmes.
  • Approach = unload tendon so it can settle, gradually reload, outlined 4 stages to rehab.

Jill Cook - key player - Informed coogle.

May indicate sudden change or increase in loading activity.

Pain pattern = worse in AM or when starting activity, may then improve and then will return or feel worse 24 hours later.

Common in sports that involve running.

Palpation: Pain may run along Achilles tendon but should be more localised or proactive around insertion point at calcaneus.

Neuro - NAD

Observation: tendon may appear thicker, or have visible lump. Potential for wastage depending on chronicity.

Tarsal tunnel syndrome

Calf pathology.

Mid portion Achilles.

Link the repetitive load in subjective history.

Absence of trauma and neuro like symptoms.

The localised pain and increase activity with use.

Jill Cook - "Inflammation does exist but not prime driver, collagen tearing exists but not primary event, cell changes seem to be primary driver of pain and pathology".

Complex pathology but key message is that = Tendons need load to maintain structure.

Insidious onset.

Likely taking part in regular activity where by the tendon is continually (chronic) loaded.

Plantar fasciitis.

Consider impact on patient, potentially very limiting and damaging from a well being perspective.

Nonoperative treatment of insertional
Achilles tendinopathy: a systematic review. Zhi et al. 2021.

  • Current evidence for nonoperative treatment favors ESWT or the combined treatment of ESWT plus eccentric exercises.

NICE Guidelines - https://cks.nice.org.uk/topics/achilles-tendinopathy/management/management/

  • Eccentric exercise, or a heavy-load, slow-speed (concentric/eccentric) exercise programme.
  • ESWT.

Stress fracture.

Retrocalcaneal Bursitis

Tests

Squeeze test for fracture.

Tinel's test for nerve.