Achilles Disorders

Tendinopathy, rupture and bursitis of the largest, strongest tendon in the body. (Consolidates the former Achilles Tendinopath” and “Achilles Bursitis” notes.) “Injuries are bimodal: acute ruptures in the younger/active, chronic overload conditions with age.

Achilles tendinopathy

Degenerative ± inflammatory change in the tendon or surrounding structures; overuse, dorsiflexor/plantarflexor imbalance, poor tendon blood supply, genetics, fluoroquinolone antibiotics, and inflammatory arthropathy all contribute.

• Non-insertional (mid-tendon, 2–6 cm above the calcaneus — the watershed zone of poor vascularity): younger, fitter, active patients (annual incidence 7–9% in high-level runners). Gradual-onset mid-tendon pain with fusiform swelling.
• Insertional: middle-aged, overweight/unfit, diabetes — often a combination of retrocalcaneal bursitis, Haglund deformity and calcific deposits at the insertion (see bursitis below).
• History: tendon pain during and after weight-bearing activity, worse in the morning.
• Examination: tenderness ± thickening/swelling of the tendon; pain on single-leg heel raise or hopping. Always check for rupture (Thompson test).
• Investigations: clinical diagnosis; ultrasound if unclear; X-ray if chronic (Haglund deformity, calcification).
• Management:
  • reduce load (e.g. running volume) then graded reintroduction; weight loss; heel raises/footwear modification
  • physiotherapy/podiatry-guided loading program — isometric then progressive strengthening (eccentric calf loading) is the evidence-based cornerstone; non-operative management succeeds in 65–90%
  • do NOT inject corticosteroid — risk of tendon rupture; PRP/GTN patches/prolotherapy have a limited evidence base
  • sport & exercise physician or orthopaedic referral if failing 6 months of conservative care (FHL tendon transfer is reserved for severe cases).

Achilles tendon rupture

• Demographics: bimodal — 25–40-year-old recreational athletes (acceleration–deceleration mechanism, up to 90%) and >60s with low-energy mechanisms on a degenerative tendon. Men >2×. Risk factors: corticosteroids, fluoroquinolones (latency 2–60 days), RA, gout, ankylosing spondylitis.
• History: sudden “gunshot”/hit-in-the-back-of-the-heel sensation, falls over, bruising/swelling, difficulty walking (especially on toes). Up to 25% are missed at first presentation — patients can often still weakly plantar flex and pain may be mild.
• Examination — Simmonds’ triad (prone or kneeling on a chair):
  1. Look — increased angle of declination (foot rests in more dorsiflexion than the other side)
  2. Feel — palpable gap
  3. Move — calf squeeze test (Simmonds/Thompson): no plantar flexion = positive. Compare sides. Any two of three ≈ 100% sensitive.
• Beware the calcaneal tuberosity avulsion fracture (elderly, diabetes, immunosuppression, osteopaenia): a bony lump on palpation or tented skin — plantarflexed cast + urgent X-ray; this is a surgical emergency (skin necrosis risk).
• Investigations: clinical diagnosis; ultrasound (better than MRI for gap/partial-vs-complete) if in doubt; X-ray to exclude avulsion.
• Management:
  • immobilise in plantarflexion (backslab or CAM boot with heel wedge) as early as possible — ideally within hours — to prevent the tendon healing long (functional lengthening → weakness)
  • crutches, light weight-bearing; orthopaedic/fracture-clinic review within 7 days
  • supervised non-operative management with an accelerated functional rehabilitation protocol now achieves outcomes equivalent to surgery (RCT: no difference in strength/ROM at 2 years; surgery halves re-rupture ~12%→5% but has ~30% vs 8% complication rate). Boot > cast; early weight-bearing improves outcomes. Typical protocol: boot with 3 cm heel raise, wean wedges from week 6, out of boot from week 12, then graded strengthening/return to sport
  • DVT/PE risk is elevated (~2.7%/~1.8%) — no routine chemoprophylaxis, but educate about calf pain/dyspnoea and encourage weight-bearing.

Achilles tendon bursitis

Two bursae: posterior/superficial (skin–tendon; classically young women, shoe friction) and deep/retrocalcaneal (calcaneus–tendon; associated with Haglund deformity, a posterosuperior calcaneal prominence).

• Examination: superficial — visible tender swelling with erythema; deep — squeeze in front of the tendon with thumb and index finger: tender bulging either side of the tendon; pain on dorsiflexion.
• Investigations: clinical; lateral X-ray shows Haglund deformity; ultrasound differentiates bursitis from tendinosis.
• Management: avoid shoe heel pressure (podiatry can modify work boots), 1–2 cm in-shoe heel raise, NSAIDs, calf/tendon stretching then strengthening once settled. Avoid corticosteroid injection (rupture risk). Refractory: surgical retrocalcaneal bursa excision + Haglund resection ± tendon debridement.

Sever disease (calcaneal apophysitis, paediatric)

A different mechanism from the adult conditions above — a traction apophysitis of the calcaneal growth plate at the Achilles insertion, seen in growing children rather than adults.

• Demographics: boys, age 7–15 (average 10); running/jumping sports (immature athletes).
• History: painful, tender heel at the Achilles insertion; tight Achilles tendon.
• Examination: positive squeeze test (pain with medial-lateral compression over the calcaneal tuberosity); tenderness over the calcaneal apophysis.
• Investigations: X-ray mainly to exclude other causes (osteomyelitis, bone cysts) — may show apophyseal sclerosis/fragmentation, but has low sensitivity/specificity (diagnosis is largely clinical).
• Management:
  • avoid flat-heeled shoes (a slight heel is beneficial); heel cups/pads
  • activity modification — restrict strenuous sport for ~12 weeks, then review
  • Achilles stretches (may reduce recurrence), ice before/after sport, NSAIDs
  • short leg cast for persistent pain.
  • Self-limiting — resolves with apophyseal maturation/closure.