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Achilles Tendinopathy or Paratenonitis?
3
Achilles Tendinopathy
OR Paratenonitis ?
UQ MSSI CLINIC
The Patient
The Case
Background:
- 68yo retired male
- Avid cyclist (40-120km per day)
Subjective Findings:
- 6 month Hx of posterior lower leg pain. Pain increases the further he rides
- Purchased new cleats around pain onset
- Self massage of the Achilles tendon reduced tendon swelling and size
Objective Findings:
- Huge palpatable lump R mid Achilles, noticable swelling
- Reduced plantarflexion/dorsiflexion ROM
- Single Leg Calf Raise 3 reps, 5/10 pain
- Double Leg Calf Raise 3 reps, 5/10 pain
"Are you sure it is Tendinopathy?"
Important Findings
Let's think about Tendinopathy.. do these fit?
- "Self Massage of the Achilles reduced tendon swelling and size"
Point: You cannot reduce the size of a tendinopathy with massage..
- 5/10 pain regardeless of a single or double leg calf raise
Point: Closely consider if LOADING or REPETITION is the issue. What are we expecting if tendinopathy?*
Paratenonitis = inflammation of the achilles tendon covering - 'paratenon'
Pain Assist (2015). Paratenonitis (Jpeg)
An Evidence Based Mx Approach: Paratenonitis
Literature Review
Reccomended 4-6 months of conservative Mx (see next slide) before surgical intervention (1)
Younger patients respond better to conservative treatment (2)
If failed conservative Mx: limited debridement of damaged tissue (excessive dissection of the tendon itself not reccomended - 1)
1. Alfredson, H & Spang, C. (2017). Clinical presentation and surgical management of chronic Achilles tendon disorders.
A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon. Foot and Ankle Surgery, 24(6), 490–494. https://doi.org/10.1016/j.fas.2017.05.011
2. Clifford, C., Challoumas, D., Paul, L., Syme, G., & Millar, N. L. (2020). Effectiveness of isometric exercise in the management of tendinopathy: A systematic review and meta-analysis of randomised trials. BMJ Open Sport & Exercise Medicine, 6(1), e000760–e000760. https://doi.org/10.1136/bmjsem-2020-000760
References
1. Alredson & Spang (2017)
2. Clifford, Challoumas, Paul, Syme & Millar (2020)
Everyday Health (2020). Inflamation (Jpeg)
Take Home Messages
1. Assessment Ideas
- Stethoscope during plantarflexion/dorsiflexion. Any crepitus?
2. Treatment ideas
- Inflammation controls
- Isometric strengthening before isotonic
3. Main Learning Point
- A detailed subjective is critical