A healthy 24-year-old woman comes to the office due to pain behind her right heel for 5 days. The pain developed gradually and is burning in quality, worse with activity, and partially relieved with rest. There is no history of trauma. The patient has no fever, back pain, swelling, or rash. She eats a healthy diet and walks 2 miles every morning. She has no chronic medical problems. The patient's only medication is naproxen, which provides some relief. Her father has gout. Vital signs are within normal limits. BMI is 24 kg/m2. Examination shows tenderness 3 cm above the posterior calcaneus. There is no leg swelling, deformity or redness. Dorsiflexion and plantar flexion of the foot are intact. Which of the following is the most likely cause of this patient's leg pain?
Achilles tendinopathy | |
Risk factors |
|
Clinical |
|
Examination |
|
Diagnosis |
|
Management |
|
*With the patient prone and feet off the end of the table, squeeze the calf muscles; the absence of plantar flexion indicates tendon rupture. NSAIDs = nonsteroidal anti-inflammatory drugs. | |
This patient has Achilles tendinopathy, presenting with acute posterior ankle pain and tenderness. Achilles tendinopathy is often referred to as a tendinitis, although inflammatory infiltrates are not always present. Achilles tendinopathy is most common in athletes and other active people and is often triggered by an increase in exercise regimen. The risk is also increased following use of fluoroquinolone antibiotics.
The diagnosis of Achilles tendinopathy is based primarily on clinical findings, particularly the location and pattern of symptoms. Pain (eg, burning sensation), swelling, and tenderness are usually most prominent approximately 2-6 cm proximal to the insertion of the tendon, where perfusion of the gastrocnemius/Achilles tendon complex is the lowest. Management of acute Achilles tendinopathy includes activity modification, cold compresses/icing, and nonsteroidal anti-inflammatory drugs.
(Choice B) Calcaneal apophysitis (Sever disease) is a common cause of posterior heel pain and tenderness. However, it usually occurs in children and adolescents who participate in running or jumping sports (eg, basketball) because the apophysis is most susceptible to stress during periods of rapid growth. Also, the findings are typically seen within 2 cm of the insertion of the Achilles tendon.
(Choice C) Crystal-induced synovitis (eg, gout, pseudogout) typically presents as acute monoarthritis with redness, swelling, and severe pain with passive movement. Although gout commonly involves the ankle joint, it usually does not affect the heel or the Achilles tendon, the area of concern in this patient.
(Choice D) Enthesitis is an inflammatory disorder characterized by local pain, tenderness, and swelling at the insertion of a tendon or ligament. It is a relatively specific finding for ankylosing spondylitis and other spondyloarthropathies and is usually associated with back pain and stiffness.
(Choice E) Subcutaneous calcaneal (superficial to the tendon) bursitis presents with pain and tenderness at the calcaneal prominence (Achilles tendon insertion point). It is typically associated with swelling, warmth, and, often, erythema. Pain 3 cm proximal to the calcaneus makes Achilles tendinopathy more likely.
Educational objective:
Acute Achilles tendinopathy presents with posterior ankle pain and tenderness and typically occurs in athletes and other active people following an increase in activity or exercise. The diagnosis is based on clinical findings, which include pain, swelling, and tenderness approximately 2-6 cm proximal to the insertion of the tendon on the calcaneus.