Majeed, A

Morton, S

Newth, A

English

Spiral - Imperial College Digital Repository

10-MINUTE CONSULTATIONPain at the back of the heelSarah Morton academic primary care F2 doctor, Aisha Newth primary care teacher developmentlead, Azeem Majeed professor of primary careDepartment of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UKA 41 year old man complains of longstanding pain at the backof his left heel and stiffness when he gets up. The pain is worsewhen he plays tennis. He asks for advice on what it is and whatcan be done.Pain at the back of the heel arises from a limited number ofanatomical structures: the Achilles tendon, the calcaneal bursa,or the surrounding soft tissues (fig 1⇓). This limits the likelydifferential diagnoses. Achilles tendinopathy is the mostcommon cause of posterior heel pain.1 Its incidence is estimatedat 1.85 per 1000.2 It is also important to note that Achillestendinopathymay underlie other pathologies, particularly partialtears of the Achilles tendon.3What you should coverTake a historyBegin by understanding the pain: see table 1⇓ and figure 1⇓ forposterior heel pain differential diagnoses.Ask about symptoms suggestive of inflammatory arthritis, suchas ankylosing spondylitis.5 Comorbidities, such as type 2diabetes and increased body mass index, are also associatedwith tendinopathy.2 6 Other biomechanical risk factors (whichare likely to bemodifiable) include decreased ankle dorsiflexion,pes planus, and increased hindfoot inversion.3 7Reviewwhat medication the patient is taking because drugs cansometimes be associated with tendinopathy, including acute useof a quinolone and long term use of statins (mean time for onsetof symptoms is 10 months).8 A family history of tendonproblems can increase the risk up to five times.4Examine the patientLie the patient prone. Look at and palpate the tendon. Notethickened tendons compared to the other side, which mayindicate tendinopathy.3 5 Note tenderness, and in particularpin-point tendon pain that makes a partial Achilles tear morelikely. In retrocalcaneal bursitis there may be swelling andtenderness on direct palpation of the bursa.5Establish if there is any crepitus present along the mid-portionof the Achilles tendon—again suggestive of Achillestendinopathy.Passively flex the foot to see whether the pain worsens ondorsiflexion or plantarflexion, to distinguish Achillestendinopathy from posterior ankle impingement.4 PerformSimmond’s squeeze test, palpate for a gap in the tendonstructure, and observe if there is more dorsiflexion of theaffected side to ensure there is no Achilles rupture.Ask the patient to hop. If this reproduces the pain, it indicatesAchilles tendinopathy.3Overall there are no formalised criteria for diagnosing Achillestendinopathy. It is a clinical diagnosis, and most of yourinformation comes from the history.What you should doRefer to the on-call orthopaedic team if an Achilles tendonrupture is suspected. If you suspect a tear, refer to a sportsphysician or orthopaedic team.Consider an ultrasound scan if the diagnosis remains unclear toassess posterior ankle structures.4 Be aware that imaging mayidentify incidental, asymptomatic pathology such astendinopathy on the non-painful side.If Achilles tendinopathy is the working diagnosis, explain tothe patient that symptomsmay persist for up to two years despitetreatment.4 Sedentary and active people may develop symptoms.Males and females are affected equally.2 It is most commonbetween 41 and 60 years of age.2 Evidence on how best tomanage this condition is poor and driven by opinion. The NICEclinical knowledge summary9 suggests that doctors might offer:• Simple analgesia (such as non-steroidal anti-inflammatorydrugs for up to two weeks)• Reduction in precipitating activities (complete rest maymake things worse).Correspondence to: S Morton sarah.morton@doctors.org.ukThis is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2016;352:i1366 doi: 10.1136/bmj.i1366 (Published 29 March 2016) Page 1 of 4PracticePRACTICEWhat you need to know• Achilles tendinopathy is the most common cause of chronic posterior heel pain• Achilles tendinopathy is a clinical diagnosis and imaging is not needed unless there is diagnostic uncertainty• Eccentric calf muscle exercises are the traditional means of strengthening the Achilles tendonConsider a self directed daily programme of Achilles tendonstrengthening exercises. There is little consensus over the typeof exercises or the duration.9 Calf muscle eccentric exercisesare the traditional first line exercises (see fig 2⇓), but heavyslow resistance training, combining eccentric-concentric isotonicloading, may be as effective, with most participants having asignificant decrease in pain and improvement in function after12 weeks of conservative therapy.4-10 Eccentric exercises areeasier to demonstrate to your patient. Advise your patient towear shoes when doing the exercises and suggest online videosto aid with exercise technique, such as www.youtube.com/watch?v=M6EKuuZ7C2E. Referral to physiotherapy forbiomechanical assessment and a more intensive exerciseprogramme can be considered.9Suggest rest from activities that exacerbate symptoms. Continuenon-weight bearing activity, such as swimming, to maintaincardiovascular fitness. The severity of the symptoms will guidereturn to normal activities. If symptoms continue after 3-6months despite the above measures, consider referral to a sportsphysician or orthopaedic surgeon.Competing interests: We have read and understood BMJ policy ondeclaration of interests and have no relevant interests to declare.Provenance and peer review: Not commissioned; externally peerreviewed.1 Berner J, Zufferey P. [Achilles tendinopathy].RevMed Suisse 2015;11:606-8, 610-1.pmid:25946872.2 de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion Achillestendinopathy in the general population. Br J Sports Med 2011;45:1026-8. doi:10.1136/bjsports-2011-090342 pmid:21926076.3 Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther 2002;7:121-30. doi:10.1054/math.2002.0458 pmid:12372309.4 Asplund CA, Best TM. Achilles tendon disorders. BMJ 2013;346:f1262. doi:10.1136/bmj.f1262 pmid:23482943.5 Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician 2011;84:909-16.pmid:22010770.6 Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy.Foot Ankle Int 2006;27:952-9.pmid:17144959.7 Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of footstructure and range of motion on musculoskeletal overuse injuries. Am J Sports Med1999;27:585-93.pmid:10496574.8 Kirchgesner T, Larbi A, Omoumi P, et al. Drug-induced tendinopathy: from physiology toclinical applications. Joint Bone Spine 2014;81:485-92. doi:10.1016/j.jbspin.2014.03.022 pmid:24962977.9 NICE Clinical Knowledge Summaries. Achilles tendinopathy 2010. http://cks.nice.org.uk/achilles-tendinopathy#!scenario.10 Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathyloading programmes : a systematic review comparing clinical outcomes and identifyingpotential mechanisms for effectiveness. Sports Med 2013;43:267-86. doi:10.1007/s40279-013-0019-z pmid:23494258.Accepted: 07 01 2016Published by the BMJ Publishing Group Limited. For permission to use (where not alreadygranted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissionsFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2016;352:i1366 doi: 10.1136/bmj.i1366 (Published 29 March 2016) Page 2 of 4PRACTICEEducation into practice• Discuss referral if there has been little improvement in symptoms of Achilles tendinopathy after 3-6 months.Further clinical guidelines• Orthopaedic Section of the American Physical Therapy Association: www.jospt.org/doi/pdf/10.2519/jospt.2010.0305Patient information• Patient.co.uk. Achilles Tendinopathy. http://patient.info/health/achilles-tendinopathy• Department of Sport and Exercise Medicine. Achilles tendinopathy: advice and management. www.ouh.nhs.uk/oxsport/information/documents/leaflet_achilles_a5.pdfTableTable 1| Posterior heel pain differential diagnosesCharacteristic historyPathology• Chronic dull ache along the Achilles tendon• Pain classically 2-6 cm above the calcaneus• Gradual onset• Worsens with activity• Morning pain and stiffness are characteristic• Pain worsens on dorsiflexion3 4Achilles tendinopathy (mid-tendon)• Pain around the calcaneusInsertional Achilles tendinopathy• Pain between calcaneus and tendon• Tender to direct palpation at that particular point4 5Retrocalcaneal bursitis• Pain worsens on plantar flexion5Posterior ankle impingement• Sudden localised pain on background of longstanding pain in Achilles tendon3Partial tear of Achilles tendon• Achilles tendon rupture is unlikely when a patient presents with chronic painAchilles tendon ruptureFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2016;352:i1366 doi: 10.1136/bmj.i1366 (Published 29 March 2016) Page 3 of 4PRACTICEFiguresFig 1 Anatomy of the heelFig 2 Performance of calf muscle eccentric exercise: unilateral heel drops (adapted from Nuffield Orthopaedic Centre.Achilles Tendinopathy: Advice and Management. 2009.www.ouh.nhs.uk/oxsport/information/documents/leaflet_achilles_a5.pdf)For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2016;352:i1366 doi: 10.1136/bmj.i1366 (Published 29 March 2016) Page 4 of 4PRACTICE

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