(upbeat rock music)
- Welcome back to The Art of Medicine.
Now that we've seen the parts list,
let's identify the symptoms of Achilles tendonitis.
- In general the symptoms of Achilles tendonitis
are basically swelling, pain, difficulty walking,
difficulty going up and down stairs,
not feeling good unless you have shoes on,
sometimes the shoe will rub the back of the foot
and they'll start to bother your ankle and foot.
They're feeling the pain mostly behind the heel,
in the back of the heel and up the back of the leg.
They'll feel cramping and difficulty walking
and pain with putting their foot to the ground.
- What happens to the tendon
when you have Achilles tendonitis
is initially it becomes just swollen.
You have a condition of peritendinitis
where you just really the outside fibres become irritated.
As time goes on, there becomes more and more swelling,
more fluid goes into the area.
Ultimately you get a lot of scarring in the area
because the tendon itself is not very well vascularized.
Achilles tendonitis pain is usually worst when you begin
your exercise program.
It'll be worst in the morning when you first get out of bed.
It can also be worst as you go up a set of stairs.
- The weekend warrior athlete or the older person
who has been relatively sedentary who starts
up a new program can be really prone to Achilles tendonitis.
They can get overuse injuries that make it very difficult
to return to what they want to do,
even activities of daily living.
Achilles tendonitis, in general, is the sedentary person,
their Achilles tendon hasn't been stretched,
it's working in a shortened position
and they get into their old sneakers
and they can develop a terrible overuse injury
of that Achilles tendon.
- When we suspect Achilles tendonitis,
we're looking for pain and tenderness of the Achilles tendon
either at the insertion into the heel bone or the calcaneus
or a little further up the tendon itself.
We're looking for a history of pain.
Either in the morning or when they go up steps
or when they start their activities.
We're looking to see if some shoes are more comfortable.
Are they happier in an athletic shoe than they are
when they are walking around in their bare feet?
I would ask the patient when do you have the pain?
Does anything make it worse?
Does anything make it better?
Did you start any new activities?
Have you changed any shoe gear recently?
Is there anything different that you've been doing
that you've noticed has made this actually worse?
Alright, have any pain up here in your calf at all?
- [Girl] A little bit.
- [Mary] Okay, worse when I get down towards here?
- [Girl] Yeah.
- Okay, most of the pain like right in this area?
- Okay, do me a favor, push against my hand
as hard as you can, very good, let's try the other side.
When we're looking for Achilles tendonitis,
we start to look for pain and swelling in the area
of pain and palpation of that tendon.
We have the patient walk and try to stand on their toes.
Do you have pain when you do that?
Most of the people that come into the office actually
will have market swelling in the tendon that's noticeable
to even the patient.
Okay, if you wanna come off the table
and just stand up for me.
One of the things that I can tell you
is that you are very pronated or flat footed.
You have a very low arch and that's one
of the predisposing problems that leads
to Achilles tendonitis.
I can tell that because your arch almost disappears
when you stand up and also because the sides
of your feet kind of flay out to the side.
If you turn around to the back,
you'll notice that the triangular portion of the calcaneus
actually tends to lean inward and you can actually
see your Achilles tendon kind of move to the inside.
- In general when we do an examination
on Achilles tendonitis, we wanna look and see
if the tendon feels smooth or if it's elevated,
if it's there a bubble or thickness
in the Achilles tendon which could indicate tearing
or chronic inflammation.
We wanna make sure that the range of motion of movement
in the ankle isn't limited.
Usually it is and we wanna measure that and make sure
that we can get that range of motion back
so we can relieve the Achilles tendonitis.
When we're looking at the Achilles tendon,
my easiest viewpoint is from having the patient lay
on their stomach.
That way I can look at the,
this is their gastrocnemius muscle and that goes
into the Achilles tendon.
The Achilles tendon goes from about here to here
and attaches into the heel bone,
it's also called the calcaneus.
In general we wanna look at, and we want to palpate
along the muscle belly, that's the muscle in here,
and this is the tendon.
Often times this is a weak point of the tendon,
so I just want to palpate down here.
And when they yell, "Ow!", that'll let me know
where they're hurting.
Most often times the pain is in here
and that's because that's a weak point,
it's a thinner part of the Achilles tendon
and that's the area that tends to be spread
or stressed more than other areas of the tendon.
When I do an exam, in addition to the range of motion
up and down, I wanna look at the side to side motion.
I want to establish the Achilles tendon,
it should be in a straight alignment like this,
as opposed to a alignment inward
or alignment outward.
Each of these kinds of alignments can lead
to increased pressures on the Achilles tendon.
In general, from this point, I would probably get
my x-ray or my MRI,
depending on the patient's symptoms.
- [Voiceover] Let's look at an x-ray of the foot and ankle
and in particular let's look at the side view.
In the side view, we see first the leg bone.
The leg bone is connected to this bone called the talus.
The talus is connected to the heel bone
called the calcaneus.
And then in the front we have the toe bones.
Now in the back is where the Achilles tendon connects
and in fact it connects to the back
of the heel bone right here.
This is the Achilles tendon and then the Achilles tendon
connects to the calf muscle.
Now in this particular patient,
we see that we have a bone spurt in the back
that's pinching into the Achilles tendon.
In order to determine the inflammation
or amount of injury to the Achilles tendon,
we need to get an MRI.
Let's now look at an MRI of the foot and ankle
and once again the side view.
Let's outline the parts list.
First of all the leg bone called the tibia
which sits on the talus bone
which in turn sits on the heel bone called the calcaneus.
And then we have the toe bones in the front.
The Achilles tendon, once again, is behind
and sits attached to the heel bone.
This is the Achilles tendon.
Now this white area that we see
within the Achilles tendon
indicates severe inflammation indicative
of a tendinitis.
And this tendinitis is severe enough so there are also
some micro tears within the tendon.
This is an MRI showing the side view of the ankle.
An ankle which has a ruptured Achilles tendon.
This is the Achilles tendon in the back
and here we see a rupture of the tendon.
One end is up here and shrivelled up.
And the other end is still attached down here
to the heel bone so the gap between the two ends
is seen right here by this white area
indicating a ruptured Achilles tendon.