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Achilles Tendonitis Part 2: Symptoms & Evaluation

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- 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?

- Yeah.

- 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.