Chapter 40

### INTRODUCTION

The anger is rage. Why the hell did this happen?!? . . Now I’m supposed to come back from this and be the same player or better . . How in the world am I supposed to do that?? . . Maybe this is how my book ends. Maybe Father Time has defeated me . . Then again maybe not!

Kobe Bryant, LA Lakers shooting guard and five-time NBA champion, after rupturing his Achilles tendon in a game against the Golden State Warriors in 2013. He returned to play until his retirement in 2016

The Achilles tendon is prone to injury when subjected to unaccustomed repetitive high loads.1, 2 Runners, for example, have a 15 times greater risk of Achilles tendon rupture and 30 times greater risk of tendinopathy as they age than do sedentary controls.3 In this chapter, we review the approach to assessment (history, examination, investigation). We then outline the specific treatment approaches.

PRACTICE PEARL

Patients most commonly present with gradual (overuse) pain in the Achilles region due to pathology in the midportion of the Achilles tendon (Fig. 40.1a).

###### Figure 40.1

The Achilles region (a) The midportion of the tendon is clearly distinct from the insertion—an important clinical feature (b) The anatomy of the Achilles midportion, Achilles insertion and posterior process of talus (c) Stylised illustration to show the blood supply of the normal Achilles tendon (top) and in tendinopathy (middle and below)

Other important conditions in order of prevalence at a sports clinic with a broad-based clientele are:

• pain at the insertion of the Achilles tendon and associated retrocalcaneal bursa (‘enthesis organ’)

• posterior impingement (an important differential diagnosis)

• Achilles pain related to the plantaris tendon

• pain related to friction between the Achilles tendon and surrounding tissues (peri-tendinopathy).

Achilles tendon pathology can also manifest in a very different, dramatic manner: via acute rupture of the Achilles tendon. This immediately disabling condition is captured in the chapter opening quote. The management of cases like that of Kobe Bryant is discussed in the last section of this chapter.

### CLINICAL PERSPECTIVE

The key areas of pain in the Achilles region (posterior heel and proximal toward the calf) are illustrated in Figure 40.1. The Achilles tendon is the combined tendon of the gastrocnemius and soleus muscles, and is the thickest and strongest tendon in the human body.4 Anteriorly, the deep surface of the tendon is supported by a fat pad (Fig 40.1b) through which most of the vessels and nerves enter the tendon (Fig. 40.1c). The tendon has no synovial sheath, but has a peritendon which is continuous with the perimysium of the muscle and the periosteum of the calcaneus, and which enfolds the anterior ...

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