Tuesday, 8 May 2007

Achilles Tendinopathy

I remember treating 4 Korean women recreational athletes in the National Sports Institute a few years ago. They used to 'train' harder than some elite athletes often clocking up to 4 hours a day. A few of them suffered from Achilles tendon problems.

I had the opportunity to see another lady who was just as passionate about badminton. Ms Lee (not her real name) came with painful Achillles tendon (see photo) with localised swelling since 1-2 years duration. Her condition worsened over the past few months and she could not play badminton.

I found it rather interesting that she could not do a normal squat and had a thickened tendon an inch above the calcaneal bone attachment. It was certainly tender but more so along the inner side. As I palpated her calf muscles, she had spasm of her medial gastrocnemius causing her much pain stretching her calf muscle (see photo above)

She then told me that she had been playing on her toes thinking that her coach wanted her to literally 'play on her toes'! I was quite concerned that she was receiving various modalities of treatment but failed to undergo proper diagnostic or rehabilitative exercises. She was also an asthmatic on regular Inhaled Corticosteroid therapy provided by the Chest Physician (see Drug Saf, January 2005).

I quickly gave her some topical Arnica Comp gel to relieve the swelling, a mild Cox-2 selective NSAIDS (as she had gastric symptoms and could not tolerate non-specific NSAIDS) and some rehabilitation exercises. The rehabilitation exercises involved calf stretching and strengthening exercises, core stability exercises, hip and gluteal stretching, gluteal and hamstring strengthening and etc. I hope to see some progress in 2 weeks time but she will probably need at least 8-12 weeks before total recovery.

I would probably send her for an Ultrasound scan of her tendon or an MRI if she fails to recover adequately. If she was an elite athlete, she would have been scanned within the next few days to determine the prognosis. The ultrasound may reveal tears and degenerative changes e.g. calclfication.

If she continues to play without proper treatment she may have Achilles tendon rupture (see photo below). I would not recommend local corticosteroid injection for Achilles tendinopathy due to the risks of tendon rupture.

Athletes should also refrain from using Quinolone antibiotics due its toxicity on connective tissue increasing the risk of rupture especially in elderly. Arch Intern Med, August 2003.

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