Common Musculoskeletal Problems by James M. Daniels

Author:James M. Daniels
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Posterior Ankle

Achilles tendinopathy is a common cause of posterior ankle pain. This problem can affect patients from competitive-level activities to the sedentary. Foot mechanics, poor foot ware, decreased flexibility of the calf muscles, trauma, and exercise on uneven ground increase the risk of developing this problem. The provider may also note swelling of the tendon and crepitus with active motion. Tendinopathy may cause insertional pain located at the calcaneal insertion of the Achilles or can cause non-insertional pain and nodularity several centimeters proximal to the tendon insertion. Conservative treatment initially is recommended which includes activity modification, ice, and heel lifts. Anti-inflammatory medications may provide some relief of symptoms. Stretching exercises that concentrate on eccentric loading are also recommended for treatment.

Rupture of the Achilles tendon can occur. A patient may describe feeling or hearing a pop or a sudden feeling of being kicked in the back of the ankle at the time of the injury. A pitfall for some providers is the patient may still be able to ambulate into the office with a partial tear of the Achilles and can be missed if not evaluated thoroughly. The Thompson test or calf squeeze test is used to evaluate for an Achilles tendon rupture. The patient lies on their stomach on the exam table, lower leg is partially off the end, and the provider squeezes at the mid-calf and should note plantar flexion of the foot. Comparison to the non-injured side will be useful. This test can miss partial tears so it is also important for the provider to palpate along the tendon into the mid-calf for a possible defect. Musculoskeletal ultrasound, if available, is a good tool to identify partial tears. Full tendon ruptures require immediate referral to an orthopedic surgeon for possible repair.

Other causes of posterior ankle pain can range from benign to more serious conditions. Bilateral ankle pain at the insertion of the Achilles tendon can be due to more serious conditions such as a seronegative arthritis, rheumatoid arthritis, or a postinfectious syndrome such as Reiter’s syndrome. These patients will describe pain that is more severe first thing in the morning and generally improves through the day. History of patient’s symptoms may reveal urinary or inflammatory bowel symptoms. Laboratory testing will generally begin with CBC, CMP, sedimentation rate or CRP, ANA, and rheumatoid factor.

Atypical pain such as pain at rest or pain at night (see red flags) should raise the examiner’s suspicion of a more serious cause of posterior ankle pain such as a stress fracture of the calcaneus, neuropathy, or peripheral nerve entrapment. These conditions will require more workup, treatment, and possibly referral. Other causes of posterior ankle pain are described in Table 10.2.Table 10.2Other causes of posterior ankle or foot pain

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