How is achilles tendon pull treated ?

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Posted on Wed, 2 May 2012 in Bones, Muscles and Joints
Question: Hello Dr.
My query is about my 11 yr old son. He is normally a very fit, lean healthy boy playing/training for sports 5 times per week.
He has been having trouble with pain in the back of his heel for 6 weeks now following a game of football. He has had an xray and ultrasound which appear normal and a bone scan which says "moderate hyperaemia involving the posterosuperior aspect of the right calcaneum. There is quite intensely increased uptake involving the posterosuperior aspect of the right calcaneum consistent with achilles tenonitis. Uptake at the posterior aspect of the talus is also slightly increased in comparison with the other foot although the significance of this is unclear."
He has been off all sport/activity except just normal walking around since it happened 6 weeks ago and it is NO better at all. Anytime he bears weight on his foot he has pain and very bad pain if you touch the back of his heel in the sore spot. He also has pain if standing for a considerable time (eg stand for 2 hrs - hurts for a whole day after) The GP said it was achilles tendonitis but I disagree given the fact that it's no better at all after 6 weeks rest, ibuprofen & elevation and he can flex his foot toward his knee & stand on his toes without significant pain. I am waiting to get into an orthopaedic specialist here but there is quite a wait and I am at a loss as to what else to do in the meantime. Does it sound possible that it could be a small fracture which has been missed and what other tests are possible to prove this? We also saw a podiatrist who thought it sounded like Severs disease, but I am also reluctant to believe this theory given the fact that the pain happened after a football game not gradually built up and worry that if I did what they suggest - (strap the foot, take painkillers and gradually get back into sport) that he will have more damage.
I am very concerned about this and it's really getting to my son being in pain every day and missing out on all his sports which he loves so much. Somebody please help... Kim, (Very concerned Mum)
doctor
Answered by Dr. Atul Wankhede 3 hours later
Dear XXXXXXX

Thank you for posting your query.

I understand what you are going through.

It is not a very complicated situation. There's a history of trauma, and the bone scan shows increased uptake. This means there is an inflammation in progress.

There could be a small hairline fracture which was not evident on xrays. This can be confirmed on a CT Scan (preferably on 3D ).

If it turns out that, then we need to immobilise the foot in a plaster. I'm not sure how much that'll help since we've already lost almost a month since the trauma.

Nevertheless we could still evaluate the prognosis and prevent further inflammation.

The other reason could be an infection at the site of tenderness. Do tell us if he's got fever. Keep him immobilised till we establish a reason for his pain.

Immobilisation will also prevent any further Achilles tendon pull over calcaneum where the uptake of bone scan is evident.

Do not administer medicines since they harm on long term. Go for physiotherapy like local ultrasonics for pain relief.

Hope this answers your question. Feel free to ask more doubts.

Good day.

Regards,

Above answer was peer-reviewed by : Dr. Shanthi.E
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Follow up: Dr. Atul Wankhede 2 hours later
Thank you Dr.
He does not and has not had a fever at all during this process. Neither has there been any redness around the area and only slight swelling on the day it happened, but not very much.

When you say immobilise - are you talking about not even walking on it - like on crutches or something? I am starting to think that's what should have been done at the time of the injury.

The Drs here just keep saying achilles tendonitis and just wait for it to heal, but if that is the case should we see some improvement by now, especially since there was no tear or damage shown on the ultrasound?

If there turns out to be no hairline fracture, would the next likely diagnosis be Severs disease? Symptoms are similar from what I've read.

Can you please tell me if we presented to your office with all the information I have shared with you - what action would you take?
OUr waiting time is 2 mths to get into the specialist here.
Thank you for your help and understanding.
Regards,
Kim
doctor
Answered by Dr. Atul Wankhede 4 hours later
Dear XXXXXXX
I'm glad there was no associated fever. So a chance of infection is ruled out.
Immobilising means primarily putting a plaster cast and allowing non weight bearing walking with help of crutches or walker. This as you said should have been done at first consultation.
Sever's disease is basically the Aposhysitis or the inflammation of calcaneum at insertion of Achiles, and the tendon per se may not tear. Even in that case initial immobilisation would be necessary, and resuming movements gradually.
In my opinion-
1. You need to go for a 3D CT to confirm a fracture.
2. Rest and ice fomentation with elevation of foot over a pillow as much as possible.
3.Start physiotherapy with local ultrasonics.
4. Use of crepe bandage support or anklet while walking.
5. Minimal use of anti inflammatory drugs under supervision.
If CT report comes normal it can be Sever's no doubt. It would've healed by now, provided it got adequate rest. It will still heal if you allow it to.
I am sorry to hear the waiting time to seek a specialist consult.
Here's wishing your son an early recovery. Please get back to us if you have more queries.
Good luck.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Atul Wankhede 9 hours later
Thank you so much for your concise and helpful recommendations. Just what I was looking for!

Unfortunately here in Australia GPs are reluctant to order tests like CTs unless they really feel it's necessary or can't just get a cast put on - so will have to see the specialist to do this. We are on a cancellation list to get an appointment earlier.
In the meantime, we will endeavour to rest, evelate & strap his foot. I will look into getting some crutches for him.

I am not familiar with the ultrasonic treatment you speak of - could you please let me know a bit more about this?

Thanks again for your very helpful information and making me feel like my instincts are correct.
Kind Regards,
Kim
doctor
Answered by Dr. Atul Wankhede 4 hours later
Dear XXXXXXX

Thank you for your kind words. Indeed as a mother your instincts will work in a right direction.

We shall stick to the protocol as discussed earlier. Local ultrasonics or TENS are administered by physiotherapist where in a pen-like probe is placed over an affected area. Short waves or ultrasonic waves come out of the probe which help reduce inflammation and brings muscle relaxation.

I hope your son XXXXXXX back to his health soon.

Take care.

Regards,
Above answer was peer-reviewed by : Dr. Shanthi.E
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Answered by
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Dr. Atul Wankhede

Orthopaedic Surgeon

Practicing since :2000

Answered : 170 Questions

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