Posterior heel pain is a common complaint seen in outpatient clinics. Just as all elbow pain is not tennis elbow, all posterior heel pain is not Achilles tendinopathy. Samantha Nupen explores the many structures that could cause posterior heel pain and the aggravating factors.
Christina Carreira and Anthony Ponomarenko of the United States skate in the Ice Free Dance program during the ISU Four Continents Figure Skating Championships at Broadmoor World Arena. Mandatory Credit: Michael Ciaglo-USA TODAY Sports
In Greek mythology, Achilles was a hero with one weakness – his heel. According to legend, his mother, Thetis, held him by one heel when she dipped him in the river Styx as an infant. This created a weak spot. Alluding to this legend, the term "Achilles’ heel" has come to mean a point of weakness, especially in someone or something with an otherwise strong constitution(1). The Achilles tendon is named as such because it is where Thetis held Achilles.
Things to assess with posterior heel pain
o Gait
o Balance/proprioception
o Big toe extension
o Medial arch strength
o Calf muscle endurance
o Equipment
o Training
o Overloading or overuse
o Structures
The most devastating and probably easiest to diagnose, an ATR injury, is a complete rupture. Common in lunging sports like tennis, squash, and more recently, padel. Athletes report an acute injury, characterized by a loud popping sound (often as loud as a gunshot) or the feeling that an opponent has hit the athlete with a racquet on the back of the heel and then difficulty walking.
Clinically, the Thompson (Squeeze) test is positive, and management may be conservative immobilization or surgical intervention followed by a prolonged rehabilitation period. There is often a family history of a complete rupture, and the estimated heritability of the liability to ATR is as high as 50%. This generates the hypothesis that genetics play a role in the pathological changes in the tendon prior to rupture(2). It is also common to rupture one Achilles tendon and then, years later, rupture the other one.
Achilles tendinopathy is common, and a lot has been written about it. As with all tendons, it takes time to improve. This is frustrating for both the athlete and the Physiotherapist. It is an overuse injury directly related to loading and repetitive strain that is very common in endurance sports. It can be emotionally devastating when practitioners tell these athletes to rest.
The key to successful treatment is an accurate diagnosis. Mid-substance tendinopathies tend to respond to treatment more quickly. Insertional tendinopathies can be more stubborn, so accurately assessing the area affected is important. More proximal medial pain could be caused by the plantaris tendon crossing over the Achilles tendon (see figure 1). The area of pain will impact treatment and management choices.
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