A 35-year-old man comes to the office due to right ankle pain. The pain has been present for the past 3 months, worsens with walking or running, and improves slightly with rest. There is no history of trauma, although the patient has been training for a marathon for the past 6 months. He took over-the-counter naproxen for a week, which provided little help. The patient has no chronic medical conditions. Vital signs are normal. Examination shows tenderness at the right Achilles tendon 4 cm proximal to its insertion. No swelling, redness, or deformity is apparent. Plantar flexion is intact. Which of the following would be the most appropriate therapy?

Question

A 35-year-old man comes to the office due to right ankle pain.  The pain has been present for the past 3 months, worsens with walking or running, and improves slightly with rest.  There is no history of trauma, although the patient has been training for a marathon for the past 6 months.  He took over-the-counter naproxen for a week, which provided little help.  The patient has no chronic medical conditions.  Vital signs are normal.  Examination shows tenderness at the right Achilles tendon 4 cm proximal to its insertion.  No swelling, redness, or deformity is apparent.  Plantar flexion is intact.  Which of the following would be the most appropriate therapy?

Quizplus · Accepted Answer

11ec25c8_d22e_28a7_bc81_d161350f84b6_MD0003_00 This patient most likely has Achilles tendinopathy (AT). AT is often referred to as a tendinitis, though true inflammation is not always present. AT occurs most commonly in patients who abruptly increase athletic activity, particularly in running and jumping sports. The risk is also increased following use of fluoroquinolone antibiotics, and these patients have an increased risk of tendon rupture. The diagnosis is based primarily on clinical findings. AT presents with ankle pain, swelling, and tenderness that are usually most prominent approximately 2-6 cm proximal to the insertion of the tendon, where perfusion of the gastrocnemius/Achilles tendon complex is the lowest. Management of acute AT primarily includes activity modification, cold compresses/icing, and nonsteroidal anti-inflammatory drugs. For chronic symptoms, a rehabilitation program emphasizing eccentric resistance exercises (ie, lengthening the muscle while under load) is recommended. (Choices B and D) Corticosteroid injections can be helpful for AT, but the benefits are inconsistent and carry a risk of tendon rupture. Systemic glucocorticoids (eg, prednisone) also increase the risk of tendon rupture and are not recommended. (Choice C) A short trial (<10 days) of a nonsteroidal anti-inflammatory drug (NSAID) is reasonable for Achilles tendinopathy, especially for acute symptoms. However, this patient already attempted NSAIDs and had no relief; additional NSAID treatment is unlikely to be helpful. (Choice E) Surgical repair can be considered for patients with complete tendon rupture who anticipate returning to strenuous occupation or athletic activity. It is not indicated for uncomplicated tendinopathy and is frequently unnecessary for patients who are able to participate in a prolonged rehabilitation program. Educational objective: Achilles tendinopathy (AT) presents with ankle pain and tenderness in the tendon proximal to its insertion on the calcaneus. It is most common in patients who abruptly increase athletic activity. Management of acute AT includes activity modification, cold compresses/icing, and nonsteroidal anti-inflammatory drugs. For chronic symptoms, a rehabilitation program emphasizing eccentric resistance exercises is recommended. References: Management of chronic tendon injuries. (http://www.ncbi.nlm.nih.gov/pubmed/23547590)

A 35-Year-Old Man Comes to the Office Due to Right