From the Guidelines
Insertional Achilles tendinopathy can indeed cause sural nerve irritation due to the close proximity of the sural nerve to the Achilles tendon insertion on the calcaneus. This occurs because the sural nerve runs close to the Achilles tendon insertion, making it vulnerable to compression or irritation when there is inflammation, swelling, or structural changes in the tendon. When the Achilles tendon becomes inflamed at its insertion point, the resulting swelling can put pressure on the nearby sural nerve, leading to symptoms such as burning pain, tingling, or numbness along the lateral aspect of the foot and ankle. The etiology and pathogenesis of Achilles tendinosus tend to be multifactorial, including improper technique, anatomic misalignment, weakness, uneven training surfaces, and improperly fitted footwear 1. Treatment typically involves addressing the underlying tendinopathy through conservative measures such as eccentric strength training, which is a particularly popular and effective option 1. Additionally, stretching and deep friction massage of the gastrocnemius-soleus complex are generally considered helpful for Achilles tendinopathy, and anatomic misalignment can be treated with shoe orthotics to correct overpronation or pes planus problems 1. Many patients will benefit from heel lift orthotics to unload the tendon for pain relief, which can also help reduce pressure on the sural nerve. It is essential to address the tendinopathy to resolve the nerve symptoms, as the anatomical relationship between these structures explains why treating the tendinopathy often resolves the nerve symptoms as well. Key considerations in management include:
- Rest and ice to reduce inflammation
- Anti-inflammatory medications for pain relief
- Physical therapy focusing on eccentric strengthening exercises
- Proper footwear with heel lifts to reduce tension on the Achilles tendon
- Potential use of nerve-specific medications for symptom management in some cases.
From the Research
Insertional Achilles Tendinopathy and Sural Nerve Irritation
- Insertional Achilles tendinopathy is a degenerative enthesopathy associated with pain and dysfunction, but there is limited evidence on its direct relationship with sural nerve irritation 2, 3, 4, 5.
- The sural nerve is anatomically close to the Achilles tendon, and injuries to the tendon can potentially lead to sural nerve damage 6.
- A case report suggests that nonoperative management of acute Achilles tendon rupture can lead to traction sural neuropathy, highlighting the importance of considering sural nerve injuries in the management of Achilles tendon injuries 6.
- However, the available evidence does not specifically address the relationship between insertional Achilles tendinopathy and sural nerve irritation, and further research is needed to fully understand this potential association 2, 3, 4, 5.
Management of Insertional Achilles Tendinopathy
- Conservative treatment options for insertional Achilles tendinopathy include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy 2, 3, 4, 5.
- Surgical treatment is recommended when nonsurgical treatment fails, and may involve debridement, primary repair, and augmentation with flexor hallucis longus transfer 3, 4.
- The management of insertional Achilles tendinopathy is complex and may involve various treatment options, but the potential relationship with sural nerve irritation is not well understood and requires further investigation 2, 3, 4, 5, 6.