Tear of Fascia Cruris: A new Diagnosis to consider in Achillodynia

Treating any condition requires knowledge of various sources of symptoms that may elicit pain. These sources of symptoms could arise from tendons, ligaments, bones, muscles, nerves and fascia. The treatment of the pain or problem will differ based on the structures involved. Thus, accurate diagnosis of the problem is required for which clinicians need to think about all the structures or conditions that may cause pain during clinical reasoning process; and test each structure and rule out to reach the final diagnosis.
A case series of 11 patients presenting at a sports injury clinic published very recently in British Journal of Sports Medicine describes a new diagnosis for the posterior ankle and leg pain or Achillodynia (pain at the Achilles tendon). This diagnosis is not considered in contemporary practice. It is time to consider fascial involvement at the Achilles region.

“The fascia cruris is that layer of connective tissue that encloses all the posterior structures of the calf down to the ankle joint and connects to the Achilles tendon.” This fascia allows sliding of its collagen layers, accommodates calf muscles and Achilles tendon, bears load and withstands high tensile force generated during walking and running. Because of these reasons, it has the potential to get injured. Fascia Cruris tear is evident generally at its lateral attachment than medial attachment at the Achilles tendon. Bilateral involvement is also possible.

Patient may complain of sensation of calf tightness days to weeks before the rapid onset of pain around Achilles region during activity. Patient may feel “bee sting” kind of sensation at the Achilles tendon. Patient may complain of sudden pain and tenderness at the inside or outside of the Achilles tendon area. Swelling may be associated with pain. Some patients complain of sensation of crepitus.

During history, patient may report of sudden change in the training type or load, history of inversion type of injury at the ankle, or history of jumping exercises, running in rough terrain in old shoes, dancing in high heels etc. Some patients may also have a previous history of problems in the contralateral side.

Examination may reveal swelling, palpable crepitus at Achilles region with tenderness, palpable tightness of soleus and gastrocnemius. Functional overpronation of the foot is also common in majority of the cases.

Diagnostic ultrasound reveals a tear of fascia cruris at the attachment of Achilles tendon. Pressure due to ultrasound probe in the area of tear elicits tenderness.

Treatment: As the diagnosis is novel, there is no recommended treatment for this case. However, the authors in this case series have used some treatment approach that has helped the participants in the study. Treatment included conservative measures including ice, acupuncture, offload taping, topical NSAIDs, low level therapeutic LASER and soft tissue manipulation. This was progressed by gradual stretching of calf, followed by strengthening and progressive loading after pain-free stretching was achieved.

When can patient or athletes return to sports/ full activity?
Return to full activity may range from 1 to 22 weeks with 5 weeks as an average time.
Recurrence is possible after return to full activity. Those not responding to conservative measures can be given injections, however, return to sports/ normal activity time will prolong for these individuals.

Tear of fascia cruris should be considered for any cause of Achillodynia. This condition can occur at age ranging from 11 to 48 years in either gender. It is generally common in individuals involving high physical activities, is triggered by unaccustomed activities. such as increase in training load and change in training type, dancing in high heels, running in rough surfaces in old shoes, jumping activities etc. It can be diagnosed by clinical features that include pain, swelling and tenderness at Achilles tendon and subjective and objective tightness of calf and crepitus. It can be managed conservatively by ice, acupuncture, taping, Low Level LASER, soft tissue manipulation, progressing to stretching, strengthening and progressive loading once the stretching is painfree.

1. Webborn N, et al. Br J Sports Med 2015;49:1398–1403. doi:10.1136/bjsports-2013-093273