SCA practice case · Video consultation
“The back of my heel/ankle has been stiff and painful for weeks, worst when I start running — and there’s a tender lump on the tendon”
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Tom Easton · 44 years · male
Setting
Video consultation — posterior heel/ankle pain (guided self-examination)
Past history
- Recreational runner
Medication
- None recorded
Allergies
None recorded
Recent notes
Weeks of posterior ankle pain, worst in the morning and at the start of runs; tender tendon lump; recent training increase. On video (guided): tender thickened swelling about 4 cm above the right heel; can do 10 single-leg heel raises on the right (painful); with his wife squeezing the calf while he kneels on a chair, the foot plantarflexes normally on both sides; no visible gap; no swelling of other joints.
Reason for contact
“Can I keep running?”
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
ACHILLES TENDINOPATHY is an overuse condition presenting with gradual-onset posterior ankle/heel pain and stiffness, worst on STARTING activity and in the MORNING, with localised tenderness and THICKENING of the tendon (mid-portion ~2–6 cm above the insertion, or insertional where the tendon meets the heel bone), typically provoked by training-load increases, poor footwear and calf tightness. The must-not-miss is ACUTE ACHILLES RUPTURE — a sudden "kicked/popped" sensation, weakness, inability to push off/stand on tip-toes, a palpable gap and a positive SIMMONDS/Thompson calf-squeeze test (no plantarflexion on squeezing the calf) — which is easily missed (some patients still weakly plantarflex) and needs same-day orthopaedic or fracture-clinic assessment. Consider gout, retrocalcaneal bursitis, spondyloarthritis enthesitis (NICE NG65), xanthomata and referred pain, and review risk factors including training-load spikes, FLUOROQUINOLONE antibiotics (ciprofloxacin — tendinopathy/rupture risk; MHRA Drug Safety Update March 2019, and since January 2024 only when other recommended antibiotics are inappropriate), corticosteroids and inflammatory arthropathy, stopping/avoiding fluoroquinolones if implicated. Manage conservatively: relative rest/load modification (reduce running volume rather than stop entirely), analgesia, and the cornerstone — a structured progressive LOADING programme (eccentric/heavy-slow resistance) via physiotherapy with calf stretching and footwear/heel raise — which is evidence-based (JOSPT/APTA 2024, international) and effective but slow (about three months). AVOID corticosteroid injection into the Achilles tendon (rupture risk), refer to physiotherapy (and orthopaedics/sports medicine if refractory, urgently if rupture suspected), and set realistic expectations (review at around 12 weeks; shockwave only with special arrangements, NICE HTG426).
The guidance behind it
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