Achilles Tendinopathy: Reviewing the most
recent Guidelines
Most individuals who suffer from Achilles Tendinopathy (AT) are reported to be recreational or competitive athletes (1). However, sedentary individuals are not exempt as AT also exists in this population (2). The mean age of onset is 30 to 50 years old and the prevalence tends to increase with age. Most commonly, Achilles tendinopathy symptoms are chronic and associated with a degenerative tendon. Similar to other tendons in the body, morphological and biochemical changes occur to the tendon with advancing age. The current opinion is that the tendinopathy that occurs is non-inflammatory in nature. Increased vascularity or neovascularization is associated with the degenerative tendon as well as an increase in varicose nerve fibers. These nerve fibers are postulated to be responsible for the pain associated with the non-inflammatory degenerative tendon (1).
Hypertension, obesity, diabetes and high cholesterol are reported to be associated with Achilles tendinopathy (3). Abnormal dorsiflexion and subtalar range of motion, decreased plantar flexion strength and increased pronation are considered risk factors for the development of AT (1). Individuals will report local pain and stiffness in the Achilles tendon that is worse after a period of rest, better during activity but may then increase after the activity (3). Differential diagnosis should include the following:
- acute tendon rupture or partial tear
- retrocalcaneal bursitis
- posterior ankle impingement
- irritation or neuroma of sural nerve
Imaging may be necessary when a clinical diagnosis is uncertain. Ultrasound and MRI are reported to have similar sensitivity (80%/95%) and specificity (49%/50%) (4).
Clinical practice guidelines developed by Carcia et al comment on the following interventions:
Eccentric loading exercises: Reported to have good outcome in athletic populations with mid portion AT. Night splints combined with eccentric loading exercises are not found to be of further benefit.
Laser Therapy: There is some evidence reported that low level laser therapy is helpful for reducing the pain and stiffness of AT. However, the evidence is derived from a limited number of studies.
Iontophoresis: There is some evidence of moderate quality that iontophoresis with dexamethasone is helpful for decreasing pain. Unfortunately, neither the concentration of the dexamethasone nor the intensity of the iontophoresis is reported. Further study is needed.
Stretching: The guidelines recommend stretching as a means to reduce pain and improve function in pts with limited dorsiflexion. But there is limited actual evidence for this found in the literature.
Foot orthosis: There is limited evidence to support the use of foot orthosis in the treatment of AT.
Manual Therapy: Clinical practice guidelines recommend manual therapy for the treatment of AT based on expert opinion.
Taping: No published studies exist that evaluate the effectiveness of taping. Clinically, several techniques are used by clinicians to help off load the tendon.
Conflicting evidence exists for the treatment of AT using the following: extracorporeal shock wave, local steroids, sclerosing injection and heel lifts. There has been no evidence reported on the use of NSAIDS for the treatment of AT.
Conservative treatment is recommended for the first 4 to 6 months. If conservative treatment fails, surgery is recommended to remove fibrotic adhesions and degenerative nodules.
Reports of conservative treatment failure have been as high as 24 – 49 %. Unfortunately posterior heel pain can certainly become the dreaded Achilles heel for some.
References:
1.Carcia CR, Martin RL, Houck J, Wukich D. Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis. J Ortho Sports Phys Ther. 2010:40(9): A1-A26.
2. Rompe JD, Furia JP, Maffulli N. Mid-portion Achilles tendinopathy- current options for treatment. Disabil Rehabil. 2008;30:1666-1676.
3. Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int. 2006;27:952-959.
4. Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br.J Sports Med. 2003;37:149-153.