ACHILLES TENDINOPATHY.. WHERE ARE WE AT?
While I am thinking about my next move with my mate's manky Achilles, I thought it might be appropriate to give an update on treatment for Achilles tendon pain. Let's first look at the insertional variant.
First of all, how common is Achilles Tendinopathy in runners?
Well, according to a very recent paper by Lopez et al, it is very common and the most common running-related musculoskeletal injury (RRMI) for both general and ultra-marathon runners.
Second, why does it happen?
During exercise and coordinated musculoskeletal movement, tendons are pivotal in transmitting force from muscle to bone allowing movement. Historically, the term overuse injury led to research focusing on medium to long-term effects of exercise on tendons. It is important to understand that tendons are metabolically active structures and they undergo complex remodelling, which can improve tensile strength and increased collagen turnover with long-term exercise.
Although acute structural changes following bouts of exercise can stimulate positive adaptations, in some situations these changes may play a role in the development of tendon injuries, illustrating the incomplete understanding of this field. Athletes training on a daily basis will undertake sessions of varying intensities and duration amid competition, yet there is little evidence correlating exercise, structural changes and injury progress.
In other words... we do not know yet, but we are working on it!!
Improved understanding of biochemical markers, sensitive imaging and mechanical property indicators provide a basis for accurate accounts of tendon response to acute loading. Recently, with the introduction of ultrasound (US) color and power Doppler, it has become possible to assess tendon blood flow changes during and following acute exercise, and therefore better understand the acute and subacute effect of exercise on tendon.
The treatment options for Achilles tendinopathy are huge, and vary from simple interventions like heel lifts and stretching to far more advanced or even experimental options.
The other problem is that Achilles tendinopathy takes several different forms, including midsubstance, i.e., injury to the main body of the tendon, usually 2-5 cm above the insertion, and insertional.
Insertional Achilles tendinopathy is far more difficult to treat than mid-substance.
Let's take a look which treatments actually have some evidence to back up their use, starting with insertional Achilles tendinopathy.
Two studies evaluated different types of injections [1,2]. In a retrospective analysis, Ryan et al.  included 22 patients treated with ultrasound (US)-guided hyperosmolar dextrose (20 mg/mL) injections. A mean of 5 injections were given. The mean VAS on daily activity decreased with 4.1 points (p = 0.001) (on a 10-point VAS scale) at follow-up (28.6 months). The authors did not report on patient satisfaction. Ohberg et al.  prospectively analyzed 11 patients, who were treated with polidocanol injections until symptoms dissolved (up to ﬁve injections). The mean VAS showed a decrease of 5.9 at 8 months follow-up, and 8 out of 11 (73 %) patients were satisﬁed with the outcome.
As tendinopathy is not inﬂammatory with no overt inﬂammatory process, there is no rational basis for the use of non-steroidal anti-inﬂammatory drugs (NSAIDs) in its treatment. They are only useful to reduce inﬂammation and pain in the acute stage and while acetaminophen (paracetamol) and NSAIDs provide short-term pain relief for patients with tendinopathy, they do not affect long-term outcomes. There is no evidence from randomized control trials that NSAIDs are more effective than acetaminophen which should be preferred for pain relief because it has fewer adverse effects. Several studies have demonstrated that NSAIDs do not reduce the time of recovery from tendon injury and may actually interfere with the healing process .
Infiltration of platelet-rich plasma has no or very poor evidence for insertional Achilles tendinopathy.
Four studies have evaluated the treatment for eccentric exercises [3,4,5,6]. A total of 92 patients with 100 painful tendons were studied. A 12-week daily eccentric treatment regime was used in every study. There were some differences in treatment protocol; three studies evaluated full range eccentric exercises (below the step), whereas the other evaluated ﬂoor level eccentric exercises (providing less stress on the Achilles’ insertion); in addition, there was some difference between ‘number of daily sets’ and ‘number of repetitions’.
All four studies used a numerical pain scale; three studies documented the patient satisfaction of the received treatment [3,4,6]. When combining the results, an overall decline on a 10-point scale was 2.7 points (weighted mean). All studies combined, and the patient satisfaction showed a large group of unsatisﬁed patients: of 83 patients only 35 (42 %) were either ‘extremely satisﬁed’ or ‘satisﬁed’. Subdividing the full range of motion eccentric group from the ﬂoor level eccentric exercises, a noticeable difference was found. The VAS (visual analogue scale) for full range of motion decreased with a weighed mean of 2.0 points, whereas in the ﬂoor level, group is decreased with 3.9 points. In addition, 18 of 27 (67 %) were satisﬁed in the ﬂoor level group, in the full range of motion only 17 of 56 (30 %) were satisﬁed. The focus of eccentric treatment should therefore be on ﬂoor level exercises. However, the level of evidence for this therapy, compared to midsubstance tendinopathy, is low.
Extracorporeal shockwave therapy
Two studies tested the effect of extracorporeal shockwave therapy (ESWT) for insertional Achilles tendinopathy, one prospective study and one randomized controlled trial [6,7]. Furia et al.  prospectively compared an ESWT group to a matched control group receiving non-speciﬁed ‘traditional treatment’. A mean decrease in VAS of four points was measured after 12 months; 29 out of 35 (83 %) patients were satisﬁed with ESWT. The control group (n = 33) showed a signiﬁcantly less decrease in VAS and patient satisfaction. Rompe et al.  compared ESWT with an eccentric training regime in a RCT, 25 patients received ESWT. The VAS decrease was 5.1 points at ﬁnal follow-up, 16 (64 %) patients were satisﬁed with their treatment. Overall, 49 out of 64 (77 %) were satisﬁed after ESWT.
One study evaluated three different non-surgical treatment modalities: Costantino et al.  compared laser CO2 with TECAR and cryoultrasound. Five patients were included in each group. Every intervention showed a signiﬁcant decrease in VAS score at follow-up. All ﬁve patients in the cryoultrasound group were very satisﬁed; in the TECAR group, two were very satisﬁed and three were satisﬁed; in the laser CO2 group, all ﬁve were satisﬁed.
Surgery for any form of Achilles tendinopathy is only considered after at least 6 months of failed conservative therapy.
That said, the results can be good.
A total of six studies have evaluated the outcome of surgical treatment for insertional Achilles tendinopathy [9,10,11,12,13,14]. The evaluated studies described ﬁve different operative techniques. None of the included surgical techniques were minimally invasive. All minimal invasive surgical studies were excluded from this discussion due to unclear terminology, minimal invasive studies focused on retrocalcaneal bursitis instead of insertional Achilles tendinopathy [15, 16]. Three studies used a medial incision: two a midline or central incision and one a lateral incision. All techniques involved resection of the posterosuperior calcaneal prominence, retrocalcaneal bursa and intratendinous calciﬁcations. All studies detached the AT partially or in total, reinserted the AT with bone anchors or performed augmentation (plantaris tendon or FHL).
Despite the (minor) differences in surgical technique, there were large differences in complication rate. One study reported no major and only 7.5 % minor complications . Others reported 23 % major and 59 % overall complications . Although the difference in complication rate was evident, there was almost no difference in patient satisfaction. Outcome on pain scores (e.g. VAS) was scarcely reported [9, 14]. Based on the included studies, it is not possible to draw any conclusions regarding the best surgical technique for insertional Achilles tendinopathy.
The final word
Tendinopathy represents a failed healing response by a tendon after injury. Despite an abundance of therapeutic options, there is a lack of randomized prospective, placebo-controlled trials to assist clinicians in choosing the best evidence-based management. The use of injectable substances in and around tendons such as platelet-rich plasma, autologous blood, polidocanol, corticosteroids has been advocated but there is minimal clinical evidence to support such therapy.
- Ohberg L, Alfredson H (2003) Sclerosing therapy in chronic Achilles tendon insertional pain-results of a pilot study. Knee Surg Sports Traumatol Arthrosc 11:339–343
- Ryan M, Wong A, Taunton J (2010) Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional and midportion achilles tendinosis. AJR Am J Roentgenol 194:1047–1053
- Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H (2003) Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 11:327–333
- Jonsson P, Alfredson H, Sunding K, Fahlstrom M, Cook J (2008) New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med 42:746–749
- Knobloch K (2007) Eccentric training in Achilles tendinopathy: is it harmful to tendon microcirculation? Br J Sports Med 41:e2
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- Furia JP (2005) Extracorporeal shockwave therapy in the treatment of chronic insertional Achilles tendinopathy. Orthopade 34:571–578
- Costantino C, Pogliacomi F, Vaienti E (2005) Cryoultrasound therapy and tendonitis in athletes: a comparative evaluation versus laser CO2 and t.e.ca.r. therapy. Acta Biomed 76:37–41
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- Yodlowski ML, Scheller AD Jr, Minos L (2002) Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity. Am J Sports Med 30:318–321
- Leitze Z, Sella EJ, Aversa JM (2003) Endoscopic decompressionof the retrocalcaneal space. J Bone Joint Surg Am 85:1488–1496
- van Dijk CN, van Dyk GE, Scholten PE, Kort NP (2001) Endoscopic calcaneoplasty. Am J Sports Med 29:185–189
- Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med 2006; 16: 1e3.