Treatment of Achilles tendinopathy: state of the art

Abstract

Achilles tendinopathy (AT) is a continued enigma for clinicians from all parts around the world. The increasing prevalence is related to physical activities, but additionally also to metabolic factors unrelated to activities that load the Achilles tendon. AT can comprise two different diagnosis: insertional AT and non-insertional AT (NIAT). This review will deal predominantly with the treatment of NIAT. The exact aetiology and pathophysiology of NIAT are not fully known, but seem to be a partly degenerative condition. This gap of knowledge is accountable for the highly variable principles of treatment. The diagnosis of NIAT can usually be made clinically but MRI scans may be used and ultrasound may be useful, with power Doppler to assess the level of neovascularisation, or to guide injection therapies. Current treatments of NIAT with highest evidence entail non-surgical methods to promote tendon healing with focused eccentric exercises and biophysical procedures. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects, but have no proven long-term treatment effects. Targeted minimally invasive surgical procedures should be considered in specific recalcitrant cases to initiate healing and alleviate pain by removing pathological tissue or abnormal neoinnervation. Other surgical options including open debridement, gastrocnemius recession and plantaris tendon excision have been described. Overall, more high-quality level 1 studies are needed to define the optimal treatment protocols. Future therapies should target the differential underlying pathologies of NIAT using combined non-surgical and minimal-invasive including biological approaches.