Chronic Achilles Tendinopathy Research Articles

Management of chronic Achilles tendinopathy

Tendons transmit force between muscles and bones and, when stretched, store elastic energy that contributes to movement.1 The tendinous portion of the gastrocnemius and soleus muscles merge to form the...

Paper 218: High Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Insertional Achilles Tendinopathy

Paper 218: High Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Insertional Achilles Tendinopathy

Paper 87: Non-invasive Treatment Options for the Management of Recalcitrant Chronic Achilles Tendinopathy

Paper 87: Non-invasive Treatment Options for the Management of Recalcitrant Chronic Achilles Tendinopathy

A Prospective Series of Patients with Chronic Achilles Tendinopathy Treated with Autologous-conditioned Plasma Injections Combined with Exercise and Therapeutic Ultrasonography

Chronic Achilles tendinopathy is a difficult problem to manage, because it can result in significant patient morbidity. We conducted a prospective case series involving 26 patients (2 bilateral cases) with painful and ultrasound-confirmed Achilles tendinopathy for a minimum duration of 6 months. Our objective was to assess whether this condition can be effectively treated with a treatment protocol combining an intratendinous autologous-conditioned plasma injection followed by a standardized rehabilitation protocol. The rehabilitation protocol consisted of full weightbearing in a pneumatic cast boot for 6 weeks, therapeutic ultrasound treatment, and an eccentric exercise program. Our results showed statistically significant improvements in terms of pain (p < .0001), other symptoms (p = .0003), activities of daily living (p = .0002), sports activities (p = .0001), and quality of life (p = .0002). We believe that the use of autologous-conditioned plasma can provide a potential treatment solution for chronic Achilles tendinopathy.

Tratamiento fisioterápico en la tendinopatía crónica de Aquiles. Revisión bibliográfica

ObjectiveTo conduct a review of that which has been published over these recent years on clinical effectiveness of physiotherapy treatment for chronic Achilles tendinopathy. Search strategyA search of the literature was performed using Medline, Web of Science, CINAHL, PubMed Central, ScienceDirect, PEDro and EnFisPo databases from 2006 to 2012. Study selectionArticles focused on the study objective and with at least one pre-test/post-test design were selected. Twenty-two results were obtained. Synthesis of resultsEccentric exercises, alone or combined with other therapeutic modalities, especially shock waves, are the most frequently used option. The best results are obtained in insertional tendinopathies. ConclusionsEccentric exercises are the most standardized physiotherapy treatment for chronic Achilles tendinopathy. Its use in this condition appears to be effective.

Psychology in sports injury rehabilitation

Using the case study of an 18-year-old track athlete with a chronic Achilles tendinopathy, this article identifies risk factors associated with training for major athletic events, such as the forthcoming Olympic Games, and presents evidence for adopting a multidisciplinary approach to the treatment and management of athletic injury, addressing the physical aspects of the injury, as well as the psychological needs of the athlete. The athlete's GP and practice nurse, as well as a podiatrist and sport psychologist, are all involved in providing an accurate clinical diagnosis, effective physical intervention, and psychological skills training to address emotional issues and encourage adherence to the rehabilitation programme. Nurses, in both secondary and primary care, can play a crucial role; in this case, the practice nurse recognised the adverse impact that the injury was having on the athlete's emotional wellbeing before making a referral to a trained sport psychologist.

An investigation of the transmission and attenuation of intense pulsed light on samples of human Achilles tendon and surrounding tissue

Light therapy is a common mode of treatment for musculoskeletal injuries but the depth of penetration of light radiation is controversial. Evidence exists for the efficacy of intense pulsed light (IPL) treatment for the rejuvenation of skin (superficial tissue) but it is not known if the IPL can penetrate deeper. If the IPL can penetrate to the depth of the Achilles tendon it may provide a potential management options in the treatment of a chronic mid-body Achilles tendinopathy. To examine if any optical radiation produced by an IPL transmits to the depth of the Achilles tendon when applied cutaneously to excised samples of human Achilles tissue. A secondary aim was to establish the relative amount of optical radiation that was attenuated within the tendon. Three samples of human Achilles tendon and surrounding tissue were harvested following elective lower limb amputation operations. Each sample was irradiated 2-6 cm above the insertion into the calcaneus (area of an Achilles tendinopathy) with IPL (model iPulse; Cyden Ltd, Wales, UK) set at a single pulse of 25 millisecond, wavelength range 530-1,110 nm and fluence of 13 J/cm(2). The transmission of light radiation was evaluated using (a) standard SLR digital camera, (b) spectrometer, and (c) an external energy meter. Light radiation was found to have transmitted through each of the three tissue samples by all three instruments. There were observable differences in the color of light detected for the control photo and the IPL irradiated tissue samples photographs. The percentage of fluence that was detected to have transmitted through the tissue samples by the energy meter was 4-8.1% and wavelengths between 645 and 843 nm were detected to have transmitted through the tissue by the spectrometer. In addition, the percentage of light radiation that attenuated with the tendon was 10.2-17.32%. The results of this study provides evidence that IPL penetrates to the depth of the Achilles tendon and attenuates with the tendon. IPL has potential to produce physiological effects in the treatment of patients with a chronic mid-body Achilles tendinopathy.

Local biochemical and morphological differences in human Achilles tendinopathy: a case control study

BackgroundThe incidence of Achilles tendinopathy is high and underlying etiology as well as biochemical and morphological pathology associated with the disease is largely unknown. The aim of the present study was to describe biochemical and morphological differences in chronic Achilles tendinopathy. The expressions of growth factors, inflammatory mediators and tendon morphology were determined in both chronically diseased and healthy tendon parts.MethodsThirty Achilles tendinopathy patients were randomized to an expression-study (n = 16) or a structural-study (n = 14). Biopsies from two areas in the Achilles tendon were taken and structural parameters: fibril density, fibril size, volume fraction of cells and the nucleus/cytoplasm ratio of cells were determined. Further gene expressions of various genes were analyzed.ResultsSignificantly smaller collagen fibrils and a higher volume fraction of cells were observed in the tendinopathic region of the tendon. Markers for collagen and its synthesis collagen 1, collagen 3, fibronectin, tenascin-c, transforming growth factor-β fibromodulin, and markers of collagen breakdown matrix metalloproteinase-2, matrix metalloproteinase-9 and metallopeptidase inhibitor-2 were significantly increased in the tendinopathic region. No altered expressions of markers for fibrillogenesis, inflammation or wound healing were observed.ConclusionThe present study indicates that an increased expression of factors stimulating the turnover of connective tissue is present in the diseased part of tendinopathic tendons, associated with an increased number of cells in the injured area as well as an increased number of smaller and thinner fibrils in the diseased tendon region. As no fibrillogenesis, inflammation or wound healing could be detected, the present data supports the notion that tendinopathy is an ongoing degenerative process.Trial registrationCurrent Controlled Trials ISRCTN20896880

Treatment of Chronic Noninsertional Achilles Tendinopathy with Endoscopic Achilles tendon Debridement and Flexor Hallucis Longus Transfer

Decompression with debridement has been shown to be effective in pain management in patients with chronic mid-portion Achilles tendinopathy; however, augmentation with the flexor hallucis longus tendon can provide additional mechanical support. The technique of endoscopic debridement of the tendinopathic tendon together with flexor hallucis longus transfer is described to treat patients suffering from chronic painful noninsertional Achilles tendinopathy with the potential advantage of minimally invasive surgery. Therapeutic, Level IV.

Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis

In Achilles tendon injuries, it is suggested that a pathological continuum might be evident from the healthy Achilles tendon to Achilles tendinopathy to Achilles tendon rupture. As such, risk factors for both tendinopathy and rupture should be the same. Hereditary and medical risk factors for Achilles tendinopathy and Achilles tendon rupture are the same to a similar extent in a matched pair analysis. Matched pair study; level of evidence: 3. Recreational sportsmen as well as athletes on national level. 566 questionnaires were analysed. 310 subjects were allocated to 3 groups (A, B, C) after matching the pairs for age, weight, height and gender: (A) healthy Achilles tendons (n = 89, age 39 ± 11 years, BMI 25.1 ± 3.9, females 36%), (B) chronic Achilles tendinopathy (n = 161, age 41 ± 11 years, BMI 24.4 ± 3.7, females 34%), (C) acute Achilles tendon rupture (n = 60, age 40 ± 9 years, BMI 25.2 ± 3.2, females 27%). We found a positive family history of Achilles tendinopathy as a risk factor for Achilles tendinopathy (OR: 4.8, 95% CI: 1.1-21.4; p = 0.023), but not for Achilles tendon rupture (OR: 4.0, 95% CI 0.7-21.1, p = 0.118). Smoking and cardiac diseases had a lower incidence in Achilles tendinopathy than in healthy subjects (both p = 0.001), while cardiovascular medication did not change the risk profile. Identifying risk factors associated with Achilles tendon disorders has a high clinical relevance regarding the development and implementation of prevention strategies and programs. This cross-sectional study identified a positive family history as a significant solitary risk factor for Achilles tendinopathy, increasing the risk fivefold. However, in this matched pair analysis excluding age, weight, height and gender as risk factors no further factor necessarily increases the risk for either Achilles tendinopathy or Achilles tendon rupture.

Regional variations of T2* in healthy and pathologic achilles tendon in vivo at 7 Tesla: Preliminary results

The aim of this study was to investigate T₂* in the Achilles tendon (AT), in vivo, using a three-dimensional ultrashort time echo (3D-UTE) sequence, to compare field strength differences (3 and 7 T) and to evaluate a regional variation of T₂* in healthy and pathologic tendon. Ten volunteers with no history of pain in the AT and five patients with chronic Achilles tendinopathy were recruited. 3D-UTE images were measured with the following echo times, at echo time = [0.07, 0.2, 0.33, 0.46, 0.59, 0.74, 1.0, 1.5, 2.0, 4.0, 6.0, and 9.0 ms]. T₂* values in the AT were calculated by fitting the signal decay to biexponential function. Comparing volunteers between 3 and 7 T, short component T(2s)* was 0.71 ± 0.17 ms and 0.34 ± 0.09 ms (P < 0.05); bulk long component T(2l)* was 12.85 ± 1.87 ms and 10.28 ± 2.28 ms (P < 0.05). In patients at 7 T, bulk T(2s)* was 0.53 ± 0.17 ms (P = 0.045, compared to volunteers), T(2l)* was 11.49 ± 4.28 ms (P = 0.99, compared to volunteers). The results of this study suggest that the regional variability of AT can be quantified by T₂* in in vivo conditions. Advanced quantitative imaging of the human AT using a 3D-UTE sequence may provide additional information to standard clinical imaging. Finally, as the preliminary patient data suggest, T(2s)* may be a promising marker for the diagnosis of pathological changes in the AT.

Is physiotherapy effective for patients with a chronic mid-body Achilles tendinopathy? A systematic review of non-surgical and non-pharmacological interventions

AbstractObjectiveTo assess the effectiveness of physiotherapy interventions (non-surgical and non-pharmacological) for a chronic mid-body Achilles tendinopathy.Materials and methodsA search of published and grey literature databases was undertaken (January 1999 to January 2011). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the PEDro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures, and results were extracted. A narrative research synthesis method was adopted since there were insufficient data to conduct a meta-analysis.ResultsTwo hundred and ninety studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; exercises (n = 2), low-level laser therapy (n = 1), low-energy shockwave trea...

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

BackgroundEccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.AimTo evaluate the...

Sodium MR Imaging of Achilles Tendinopathy at 7 T: Preliminary Results

To investigate the feasibility of sodium magnetic resonance (MR) imaging in the diagnosis of Achilles tendinopathy. Institutional review board approval and written informed consent were obtained. Twenty healthy volunteers and eight patients with Achilles tendinopathy were examined by using a 7-T whole-body MR imager with a 15-channel sodium knee coil. The sodium signal-to-noise ratio (SNR) from each region, as well as from the whole Achilles tendon, was compared between patients and healthy control subjects. The changes in SNR were assessed with a two-tailed unpaired t test in three regions of the Achilles tendon: the insertion area, the middle portion, and the muscle-tendon junction. P values less than .05 were considered to indicate a statistically significant difference. To validate a relationship between the sodium SNR and the glycosaminoglycan content in tendon, five cadaver ankles were examined with MR imaging and immunohistologically. The Pearson correlation coefficient between sodium SNR and glycosaminoglycan content was calculated. Significant differences (P < .05) in the mean sodium SNR of healthy control subjects (mean SNR, 4.9 ± 2.1 [standard deviation]) and patients with chronic Achilles tendinopathy (mean SNR, 9.3 ± 2.3) were observed. Similar results were found at the insertion (mean SNR in control subjects, 6.7 ± 2.3; mean SNR in patients, 12.3 ± 4.5; P < .05) and the midportion (mean SNR in control subjects, 5.1 ± 1.9; mean SNR in patients, 9.4 ± 3.0; P < .05) of the Achilles tendon. At the muscle-tendon junction, the sodium SNR difference between control subjects and patients was small but still bellow the significance level (P = .0137). The increase in sodium SNR was observed in all regions independently of the location of morphologic findings. The Pearson correlation coefficient between sodium SNR and glycosaminoglycan content was 0.71. Sodium MR imaging may allow detection of the proteoglycan content increase in Achilles tendinopathy and thus identify the biochemical changes in the early stages of tendinopathy.

Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale-Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

Clinical and Magnetic Resonance Imaging Outcomes following Platelet Rich Plasma Injection for Chronic Midsubstance Achilles Tendinopathy

The successful treatment of chronic mid-substance Achilles tendinopathy remains elusive. Approximately 25% to 50% of patients fail conservative treatment modalities. Scientific evidence has supported the use of platelet rich plasma (PRP) in the tendon healing process, however despite initial promise there is a paucity of clinical data to validate a role for PRP in the treatment of tendon disorders including chronic midsubstance Achilles tendinopathy. As an alternative to operative treatment, our practice offers patients with chronic midsubstance Achilles tendinopathy intratendinous injection of PRP. We retrospectively reviewed all patients treated for Achilles tendinopathy with PRP injection over a 2-year period. Baseline and post injection functional scores including the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Ability Measure - Sports (FAAMS), and the Short Form health survey (SF-8) were examined. Patients also underwent post-injection magnetic resonance imaging (MRI), which were compared to available pre-injection MRI data. Ten patients were identified for this study. Pre- and postinjection functional outcome scores were available for eight of ten patients. The average SF-8 score improved from 24.9 to 30.0, the average FAAM score improved from 55.4 to 65.8, and the average FAAMS score improved from 14.8 to 17.4. Complete MRI data was available for six patients. Only one in six Achilles tendons demonstrated qualitative MRI improvement post-injection. Patients who received PRP injection demonstrated modest improvement in functional outcome measures, however MRI appearance of diseased Achilles tendons remained largely unchanged following PRP injection.

Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented. Level of evidence V.

Achilles tendon tear following shock wave therapy for calcific tendinopathy of the Achilles tendon: A case report

IntroductionExtracorporeal shock wave therapy (ESWT) is becoming a popular method for the treatment of musculoskeletal disorders. We herein report a case of Achilles tendon rupture possibly related to ESWT. Case reportA 49-year-old female was treated with a calcaneal osteotomy due to Haglund’s disease on the right. However, she developed chronic calcific Achilles tendinopathy postoperatively, and during the following 2 year period after surgery she received various non-steroidal anti-inflammatory drugs and one injection of corticosteroids. She was subsequently treated with extracorporeal shock wave therapy (ESWT), but persistent pain, local swelling and redness over posterior right ankle were noted. Two months after ESWT she experienced an Achilles tendon tear and received Achilles tendon reconstruction. ConclusionWhile ESWT is generally considered safe, physicians should be aware of potential major complications.

Evoked Spinal Reflexes and Force Development in Elite Athletes With Middle-Portion Achilles Tendinopathy

Controlled laboratory study. To compare the neuromuscular function of the triceps surae muscle bilaterally in elite athletes with unilateral chronic Achilles tendinopathy. Previous studies suggest that tendinopathies or chronic pain may lead to a spinal/supraspinal level modulation of the excitability or voluntary activation of ipsilateral motor units. However, this has not been studied in Achilles tendinopathy. Fourteen college athletes (mean ± SD age, 24.2 ± 1.7 years) who had unilateral chronic middle-portion tendinopathy in their Achilles tendons were recruited. Bilateral measurements of soleus reflex tests, including H-reflex and V wave, and rate of force development (RFD), as well as corresponding electromyography of the tibialis anterior and triceps surae muscles, were performed. Statistical within-subject and between-leg comparisons were made. In the leg with tendinopathy, the V wave of the soleus muscle was significantly increased (P<.001). The side with tendinopathy also had a reduced normalized RFD (0-30, 0-50, and 0-100 ms) in plantar flexion, and concomitant higher electromyography ratios between the tibialis anterior and soleus (0-30 and 0-50 milliseconds) during the early stage of explosive contractions (P<.05). No significant differences were found for H-reflex, maximal plantar flexion and dorsiflexion torque, and absolute RFD. Higher volitional supraspinal reflexes and lower maximal-strength independent force development occur in the triceps surae of elite athletes with unilateral middle-portion Achilles tendinopathy. These changes potentially indicate an acquired compensatory mechanism for maximal force production and deficits in explosive strength. The RFD is also suggested as a sensitive parameter to depict neuromuscular changes during treatment of chronic tendinopathies.

Chronic Achilles Tendinopathy Treated With Eccentric Stretching Program

This study assessed the efficacy of a modified eccentric heel-drop program (reduced time and increased duration of stretch) in treating chronic Achilles tendinopathy. Athletes with at least 12 weeks of symptoms diagnosed clinically as chronic Achilles tendinopathy were enrolled in the study. The only treatment recommended was a 6-week eccentric stretching regimen, with each stretch being maintained for at least 15 seconds. Athletes were followed to assess the response to treatment using a Visual Analogue Scale (VAS) for pain and a patient effectiveness rating for treatment satisfaction as well as time to return to pre-injury activity level. Followup was successful in 156 (82%) of the athletes. A total of 190 athletes were seen with chronic Achilles tendinopathy. Mid-substance injuries were diagnosed in 168 (88%) with the remainder 22 (12%) having distal insertional injuries. Pain as assessed by VAS reduced from mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Six months post commencement of program mean pain was 1.1. Patient satisfaction was rated at 7 or above (excellent) in 124 (80%) of the athletes. For mid-substance injuries the satisfaction rating was excellent in 86%. Overall mean time to return to pre-morbid activity was 10 weeks. A modified 6-week eccentric heel-drop training regimen as the only treatment for chronic Achilles tendinopathy resulted in a high degree of patient satisfaction, reduced pain and a successful return to pre-morbid activity levels. These results were best for mid-substance rather than insertional tendinopathy.