Mid-substance Achilles Tendinopathy Research Articles

Foot Posture and Ankle Dorsiflexion as Risk Factors for Developing Achilles Tendinopathy and Plantar Fasciitis: A Case-Control Study.

Plantar fasciitis (PF) and Achilles tendinopathy (AT) are common injuries that primarily affect people engaged in sport or occupational weightbearing activities. Identifying modifiable risk factors is important for the treatment and prevention of these injuries. The purpose of this study was to evaluate whether foot posture or ankle dorsiflexion are risk factors for developing AT or PF, and if there were any differences between PF and AT patients. This was a case-control study of 108 patients with PF and 114 patients with AT, compared to the same number of referred patients in 2 control groups never having had these injuries, matched for sex, age, body mass index (BMI), sport, and occupational weightbearing activities. Included patients were 20-65 years with ultrasonographic-verified PF or midsubstance AT. Foot posture was assessed using Foot Posture Index (FPI) classifying the feet into 3 categories: FPI 0-5 normal foot, 6-12 hyperpronated, <0 hypopronated. Ankle dorsiflexion was measured with a goniometer in weightbearing with straight and bent knee. Abnormal foot posture was associated with an increased risk for sustaining both AT (odds ratio [OR] 3.4-4.1) and PF (OR 3.2-3.8). Hyperpronation being the major reason for this association with ORs 5.4-5.5 compared with hypopronation with ORs 2.6-2.9. However, decreased dorsiflexion was not a risk factor: instead, there was an increased ankle dorsiflexion in patients with AT or PF compared with their control groups. Comparison between PF and AT patients demonstrated that PF affected mostly women, and AT mostly men, PF patients were 2.4 years (CI 0.2-4.5) younger, and had 25% more occupational weightbearing than AT patients. However, no differences in BMI or weightbearing physical activity was demonstrated. Hypopronation and hyperpronation but not limited ankle dorsiflexion was associated with increased risk for AT or PF.

Contemporary treatments for mid-substance achilles tendinopathy: a review

Mid-substance Achilles tendinopathy is primarily a degenerative condition that frequently affects quality of life, especially for patients wanting to continue a high level of activity. It can differ from insertional Achilles tendinopathy both in terms of its epidemiology as well as its management strategies. Currently, numerous treatment options exist in the literature for this fairly common musculoskeletal condition. However, many of these treatments remain experimental with no substantial evidence for efficacy. A number of these options, including regenerative and biologic medicines, have nonetheless demonstrated improvements in patient-reported outcomes and promising potential. As such, there remains no standard approach for management beyond stretching/exercise therapy. This article reviewed the current literature surrounding treatment options and provided summaries and recommendations of eight treatment modalities for this condition. It is intended to serve as a general review as well as an objective evaluation of recent evidence that may provide some guidance for healthcare providers when discussing treatment options with patients.

Health-related quality of life in patients with Achilles tendinopathy: Comparison to the general population of the United Kingdom

BackgroundThere is little evidence available regarding the impact of Achilles Tendinopathy (AT) on health-related quality of life (HRQOL). The primary aim of this study was to quantify the clinical and health-related quality-of-life patient-reported outcome measures for a population presenting with either mid-substance or insertional Achilles tendinopathy. MethodsA prospective comparative observational study of consecutive patients with AT presenting for extracorporeal shockwave therapy (ESWT) at a large teaching hospital. The primary outcome was assessment of a validated health-related quality of life PROMs (Euroqol EQ-5D-5L) and comparison to 2 general UK population datasets. The secondary outcomes were Visual Analogue Pain Scale (VAS-Pain) and two validated foot-specific patient reported outcome measures (Foot Function Index (FFI) and Victorian Institute of Sports Assessment-Achilles (VISA-A)). ResultsBetween March 2014 and June 2021, 320 consecutive patients (125 male; 195 female) were diagnosed with AT and referred for a first course of ESWT. EQ-5D-5L PROMs were prospectively collected for 303 of these patients (94.7%). The mean age (± standard deviation(SD)) was 52.1 ± 11.4 years. The mean EQ-5D-5L Index score (mean±SD) for the AT cohort was 0.783 ± 0.131. Patients less than 55 years with AT had a statistically significantly worse quality of life compared with members of the same age group in the general population. The mean VAS-Pain, FFI, VISA-A clinical outcome scores were 6.0 ± 2.3, 49.5 ± 21.2 and 34.1 ± 14.4 respectively. There was a statistically significant moderate correlation between HRQOL and clinical PROMs (VAS-Pain and FFI vs EQ-5D) however there was no correlation with age. ConclusionThis study demonstrates that patients under the age of 55 with AT have a significantly reduced quality of life compared with the general population. Level of evidenceIII

Platelet rich plasma versus placebo for the management of Achilles tendinopathy: protocol for the UK study of Achilles tendinopathy management (ATM) multi-centre randomised trial

IntroductionIn the UK, 150 000 people every year experience mid-substance Achilles tendinopathy. Typically patients are offered a range of treatment options such as exercise, electrotherapy, injections and surgery. With large...

Applying physical science principles to mid-substance Achilles tendinopathy and the relationship to eccentric lengthening exercises.

Mid-substance Achilles tendinopathy is common in the active population. Eccentric (lengthening) exercises are known to be effective in alleviating the clinical condition. To better understand mid-substance Achilles tendinopathy and the response to lengthening exercises physical science principles of elasticity are applied. We apply elastic motion laws to the spring-like tendon as well as the normal and pathological adaptation seen with this common injury. We will validate important assumptions of the spring-like behavior of the tendon and then apply these findings to the injured and rehabilitating states. Our analysis considers that the tendon can be viewed as being spring-like with elasticity principles being applicable and the force exerted on the tendon during lengthening is primarily in a uniaxial direction. This applied lengthening force results in tendon mechanical and structural adaptation. Injury, and ultimately the clinical condition, occurs when the applied force exceeds the ability of the tendon to normally adapt. Morphological changes of the injured tendon are an attempt by the body to make the tendon more compliant. Lengthening exercises can be assessed as achieving this task with an improvement of tendon compliance. Physical science analysis proposes that the preferred rehabilitation tendon pathway is to try and decrease tendon stiffness to allow for more tendon lengthening. The body's morphological alterations of the pathological tendon are also consistent with this approach. For mid-substance Achilles tendinopathy, this adaptation of decreased stiffness ultimately increases the tendons ability to withstand applied force during lengthening.

Achilles tendinopathy management

ObjectivesTo conduct a pilot randomised controlled trial to evaluate the feasibility of conducting a larger trial to evaluate the difference in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores at six months between patients with Achilles tendinopathy treated with a platelet-rich plasma (PRP) injection compared with an eccentric loading programme.MethodsTwo groups of patients with mid-substance Achilles tendinopathy were randomised to receive a PRP injection or an eccentric loading programme. A total of 20 patients were randomised, with a mean age of 49 years (35 to 66). All outcome measures were recorded at baseline, six weeks, three months and six months.ResultsThe mean VISA-A score for the injection group at the primary endpoint of six months was 76.0 (95% confidence interval (CI) 58.3 to 93.7) and for the exercise group was 57.4 (95% CI 38.1 to 76.7). There was no statistically significant difference between these scores (p = 0.171), which was expected from such a pilot study.ConclusionsThis pilot study has been key to providing data to inform a larger study and shows that the methodology is feasible.Cite this article: Bone Joint Res 2013;2:227–32.

High-volume injection in the management of recalcitrant mid-body Achilles tendinopathy: a prospective case series assessing the influence of neovascularity and outcome

AbstractObjectivesTo determine the effectiveness of ultrasound-guided high-volume injection (HVI) and relevance of neovascularity on outcome in Achilles tendinopathy.MethodsThis prospective clinical study at the Homerton University Hospital included 32 patients with recalcitrant unilateral mid-substance Achilles tendinopathy. Outcome measures used were Victorian Institute of Sport Assessment-Achilles tendon (VISA-A), Visual Analogue Score (VAS), modified Ohberg score and mean maximum tendon thickness.ResultsSignificant improvements in both VAS and VISA-A scores at 1 month (95% confidence interval (CI), 6.6–3.2, P < 0.001 and 37.2–63.7, P < 0.001). This improvement was maintained at 3 months (95% CI, 6.6–2.9, P < 0.001 and 37.2–65.9, P < 0.001). Symptomatic tendons were significantly thicker at baseline than the asymptomatic side (95% CI, 8.3 mm compared to 5.9 mm, P < 0.001). There was a significant decrease in maximum tendon thickness in the symptomatic tendons at baseline and at 3 months (95% CI, 8.3–7....

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.

Eccentric loading for Achilles tendinopathy - strengthening or stretching? : editor's choice

The prescription of eccentric loading is considered as a mainstay of non-operative rehabilitation programmes for mid-substance chronic Achilles tendinopathy. Such exercises have some degree of clinical utility in comparison with concentric training and are often referred to as a strengthening programme. Yet the dose parameters of the eccentric loading do not reflect an optimal strengthening programme and specifically avoid the normal eccentric-concentric coupling typical of the stretch shortening cycle. This manuscript identifies the arguments and counterarguments for why eccentric loading rehabilitation is not an optimal strengthening programme. It is proposed that such exercises reflect a specific stretching programme directed at the passive structures. This has two important clinical implications. Firstly, this reinterpretation of the role of eccentric exercises may direct future research into the underlying mechanisms of tendinopathy and, secondly, it may reinforce the importance of adjunct sports specific strengthening programmes.

Eccentric loading for Achilles tendinopathy — strengthening or stretching?

The prescription of eccentric loading is considered as a mainstay of non-operative rehabilitation programmes for mid-substance chronic Achilles tendinopathy. Such exercises have some degree of clinical utility in comparison with...