Treatment Of Non-insertional Achilles Tendinopathy Research Articles

Maximum dorsiflexion increases Achilles tendon force during exercise for midportion Achilles tendinopathy.

Rehabilitation is an important treatment for non-insertional Achilles tendinopathy. To date, eccentric loading exercises (ECC) have been the predominant choice; however, mechanical evidence underlying their use remains unclear. Other protocols, such as heavy slow resistance loading (HSR), have shown comparable outcomes, but with less training time. This study aims to identify the effect of external loading and other variables that influence Achilles tendon (AT) force in ECC and HSR. Ground reaction force and kinematic data during ECC and HSR were collected from 18 healthy participants for four loading conditions. The moment arms of the AT were estimated from MRIs of each participant. AT force then was calculated using the ankle torque obtained from inverse dynamics. In the eccentric phase, the AT force was not larger than in the concentric phase in both ECC and HSR. Under the same external load, the force through the AT was larger in ECC with the knee bent than in HSR with the knee straight due to increased dorsiflexion angle of the ankle. Multivariate regression analysis showed that external load and maximum dorsiflexion angle were significant predictors of peak AT force in both standing and seated positions. Therefore, to increase the effectiveness of loading the AT, exercises should apply adequate external load and reach maximum dorsiflexion during the movement. Peak dorsiflexion angle affected the AT force in a standing position at twice the rate of a seated position, suggesting standing could prove more effective for the same external loading and peak dorsiflexion angle.

Short- and Intermediate-Term Results of Extracorporeal Shockwave Therapy for Noninsertional Achilles Tendinopathy.

Earlier randomized controlled trials (RCTs) reported only midterm (3-4 months) results of extracorporeal shockwave therapy (ESWT) as a treatment for noninsertional Achilles tendinopathy (NAT). This study compared the effectiveness of an eccentric loading program followed by stretching exercises combined with ESWT (study group) or sham ESWT (control group) for treating chronic NAT in both the short and long term. This double-blind RCT was conducted between 2018 and 2020. Adult patients with unilateral NAT who failed standard conservative treatment were randomly allocated to either group. Function and pain were assessed at baseline, 1 month, and 16 months using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and visual analog scale (VAS), respectively. Mixed-design analysis of variance and nonparametric statistics were performed. Twenty-two men and 28 women aged 18 to 40 years were allocated into 2 equally matched groups. Function and pain scores in the study group were not significantly different from control group scores at baseline (VISA-A: 22.2 ± 6.5 vs 21.0 ± 5.2 and VAS: 8 ± 1 vs 8 ± 1, respectively). Both groups significantly improved posttreatment (VISA-A: 85 ± 6.2 vs 53.4 ± 7.7 and VAS: 1 ± 2 vs 7 ± 2, respectively). At the 16-month follow-up, outcome scores declined slightly but significantly in the study group (VISA-A: 80 ± 5.3; VAS: 3 ± 2) and improved in the control group (VISA-A: 67 ± 5.6; VAS: 5 ± 1). However, both groups were significantly better than baseline. At both time points, the study group had significantly superior scores (statistically and clinically) than the control group (P = .0001). Combining calf eccentric loading with stretching exercises resulted in significant improvements in the pain and functional scores in patients with NAT. Adding ESWT to this combined protocol resulted in significantly greater improvements in both the short and long term. Level I, randomized controlled trial.

Platelet-rich plasma (PRP) treatment of noninsertional Achilles tendinopathy in a two case series: no significant difference in effect between leukocyte-rich and leukocyte-poor PRP.

BackgroundThere is a theoretical basis for the treatment of chronic tendinopathies by platelet-rich plasma (PRP), and it can, therefore, be considered a possible treatment of chronic Achilles tendinopathies (CATs), even though the clinical evidence for the use is not clear and, in addition, there is a lack of treatment algorithms and it is unclear which type of PRP is most effective. The objective of this study was through the comparison of two case series to assess: 1) the effect of PRP on CAT and 2) if there is any difference in effect between leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) in the treatment of CAT.Patients and methodsTwo separate series of achilles tenodinopathies treated with either LR-PRP or LP-PRP were evaluated with a natural experiment/quasi-experimental study design, with a short-term (2 months) and long-term (8–42 months) follow-up to assess the effect and stability of the treatment. In total, 84 patients with failed basic treatment for CAT for at least 6 months were treated with either Biomet’s GPS III recovery kit with LR-PRP (36 patients) or with Arthrex ACP LP-PRP (48 patients).ResultsThe overall probability of reaching a minimal clinically important change (MCIC) of at least 30% reduction in visual analog scale (VAS) was in activity (63%) and during rest (81%), and for Victorian Institute of Sport Assessment Scale (VISA-A), it was 61%. There was no statistical difference in change of VISA-A score or VAS between the patients treated with LP-PRP and LR-PRP.ConclusionPRP seems to be a possible treatment when all other treatment regimens have failed, with a reasonably high probability of reaching MCIC. The choice of either LR-PRP or LP-PRP seems to be up to personal preference as there were no significant differences between patients treated with LR-PRP and LP-PRP.

It is possible to release the plantaris tendon under ultrasound guidance: a technical description of ultrasound guided plantaris tendon release (UPTR) in the treatment of non-insertional Achilles tendinopathy

Open plantaris tendon excision and ventral paratendinous stripping is a recognised treatment option in selected patients with non-insertional Achilles tendinopathy. The aim of this study was to develop a minimally invasive outpatient technique of ultrasound guided plantaris tendon release (UPTR). A 19 gauge needle, 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and a beaver blade (Arthrex, Naples, FL, USA), were used under ultrasound guidance to identify and divide the plantaris tendon in 12 cadaveric legs. Specimens were dissected to identify whether division of the plantaris tendon had been successful. UPTR was subsequently performed on patients. The 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and beaver blade (Arthrex, Naples, FL, USA) were all able to cut the plantaris tendon. However, on dissection the hook knife (Smith and Nephew, Boston MA) caused less damage to surrounding structures. Subsequently, the plantaris tendon was successfully divided in three patients using UPTR technique without complication. UPTR is a viable technique for treating plantaris related non-insertional Achilles tendinopathy.

Platelet rich plasma compared to dry needling in the treatment of non-insertional Achilles tendinopathy

ABSTRACTObjectives: The efficacy of platelet rich plasma in the treatment of Achilles tendinopathy is controversial. Despite positive results observed in open studies, randomized controlled trials failed to show difference against saline or rehabilitation. Aims of this retrospective observational study were to compare the efficacy of platelet-rich plasma and dry needling and to assess possible differences age and sex-related.Methods: Groups of 46 and 38 patients with non-insertional Achilles tendinopathy were treated with platelet-rich plasma and dry needling (once a week for 3 weeks), respectively. At baseline, 3 and 6 months, pain and function scores and the percentage of satisfactory outcomes were evaluated. Sub-group analyses were performed according to age and sex.Results: At 3 and 6 months no differences in terms of pain and function between groups were observed, but the percentage of subjects reporting satisfactory results, at 6 months, was higher in platelet rich plasma group. Better results were observed in younger subjects, with a greater reduction of pain, improvement of function, and accordingly of the percentage of positive outcomes. A trend toward better results was also observed in males.Conclusion: Beneficial effects of platelet rich plasma and dry needling in non-insertional Achilles tendinopathy have been observed only in some subjects, but not in others; platelet rich plasma shows a slight superiority against dry needling, mainly in younger persons; finally, a gender difference in the therapeutic response can be hypothesized.

Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up.

Although platelet-rich plasma (PRP) injection has shown controversial results for the treatment of Achilles tendinopathy, it remains the most used biological treatment. Recent findings seem to demonstrate that the stromal vascular fraction (SVF) within adipose tissue may counteract the impaired tendon homeostasis. The aim of this study was to prospectively compare the efficacy of PRP and SVF injection for the treatment of non-insertional Achilles tendinopathy. Fourty-four patients were recruited in the study; 23 of them were assigned to the PRP group whereas 21 to the SVF group, treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18-55years) were clinically assessed pre-operatively and at 15, 30, 60, 120 and 180days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after 4 (US only) and 6months. Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A scored significantly better at 15 and 30days in the SVF in comparison to PRP group (p < 0.05). At the following time points the scores were not significantly different between the two groups. No correlation has been found between clinical and radiological findings. Both PRP and SVF were safe, effective treatments for recalcitrant Achilles tendinopathy. The patients treated with SVF obtained faster results, thus suggesting that such a treatment should be taken into consideration for those patients who require an earlier return to daily activities or sport. Randomized Controlled Clinical Trial, Level 1.

Achilles tendinopathy Part 2: Surgical management

Although non-surgical management is the mainstay of treatment for non-insertional Achilles tendinopathy, many patients fail to respond to conservative measures. If symptoms persist after an extended period of conservative management, usually at least six months, surgery should be considered. Classically, open surgery was performed with excision of the diseased areas of the tendon. Due to a high rate of complications, as much as 10%, less invasive surgical techniques have been developed and are widely employed with good surgical outcomes and far fewer complications. The reported success rates of open and minimally invasive surgery are comparable and range from 46-100%. Considering the significant morbidity associated with open surgery, minimally invasive surgery is recommended as initial intervention, followed by open surgery if symptoms persist.

Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes

BackgroundAchilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy.AimTo assess whether excising...

Endoscopic surgery of the Achilles tendon

The value of endoscopic surgery as a minimally invasive treatment is well recognized and includes less perioperative pain, less scarring, minimal blood loss, and faster recovery. While open surgery on the Achilles tendon is notorious for wound complications, the tendon is situated in a well-formed tunnel allowing surgical procedures to be performed endoscopically. Various endoscopic techniques have been successfully applied to the treatment of non-insertional Achilles tendinopathy, Haglund's syndrome, Achilles tendon rupture, and equinus contracture. Although the evidence is currently limited, results from authors acquainted with the techniques have been encouraging. Both an understanding of surgical anatomy of the hindfoot and familiarity in soft tissue endoscopy are required to achieve successful outcomes while minimizing complications.

Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy

The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months. A consecutive series of 11 patients with a minimum of 2 years follow up. The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p=0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p=0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied. The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.

Topical Glyceryl Trinitrate and Noninsertional Achilles Tendinopathy

Background Topical glyceryl trinitrate (GTN) therapy has been advocated in the treatment of Achilles tendinopathy. The mechanism of action is unknown but may be related to modulation of local nitric oxide levels. Hypothesis Topical GTN therapy for noninsertional Achilles tendinopathy will significantly enhance clinical improvement and will be associated with increased collagen synthesis within the tendon. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Forty patients were recruited. Twenty underwent standard nonoperative physical therapy, and 20 underwent physical therapy and topical GTN daily. Clinical outcome was assessed using the Ankle Osteoarthritis Scale (AOS) visual analog score. Patients who failed to improve with conservative measures and who underwent surgical decompression had histological and immunohistochemical examination of samples from the Achilles tendon. Results Glyceryl trinitrate did not offer any additional clinical benefit over standard nonoperative treatment for noninsertional Achilles tendinopathy. After 6 months of treatment, there was no significant difference in scores between the groups for pain (3.0 vs 3.1, P = .42) or disability (2.15 vs 2.25, P = .38). Histological examination did not show any difference in neovascularization, collagen synthesis, or stimulated fibroblasts between the 2 groups. There was no evidence of modulation of nitric oxide synthase, a marker of nitric oxide production, in those tendons treated with GTN. Conclusion and Clinical Relevance This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperative therapy.

High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy

Background High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertions Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined. Hypothesis Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy. Study Design Case control study; Level of evidence, 3. Methods Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score. Results One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P < .001), 6.5 and 2.9 (P < .001), and 5.6 and 2.2 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P < .001), 17 and 9 (P < .001), 5 and 17 (P < .001), and 0 and 8 (P < .001), respectively. A χ2 analysis revealed that the percentage of patients with excellent (“1”) or good (“2”) Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P < .001). Conclusion Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.