Management

Although many treatment methods are offered to patients with painful tendons, most regimens based on conservative and operative treatments are without much scientific evidence to support these regimens (1).

Conservative therapy

• considered as the first option in most Achilles tendon disorders
• main aim is to identify and correct possible aetiological factors and to relieve symptoms
• treatment usually consists of a combination of the following:
  • rest
    • braces and immobilization with a cast or pneumatic walking boot are combined with modified activity
    • exacerbating factors are controlled by immobilising the patient during the acute stage (prolonged immobilization should be avoided)
  • medication
    • NSAIDs - although this is controversial since acute tendinopathy is actually a well-advanced chronic failure of healing response, anti inflammatory medication are still commonly used (2)
    • corticosteroids
      • have shown to reduce pain and swelling and improve the ultrasound appearance of the tendon
      • is a more aggressive treatment option and should only be undertaken by a specialist
      • the injection should be into the space between the tendon and the paratenon - not into the tendon itself (intratendinous injections are contraindicated) (3)
      • steroid injections should be used with care as scar formation is a recognised complication. Also there is an increased incidence of tendon rupture associated with steroid injections
      • peritendinous injections are most beneficial when used to relieve pain while undertaking exercise programmes (3)
  • orthotic treatment
    • heel lift, change of shoes, corrections of malalignments
  • stretching and strengthening exercises - once the acute stage has passed, stretching and strengthening exercises of the calf are more important. These include:
    • achilles tendon and plantar fascia stretch
    • wall push-ups or stretches for the Achilles tendon - when stretching the tendo-achilles, the stretch should be gently held for the count of 10-30 seconds, in groups of 5-10, four times per day (4). This is done with the knee straight and flexed, thus stretching all the muscular components of the tendo achilles
    • stair stretches for the Achilles tendon and plantar fascia (5)
  • eccentric exercises
    • a 12 week programme used when rest, NSAID's, change of shoes, orthoses, physical therapy and other ordinary training fail
    • the patient should complete the exercise protocol despite pain in the tendon and it does not involve concentric loading
    • is successful in around 90% of the patients with mid tendon pain and pathology
    • other eccentric exercise regimes e.g. - calf raises has not been proven to be as effective as Alfredson's heel-drop model (3,6)
  • other modalities
    • ultrasound
      • is a common prescribed program of physical therapy
      • there is insufficient evidence to support its clinical use
    • extracorporeal shockwave therapy (ESWT)
      • has been shown to promote the healing response
      • may be useful in patients with a poor initial response to eccentric loading exercises.
      • the most effective dose and duration of ESWT are still unknown
    • low level laser therapy
      • may be useful in patients who do not respond to the initial eccentric exercises (when added to eccentric exercise)
    • topical glyceryl trinitrate
      • can be used in addition to an eccentric exercise programme
      • applied as a patch
      • there is also evidence that topical glyceryl trinitrate significantly reduced pain with activity and at night, improved functional measures, and improved outcomes in patients with Achilles tendinopathy (6)
    • platelet-rich plasma (PRP) at the site of tendon injury
    • sclerosing agent (6,7,8)

Surgery

Noninsertional Achilles Tendinopathy

• aim of surgery is to resect degenerative tissue, stimulate tendon healing by means of controlled, low-grade trauma and/or augment the Achilles tendon with grafts
• usually carried out when conservative therapy is proved ineffective after 4 months
• operative methods include
  • percutaneous longitudinal tenotomise
  • minimally invasive tendon stripping
  • open tenosynovectomies
  • open debridement and tubularization
  • tendon augmentation with flexor hallucis longus (FHL).
• overall complication rate was 11% with complications such as wound necrosis, superficial infection, sural nerve injury, haematoma, seroma, and thrombosis while reoperation rate was 3% (6)

Insertional Achilles Tendinopathy

• a minimum of 3-6 months of conservative therapy should be carried out before considering surgery
• operative strategy include removal of the degenerative tendon and associated calcification, excision of the inflamed retrocalcaneal bursa, resection of the prominent posterior calcaneal prominence, reattachment of the insertion as required, and/or augmentation of the tendo-Achilles with a tendon transfer/graft (6)

Reference:

• (1) Paavola M et al. Current Concepts Review: Achilles Tendinopathy. The Journal of Bone and Joint Surgery (American)2002; 84:2062-2076
• (2) Maffulli N, Longo UG. Conservative management for tendinopathy: is there enough scientific evidence? Rheumatology (Oxford). 2008;47(4):390-1
• (3) Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41(4):211-6
• (4) Rheumatic Disease in Practice (September 2001). The therapeutic scope of modern podiatry. Issue number 6, Arthritis Research Campaign
• (5) Arthritis Research Campaign. Information and Exercise Sheet (HO2). Plantar fasciitis (Inflammation of the instep tendons)
• (6) Li HY, Hua YH.Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. Biomed Res Int. 2016;2016:6492597.
• (7) Paolonin JA et al. Topical glyceryl trinitrate treatment of chronic non-insertional achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 2004;86:916-22
• (8) Asplund CA, Best TM. Achilles tendon disorders. BMJ. 2013;346:f1262.