Achilles Tendinopathy

Introduction

Achilles tendinopathy with tear

Achilles tendinopathy (common overuse injury) refers to pathological changes affecting the Achilles tendon usually caused by overuse and chronic excessive pressure on the tendon. It can be found in both athletes and non-athletes. It may or may not be related to an Achilles tendon hear. Lack of flexibility or a stiff Achilles tendon can increase the risk of this injury.[1][2]

Surgical specimens show mild changes in the affected tissue e.g. muscle fiber structure and organization; glycosaminoglycans (water-binding molecules capable of holding up to 1000 times their own weight) which may explain the increased swelling of the tissue. [3][4] .

The exact cause of arthritis remains unclear. Even though Achilles tendon tendinitis is often associated with athletic activities, the disease is also commonly seen in non-athletic populations. The most common cause is overloading of the muscles. A light degeneration The Achilles tendon may be hidden but the pain only becomes apparent when the tendon is overloaded. It is also noted that the disease is usually not preceded by depression[5][6].

Terminology

Implantable Achilles tendinopathy with calcific enthesopathy

The current term recommended to describe this group of patients is ‘tendinopathy’. Cook and Purdum[7]proposed a new approach when approaching tendon pain and this is called the Tendon Continuum. The continuum model proposed a model for establishing tendinopathy based on the variable and disorganized distribution in the tissue. The three factors are as follows:

• Reactive tendinopathy
• Tendon dysrepair
• Degenerative tendinopathy

Tendons have been shown to be able to move up and down this continuum and this can be achieved by adding or removing load from the tendon especially in the early stages of tendinopathy.

Location

Achilles tendinopathy can be described as insertional or mid-section defect has localization. The implant is located at the transition point between the Achilles tendon and bone (<2 cm from the implant) the midline is located at the level of the tendon body (>2 cm from implant).[2]

Clinically Relevant Anatomy

The Achilles tendon is the largest and strongest tendon in the human body. The muscle has the ability to resist large tensile forces. It originates from the distal attachment of the gastrocnemius and soleus muscles and inserts into the base of the calcaneus.

A typical tissue structure consists of thin, spherical cells and an extracellular matrix. All extracellular processes are regulated by the endothelial cells (tenocytes and tenoblasts). In the matrix we find clusters of type I collagen and elastin. This type-I collagen is responsible for the elasticity of the muscles. Between collagen, a digested substance consisting of proteoglycans and glycosaminoglycans is formed. [8] .

Tendon structure

The Achilles tendon is surrounded by paratendinous tissue, which acts as an elastic sleeve around the tendon, allowing the tendon to move freely between the surrounding tissues. A paratenonous areolar structure composed of loose connective tissue is found around the extra-articular tendon without Synovial sheath (eg Achilles tendon). It supplies the tendon with blood from nearby vessels[9][10] Blood supply throughout the tendon is poor, with few vessels per cross-sectional area, especially above 4-6 cm. calcaneus. Poor vascularity may be a feature of slow healing after trauma [11] [12].

Aetiology

Reactive tendon is the first stage of the tendon continuum and is a non-inflammatory proliferative response in the cellular matrix. This is the result of compression or tension overload. Tendon strains during physical activity have been recognized as one of the greatest pathological stimuli, Systemic overloading of the Achilles tendon beyond physiological limits can result in microtrauma. Repetitive microtrauma associated with uneven tension between the gastrocnemius and soleus leads to friction between fibers and abnormal load concentration Achilles tendon. This can have consequences such as degeneration and inflammation of the tendon sheath or both. Without minimal recovery time, this can lead to tendinopathy [13].

Reduced arterial blood flow, regional hypoxia, decreased metabolic activity, nutrition, and persistent inflammatory response have been considered as possible factors that may contribute to chronic tendon overuse injury and tendon degeneration.

Foot pronation

One of the most common and possibly most important misalignments is the ankle caused by excessive pronation of the foot. Increased foot pronation has been proposed to be associated with Achilles tendinopathy.

1. In acute trauma, external factors predominate, whereas injuries from overuse are often multifactorial. The acute phase of Achilles tendinopathy is caused by acute overload blunt trauma or acute muscle fatigue and is characterized by an inflammatory response and edema formation. if Treatment in the acute phase fails, or if they neglect it, it leads to fibrin and tendon adhesions.
2. Reactive tendinopathy may progress to tendon disrepair if the tendon is not unloaded and allowed to return to its normal state. During this phase, protein production continues to increase, which has been shown to lead to collagen and Disintegration within the cell matrix. Like the first stage, this is an attempt at tendon healing, but with greater physiological involvement and disruption.
3. Degenerative tendinopathy is the final stage of the continuum, indicating that the tendon has a poor prognosis at this stage and that the changes are now irreversible. Tendon degeneration is often found in combination with peritendon adhesions, but this does not imply a condition lead to another.

Recent research also shows

1. Older men with fat mass ratio and waist circumference >83 cm are associated with higher odds of Achilles tendinopathy [14][15].
2. The presence of a COL5A1 gene variant was also found to be a possible risk factor. This gene is normally responsible for tenascin production, but patients with this disorder have a significantly different frequency of the COL5A1 BstUI RFLP allele compared to normal individuals Subject[16][17][18][19]
3. Individuals with chronic Achilles tendinopathy show signs of peripheral and central sensitivity to pain. [20] Physiotherapy management of chronic Achilles tendinopathy should consider this in the interventions used to treat chronic Achilles tendinopathy.

Summary Overuse Poor circulation Lack of elasticity Sex Endocrine or metabolic influences can lead to tendinopathy. The structure of the tendon is disrupted by this repetitive strain (usually eccentric) and the collagen fibers begin to slide past each other, disrupting their structure Crosslinks and causes tissue degeneration leading to inflammation. This cumulative microtrauma is thought to impair collagen crosslinks and affect the noncollagenous matrix and vascular components of the tendon, ultimately leading to tendinopathy. [6]

Risk factors

There are known risk factors associated with Achilles tendinopathy. a few of these risks include:

• Obesity
• High blood pressure
• Rapid changed to load
• Type II Diabetes
• Prolonged steroid use
• Family history of tendinopathy
• Other factors include inappropriate footwear and older people.

Clinical Presentation

Morning pain is a prominent symptom because the Achilles tendon must withstand all movement including immediate stretching upon awakening in the morning. Symptoms are usually located in the veins and immediately surrounding areas.

Nausea and pain are rare. It appears that the muscle can undergo subtle changes in shape that become more pronounced in the A-P and M-L planes.[21]

In someone with Achilles tendinopathy, which has a sensitive area with swelling within the tendon that moves with the tendon, the sensitivity increases or decreases when the tendon is stressed, which would be of high predictive value There are cases of tendon degeneration. [22] The affected side of the tendon displayed a larger diameter, higher stiffness, and lower strain than the unaffected side.

Differential Diagnosis

• Plantar fasciitis
• Calcaneal fracture stress
• Heel pad syndrome (deep bruising and pain in the center of the heel)
• Haglund deformity – this is a distinctive feature of the calcaneus that can cause bursitis between the calcaneus and the Achilles tendon
• Sever’s Disease – An external inflammation of the calcaneus on the growth plate. It occurs primarily in young children and adolescents during adolescence and the growth spurt.
• Posterior Ankle Impingement
• Medial Tendinopathy
• Retrocalcaneal Bursitis
• Sural Nerve
• Lumbar Radiculopathy
• Ankle OA
• Deep vein thrombosis
• Achilles Tendon Rupture. [21] .

Examination

Subjective Assessment: It is important to provide clues about the mechanism of injury and the history of the condition. Physicians can use a gradual onset of pain near Achilles tendon insertion and self-report of pain to palpation to diagnose the Achilles I’m big in yare[23].

Objective assessment: Careful assessment of the lower limb is essential. Examination of the hip and knee will reveal biomechanical support and muscle imbalance. In foot and ankle we are looking for more local supplements and results:

• See: look for muscle atrophy swelling asymmetry joint effusions and erythema. Atrophy is an important determinant of the duration of tendinopathy and is common in relation to chronic conditions. Irregular swelling and erythema in pathologic tendons are frequently observed during the examination. Joint effusions are rare with tendinopathy and suggest possible intra-articular pathology.
• Range of motion testing for strength and flexibility: usually limited to the tendinopathy side [24][22].
• Palpation: Tends to elicit well-localized tenderness similar in quality and location to pain experienced during activity [25] Palpation usually reveals palpable nodules and thickening.
• Anatomical deformities such as flat feet or pronation with excessive foreheel inversion should be given particular attention. These anatomical deformities are often associated with this problem [5][26]
• The positive arc sign and positive result [23] of the Royal London Hospital test is shown in the 30 second video below.

[

Clinicians should use physical fitness measures, including jumping and heel lift endurance tests, as appropriate, to assess the patient’s functional status and document findings.

When assessing physical impairment during a single care of a patient with Achilles tendinopathy, ankle dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain on palpation should be measured [23]

Imaging: Not necessary for the diagnosis of Achilles tendinitis, but may be helpful in the differential diagnosis. Ultrasound is the preferred imaging modality as it can clearly indicate changes in tendon width, water content and collagen integrity within the tendon, and The bursa of Fabricius is swollen. If the diagnosis is unclear or symptoms are atypical, an MRI may be needed. MRI may show increased signal within the Achilles tendon. [21] evaluated the Achilles tendon (mechanical structure and biomechanical Features) relatively young in vivo. Ultrasound elastography and ultrahigh-field magnetic resonance imaging (MRI UHF) have recently emerged as potentially powerful techniques for examining tendon tissue. [29]

Outcome Measures

Patient-reported outcome measures such as:

• Global measures of lower nerve function: e.g. Lower Extremity Functional Scale (LEFS) ‐ not specific for Achilles tendinopathy
• A detailed questionnaire specific to Achilles tendinopathy e.g. the VISA‐A questionnaire.[21][30]

Patient-specific functional outcome measures such as:

• How much weight can be placed on the foot on a weighing scale before pain begins
• Increased hip count before the onset of pain
• Femoral volume decreases before pain begins
• The number of hips drops with a certain amount of weight in a backpack before the pain starts
• How far can the patient walk or run before the pain starts

It was recently suggested that clinicians should use the Victorian Institute of Sport Assessment-Achilles (VISA-A) to assess pain and stiffness and use either the Foot and Ankle Ability Measure (FAAM) or the Lower Extremity Functional Scale (LEFS) [ 10 ]. monitor activity and patients with a diagnosis of Achilles tendinopathy.[23]

Physiotherapy Management

Management of tendinopathy

It is best to educate your patients on activity modification and counsel them accordingly. For patients with mild Achilles tendinopathy, physicians should advise that it does not mean complete rest and should continue their recreational activity within their pain tolerance when engaged in preparation. Clinicians may counsel patients with Achilles tendinopathy. Key components of patient counseling may include[23];

• Theories supporting exercise use and the role of portable devices
• Modifiable risk factors including body weight and shoe wear
• A common time to recover from symptoms.

The Achilles Tendinopathy Toolkit is an evidence-based clinical decision aid to assist clinicians in their management of Achilles tendinopathy. Check out the infographic below.

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Optimize Biomechanics

Individuals presenting with Achilles tendinopathy should undergo a thorough biomechanical evaluation. BC Physical Therapy Tendinopathy Task[31] Force suggests that there is limited clinical evidence to support the use of orthotics in the acute stage and moderate clinical evidence to suggest that supports the use of injections on the chronic. Clinically consider using orthotics perhaps with taping first priority in the acute stage; consider the use of stimulants during the chronic phase.

Controlled Tendon Loading

Less load-bearing activities should be encouraged in order to decrease the load on the tendon but absolute muscle strain should be avoided as it may lead to weakness[32][5] BC Physical Therapy Tendinopathy Task Force[31] notes that there is a number of clinical evidence supporting that exercises in the chronic phase but the specific criteria for efficacy are unclear. Eccentric exercises are primarily supported although some protocols use both concentric and eccentric exercises. One RCT showed that slow weight resistance training is surprisingly effective training.

Externally stimulated and activity-related strength training has been shown not only to help reduce muscle soreness but also to alter the excitatory and inhibitory control of the muscle and thus muscle loading can occur work A popular and effective method is phenomenal strength training.[5] Over the last decade, eccentric exercises have been shown to have a positive effect on Achilles tendinopathy and became the main non-surgical treatment of choice for Achilles tendinopathy[34].

There is no conclusive evidence as to which exercise program is most effective.

1. A recent systematic review concluded that there is little clinical and technical evidence to support the use of the eccentric component and compared that well-designed research on loading systems is largely absent [34].
2. New load-based exercise regimes such as isolated concentric exercise heavy slow resistance training (HSR) and eccentric-concentric have recently been proposed but lack strong scientific evidence of effectiveness in Achilles tendinopathy

Complete guidelines for the management of Achilles tendinopathy are detailed in the Achilles Tendinopathy Toolkit.

The primary goal in the treatment of tendinopathy is to improve the strength reserve of the tendon. It is the ability of the muscles and associated muscles to regulate load which acts primarily as a ‘spring’ in storing and then releasing energy. Three basic exercises for the Achilles tendinopathy ne:

1. Isometric Loading
2. Isotonic Loading
3. Energy Storage Loading. [36]

Achilles Tendinopathy Toolkit: Part D – Exercise Programs is a great place to find an exercise-appropriate program

Part 1: Isometric Loading- Holding Achilles tendon

The management of Achilles tendon pain has changed dramatically in recent years. One major change was the emergence of isometric tendon loading as a mainstay of tendinopathy treatment. Isometric tendon loading has been found to have a pain relief effect while simultaneously maintaining some strength dependence. These can be done with either two feet or one foot depending on the symptoms and offending muscles. For more irritated (active) Achilles tendons, bipedal holds can be performed usually for a short time followed by several repetitions. The isometric holding position can whether medial or terminal (ie, just above the toe or halfway up).

[37]

Phase 2: Isotonic Loading- Calf raises

This exercise is usually started when the athlete’s pain level and muscle irritability have decreased. There is no ‘hard and fast’ rule for when to start an athlete on isotonic loading to correct Achilles tendinopathy. Completed isotonic loading is initiated when they have achieved a pain rating of less than 5/10 on the NRS or tolerable and acceptable pain on repeated single leg lifts and their morning stiffness has significantly decreased.

The primary goal of isotonic exercise is to strengthen the muscles and surrounding muscles. For the Achilles tendon, the strength of the soleus and gastrocnemius muscles play an important role. Load recovery such as during walking or running does not result in sufficient flexibility in the nervous system or the capacity of the nerve-nerve system. Heavy loads are therefore important with the isotonic loading exercises.

• Isotonic seated calf raises can be performed with gradual increases in loading. Perform each set of 3-6 seconds in length to create tension in the muscles.

[38]

• Isotonic standing calf raises should be performed in the middle of muscle movement. The advantage of doing Heavy slow resistance (HSR) exercises in the middle is that it avoids the muscles at the end of the range that can occur during heavy exercises loads of loads. For example in eventual ankle plantarflexion (toe pointing) or dorsiflexion (think of dropping the hip off the edge of a step), the Achilles tendon imposes a load on the heel bone (calcaneum) that it can anger and which causes pain.

[39]

Part 3: Strength Conservation Loads- Plyometric Exercises

The last important preparatory step is the initiation and execution of ‘energy conservation’ muscle exercises. These exercises include modifying the muscles through jumping and squatting based exercises. This exercise helps the muscles regain their ability to contract and then release strength through the cycle of extension that occurs when an athlete lands and then pushes while squatting.

This exercise can be initiated when the athlete is reporting a minimal or significant decrease in morning stiffness in the Achilles tendon upon awakening. Again other criteria for starting an athlete on this exercise are: when the athlete has progressed well with isotonic calf lifting exercises at a relatively mild gentleness when the Achilles tendon is palpated and has been able to withstand light running without muscle irritation and severe symptoms.

For example longer periods of increased tension during heavy slow resistance training can increase the strain on the muscles and cause greater flexibility but increased speed is going to be noticeable great to improve power and prepare for sporting activities involving Stretch Shortening Cycle.

Exercises outlined is as follows:

• Double-leg hop
• Single leg hop
• Single leg step hops
• Hopscotch with activation band

[40]

Adjunct Therapies

When combined with strategies to optimize biomechanics and prescribe exercise therapy, other therapies can be used. These treatments often fail to repair or prevent injury they are mostly used to manage symptoms.

Manual Therapy

There is no clinical evidence but there is expert level opinion to support the use of joint mobilization in the acute stage if the examination reveals joint restriction. There is limited evidence of significant clinical and expert level opinion supporting joint manipulation mobilizations in the chronic stage if the examination reveals joint restriction[31] He may consider the use of manual therapy after a comprehensive hip knee foot and hip examination reveals joint dysfunction. Ankle mobilizations can be used for dorsiflexion limitation of the talocrural joint and varus- or valgus limitation of the subtalar joint [41][5].

The efficacy of deep cross frictions has not been scientifically proven and results are limited[24][42][43] There is limited clinical evidence to support the use of soft tissue techniques such as frictions in the chronic period. We may wonder how to test soft tissue methods such as frictions during the chronic period[31].

Electrotherapy Modalities

There is conflicting evidence supporting the use of Extracorporeal Shock Wave Therapy (ESWT) in the chronic setting. There is evidence that the results depend on the amount of shock wave exposure (EFD ‐ energy flux density = mJ/mm2) rather than on the nature of the shock wave generation (focused vs. radial ESWT). There is also evidence that the use of anesthetics required in high intensity protocols reduces the effectiveness of ESWT. Low-intensity ESWT protocols that do not require anesthesia are therefore recommended as being more beneficial tolerable and simpler expensive with the same results. Low-energy ESWT protocols can be used for both focused and radial ESWT. Consider trying ESWT in the chronic phase especially if other interventions have failed the following criteria:

• Low Energy SWT: EFD = 0.18 – 0.3 mJ/mm2 (2‑4 Bars) .
• 2000‐3000 shocks
• 15‐30 Hz
• 3‐5 sessions, weekly intervals.

There is no clinical evidence for the use of Ultrasound and Low-Level Laser Therapy.

Iontophoresis

There is limited evidence to support the use of iontophoresis with dexamethasone in the acute but not the chronic setting. The role of iontophoresis is still under investigation. May be considered in the acute stage as a test of iontophoresis 0.4% dexamethasone (water) 80 mA‐min; 6 sessions in 3 weeks. A program of concentric‐eccentric exercise in combination with iontophoresis should be continued if exercise load is tolerated.

Taping

Antipronation taping is supported by expert opinion and not clinical evidence. He may consider using taping perhaps before Introduction to Orthotics in the acute stage[31]. Physicians should not use thick medical tape to reduce pain or improve function in patients with Achilles weak tendinopathy. Physicians may use dynamic taping to reduce pressure on the Achilles tendon and/or change foot position in patients with Achilles tendinitis.[23]

Night Splints

There is expert opinion to

• Support the use of night splints and braces in the acute stage
• Relevant evidence against the use of night splints and braces in the chronic condition.

Consider a trial of night splints and braces in the acute stage but DO NOT use night splints and braces in chronic period in conjunction with exercise[31].

Dry Needling

Practitioners may use a combination of dry needling and injection under ultrasound guidance and elaborate exercises to reduce pain for individuals with symptoms greater than 3 months and increased muscle mass.[23 ]

Medical Management

Medication

Inflammation is necessary to initiate restoration in the damaged tissue but the use of certain drugs such as corticosteroids and quinolones inhibits inflammation and consequently remodeling as well. Even if the patient is not taking this medication, tendinopathy is also a the result of a defective restoration system[44].

Corticosteroid Injections

Corticosteroid injection (CSI) appears to have a short-term analgesic effect but no effect or adverse long-term effects. Transient effects of CSI have been demonstrated in the Achilles tendon with improvement in gait and reduction in tendon size as measured by ultrasonography. Intratendinous injection is contraindicated due to catabolic effects although a recent study of CSI in intratendinous vessels in six tendons has shown promising results. Peritendinous injection has minimal effects on the nerve and may be a useful adjunct to the proposed treatment the program of the. CSI can be very useful when used for pain relief while continuing an exercise program[45].

Sclerosering Injections

The role of neovascularization in neuropathic pain has also been examined in a pilot study in which a vascular sclerosant (Polidocanol-an aliphatic non‐ionized nitrogen‐free substance with a sclerosing and anesthetic effect) was applied to the site of neovascularization anterior to the artery the face of the. A A short-term (6-month) study of this treatment showed that a clear majority were pain-free after two treatments. The painless muscles had no other muscles externally or internally. A 2-year follow-up of these patients showed the same eight patients remained painless with no nerve fibers. Ultrasonographically the tendon thickness was reduced and the structure appeared rather normal [45].

Rehabilitation after sclerosing injection is 1 – 3 days rest; then tendon-loading activity gradually increases avoiding maximum loading. After 2 weeks tendon loading activities (jumping fast runs heaving strength training) are allowed. This study suggests a medical role for sclerosing treatment for those unable to respond to eccentric exercise[45].

Platelet-Rich Plasma Injections

Studies show that Platelet-Rich Plasma (PRP) injections in people with chronic Achilles Tendinopathy over a period of 3 months have no beneficial effects compared to placebo (saline). The only significant effect of PRP injection compared to placebo was the change in tissue thickness: this contrast shows that PRP injections can increase tissue volume compared to saline injections[45].

Minimal Invasive Procedures

According to a recent study, Minimal invasive procedure treats insertional Achilles tendinopathy which is a common and chronic musculoskeletal disorder in which patients experience pain in the Achilles tendon.[46] The chronic degenerative condition is often painful for push-up athletes such as basketball and football players. The key-hole procedure, known as a percutaneous Zadek osteotomy (ZO), can significantly reduce pain and provide significant pain relief at six weeks after this procedure compared with 23 weeks for open surgery repeated after ritual ho.

The short recovery period involves protecting the foot in a cast or walking boot for 2 weeks then resuming weight bearing while wearing removable walking boots for another 4 weeks. Exercise also begins two weeks after surgery. Athletes are allowed to return to shoes after 6 weeks of. outpatient treatment.[46]

Operative Surgery

The goal of surgery to treat rheumatoid arthritis is to irritate the nerves to initiate a chemical reaction. Surgery can include simple percutaneous tenotomy open procedures and removal of the infected portion of the nerve. In 75% of cases, people who underwent tenotomy experienced good results after 18 months. An open Achilles tendon resulted in a successful scar-free nerve outcome[45].