Jake Pearson and Andrew Jones
Dr Jake Pearson, Sport and Exercise Physician
Capital Sports Medicine, Wellington
We all know how common Achilles tendinopathy is, particularly in our middle and older age running athletes, but also in the ‘out of shape’ often overweight individual who does a bit more than they’re used to or has an acute precipitating event. When I began my sports medicine specialist training in the mid-2000s, the Alfredson eccentric strengthening exercises seemed to be being applied universally, from my perspective with mixed outcomes. That was also when autologous blood injections were becoming popular, and I performed my research on this (a fairly poor quality RCT that was the forerunner to Kevin Bell’s much improved study on the same). I have maintained an interest in the management of this condition, and will outline my current approach here.
Confirm the diagnosis
My first point would be to be sure of what you are dealing with. I think many of my colleagues have had the experience of a so-called Achilles tendinopathy in fact being primarily related to posterior ankle impingement, a calcaneal bone stress injury, a lumbar disc causing nerve root irritation, or other less common pathologies. This is a mainly clinical diagnosis, and relying on imaging of the Achilles is complicated by the high rate of asymptomatic Achilles that look abnormal on ultrasound.
Load management – unsexy but pivotal
I am a fan of the Purdham-Cook continuum model of tendinopathy1 (although in practice I find the ‘dysrepair’ phase difficult to identify). I believe that having a conceptual basis is crucial to then frame the principles of treatment. Identifying the stage of tendinopathy is the first step, and in my clinic the most common presentation by far is the mixed reactive and degenerative type, ie, a subclinical tendinosis that becomes symptomatic from either overload or an acute event, and then becomes trapped in the ‘injury → failed healing response → reinjury’ loop. Related to this, determining the current load capacity tells me where we need to start. Someone who is getting pain with simple ADLs needs to be further offloaded, such as a relatively brief period of time in a moonboot or the use of heel raises, or simply to modify their weightbearing activity levels if this is practical. Some of course just need to be told to stop running for a decent period of time and work on a more controlled loading program. Educating patients on the realistic time frames for tendon recovery is useful early on. During the time of relative offloading some form of controlled strengthening is definitely preferable, usually in the form of isometric inner range holds (either double- or single-leg heel raise depending on pain levels) to build up muscle strength and provide low level tendon load. After about 4 weeks they are reassessed regarding whether they are ready to progress to some concentric exercises and then eventually a predominant eccentric and finally plyometric component. Of course throughout this time their tolerance for non-rehab weightbearing activities should be expected to progressively increase.
I often reflect that there is nothing ‘medical’ about this advice to date, but it seems that perhaps I have the benefit of spending the requisite time initially with the patient to go through this and then the authority of the specialist to perhaps underline and reinforce much of what they have been told prior to seeing me, usually with subsequent compliance.
Objective functional measures
It can be difficult for patients to remember what their condition was like 3+ months ago and thus what progress they have made. I therefore find it useful to have them complete a baseline VISA-A (Victorian Institute of Sport – Achilles2) questionnaire at their first appointment, and then at subsequent follow-up visits to allow tracking of an objective measure over time. They can do this in the waiting room so does not add to the consultation time. I acknowledge that the VISA-A has limitations, particularly for the less ‘dynamic’ patients, but some of the measures (e.g. duration of morning stiffness) are relevant across the board.
Mid vs insertional
I feel as if a bit too much is often made of the distinction between mid and insertional pathology. Of course I acknowledge the theory of entheseal compression and agree with avoidance of excessive loading in a stretched position, but that is how I treat the mid tendon early on as well. And with the Haglund’s deformities, these have usually been present and asymptomatic for years before presentation so again taking a load management approach initially seems appropriate, rather than referring everyone off to the surgeon straight away.
I have a low threshold for recommending the involvement of one of our local sports podiatrists if I feel that there is a significant biomechanical and/or footwear contribution to the patient’s presentation. If the patient’s time or resources preclude this then I can provide a rudimentary service but my preference is to engage the experts in the area. Of course evaluating the contribution of the kinetic chain and addressing any proximal weakness in particular is often helpful.
As I said above, I conducted some relatively early research on autologous blood injections, and reviewed the literature then on the range of so-called adjunctive treatments including the likes of other injectables, shock wave therapy, and nitrate patches. Since then of course PRP has come on the scene, and I have monitored the evidence (or lack thereof!) that has come out and not been impressed enough to jump onboard at this stage (this was used as the example of a literature search in by Ardern et al3). I appreciate that a number of my colleagues offer some of these options, and acknowledge that some patients are undoubtedly looking for something additional and that this meets this apparent need. Given that in my experience I have found that the short-term efficacy of such treatments seems to correlate positively with the enthusiasm and optimism of the person explaining and delivering it (and therefore the expectations of the patient), I feel as if I am not the best person to be offering it. While it is no longer common practice to inject corticosteroids into or around the Achilles tendon, it can sometimes be tempting to arrange an ultrasound-guided injection of a prominent retrocalcaneal bursa that appears to be contributing to an enthesopathy. Having had a patient rupture their Achilles 3 weeks after this I am now even more gun shy, even with the precaution of having the patient go into a moonboot for 2-3 weeks post-injection.
The curly ones
There remains ongoing debate about the potential role of plantaris compression, but from a pragmatic perspective if a patient is responding atypically to load management and imaging reveals a plantaris then I would have a lower threshold for obtaining a foot and ankle orthopaedic opinion. Sometimes adhesions without a plantaris present can present similarly and while brisement is not part of my current practice, perhaps it should be. I keep my radar on for presentations associated with systemic inflammatory or metabolic disease. It is fairly well recognised that the recently post-menopausal woman is at higher risk, and there also seems to be a difficult to quantify association with lipid metabolism but also confusingly statins in some patients.
And finally, I try to find some time in every consultation to initiate or reinforce a more general wellness concept, usually related to physical activity for those patients I feel would benefit from this. I see this a little like the smoking cessation approach (but in reverse) where a number of small nudges and encouragement over time is more likely to lead to eventual sustained behaviour change.
1 Cook JL & Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009; 43:409-16
2 Robinson J, Cook JL, Purdham C et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001; 35:335-41
3 Ardern CL, Dupont G, Impellizzeri FM, et al. Unravelling confusion in sports medicine and sports science practice: a systematic approach to using the best of research and practice-based evidence to make a quality decision. BJSM Online First 10.1136/bjsports-2016-097239
Andrew Jones, Sports Podiatrist
Waikato Podiatry Clinic, Hamilton
From a podiatry perspective, too, the Purdam Cook model is useful in clinical decision making. In addition, updated input from Ebony Rio recognises increasing inclusion of neural factors in different areas of tendinopathy management.
By the time I see tendinopathy clients they have often already been enrolled in an exercise regime. Frequently they have stopped the programme part way through.
In my 20 years of podiatry practice, the request for biomechanical input for achilles tendinopathy has reduced. This is undoubtedly associated with the newer information we have around the causative mechanisms of this sort of condition, and its aetiology being primarily biological. Nevertheless, it is important to assess whether there is a biomechanical component – and how large that component is – before discussing options with the client.
During my client consultation I reinstate and reinforce the need for a fundamental exercise base to be well established (and often reintroduced). The staging paradigm presents a good basis to help form this around. I see quite a few “acute on chronic injuries” of this type and patient education is very important to achieve successful resolution. I run through the basic pathophysiology of this condition with the patient so they have a good understanding of the benefit of the exercises and what we are trying to achieve.
A key point is to integrate plyometric exercises as a final step before full transition back into sports.
I have observed a big difference in responses between compression and mid-section achilles tendinopathy. The reduction of compression is a good adjunct to treating people with chronically painful insertional achilles tendinopathy. I find that heel raises are often better suited to this variation of the condition.
Footwear selection and footwear components are very important, typically including different pitch heights for rugby boots, cross training shoes etc. In decompressive loading for the compression retrocalcaneal insertional tendinopathies we use FS6 socks and integrate a small offloading device external to this, stitched into the sock (see figures). This prevents it from moving in the shoe and provides real-time relief where footwear compression can be a problem. We have found good results using this for retrocalcaneal contusions also.
In summary, while there are still biomechanical issues to be addressed in some cases, training loads and exercise regimes are the mainstays of treatment. How we educate our clients, to build their understanding, buy-in and follow through on their treatment regime, is vital.
Published in the New Zealand Journal of Sports Medicine 2018