Achilles Tendinopathy

According to Maffulli et al. (1) Achilles tendinopathy is a clinical syndrome characterized by pain, swelling and functional impairment in the Achilles tendon. Classically the term “Tendinosis” has been used systematically (referring to a degenerative non-inflammatory condition) however the anatomical disposition of the tendon fibres are not always responsible for the pain since up to 34% asymptomatic tendons show abnormal modifications or alterations on the tendon fibres. (2)

Despite its strength, the Achilles is one of the most frequently injured tendons in the body. Along with the patella tendon is the most common ruptured tendon(3) and it is one of the two tendons most frequently impaired as a result of overuse for both athletic and non-athletic population. (4) It is reported that the middle-aged population are the most frequently affected (30 – 55 years old) (5)
Patients who suffer from Achilles tendinopathy usually complain of pain during initial loading or after prolonged activity. If the condition becomes chronic, the pain can be persistent. (6) As mention before, overuse or micro-traumatism is the most common trigger, however there are a number of intrinsic risk factors associated such as increased body weight, age, certain systemic diseases (such as Diabetes mellitus, thyroid disorders, renal diseases, rheumatoid arthritis, gout, among others) muscle strength, flexibility, previous injuries, blood supply, foot and ankle misalignments, such as flat foot, pronation or supination. (2,3,6)

However, “Achilles tendinopathy” is a too broad term and not a diagnosis itself. It is necessary to make differentiation according to the level or portion of tendon affected(7):

• a) Paratendinopathy: The inflammation of a connective tissue sleeve which surrounds the tendon and protects it from friction, irritation, and repeated trauma
• b) Insertional: Eminently overuse-injury which frequently occurs in running and jumping athletes. Patients affected by insertional Achilles tendinopathy complain of pain on the posterior aspect of the heel and may have morning stiffness, swelling with activity and tenderness at the tendon insertion level (7). If this condition becomes chronic, calcific deposits at the Achilles insertional level may be developed (due to microfractures and healing of the osteotendinous union) which can degenerate, if it persists over time, in the abnormal bony prominence on the posterior aspect of heel, condition known as Haglund deformity (8), which can be painful and difficult close-shoes fitting due to friction and irritation.
• a) Mid-portion: Occurs approximately 2 – 7 cm proximal from the Achilles insertion into the calcaneus (9). Characterized by a combination of pain and swelling at this level. It has associated a remarkable impaired performance.

Initial treatment options are always going to focus on conservative management such as manual therapy (Stretching, eccentric exercises, etc.), cryotherapy (ice applied on painful areas if inflammation is present), NSAIDs, Low-level laser, Taping, Night splints. Several studies have shown benefits of Extracorporeal shockwave in Achilles tendinopathy. (10,11)
Foot posture plays an important role since certain foot and ankle conditions may have a direct impact on the Achilles tendinopathy such as flat feet, pronated or supinated foot. In this case to compensate this foot and ankle misalignments are essential regardless conservative or non-conservative treatment is carried out.

The use of regenerative medicinetreatments on musculoskeletal conditions has become widespread nowadays in fields like Podiatry, Orthopaedics, and sports medicine and Achilles tendinopathy is one of the frequent conditions treated with this interventional non-operative technique. Specific studies have shown promising positive results using PRP (Platelet-rich plasma) on this condition (12–14). The theory behind this treatment is to enhance natural self-healing through the concentration and delivery of certain bioactive agents responsible for the healing process. This adjuvant treatment modality is compatible with other conservative treatments.

As part of our philosophy, surgical interventions are reserved for those cases where conservative approaches have failed or haven’t provided enough relief regarding pain and disability. There are some different surgical techniques, and every case should be evaluated individually. Available surgical options are open debridement (recommended for those cases where abnormal tissue and fibrotic adhesions are present (15), percutaneous tenotomies (usually guided by ultrasound) minimally invasive tendon stripping, endoscopic debridement, Plantaris tendon release, gastrocnemius recession, etc.

If you suffer from Achilles tendinopathy, here at Emirates Integra, we can guide you into the adequate treatment choice through our multidisciplinary team approach.

References

1. van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee Surgery, Sport Traumatol Arthrosc. 2011;
2. van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: Why painful? An evidence-based philosophy. Knee Surgery, Sport Traumatol Arthrosc. 2011;
3. Wren TAL, Yerby SA, Beaupré GS, Carter DR. Mechanical properties of the human achilles tendon. Clin Biomech. 2001;
4. Jozsa L, Kannus P. Overuse injuries of tendons. In: Jo´ zsa L, Kannus P, eds. In: Human tendons: anatomy physiology and pathology. 1997.
5. JL C, KM K, Purdam C, J.L. C, K.M. K, C. P, et al. Achilles tendinopathy. Man Ther. 2002;
6. Magnan B, Bondi M, Pierantoni S, Samaila E. The pathogenesis of Achilles tendinopathy: A systematic review. Foot Ankle Surg [Internet]. 2014;20(3):154–9. Available from: http://dx.doi.org/10.1016/j.fas.2014.02.010
7. Weinfeld SB. Achilles tendon disorders. Medical Clinics of North America. 2014.
8. Sundararajan PP, Wilde TS. Radiographic, clinical, and magnetic resonance imaging analysis of insertional Achilles tendinopathy. J Foot Ankle Surg. 2014;
9. Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: A systematic review. Knee Surgery, Sport Traumatol Arthrosc. 2013;21(6):1345–55.
10. Furia JP. High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy. Am J Sports Med. 2008;
11. Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int. 2013;
12. Di Matteo B, Filardo G, Kon E, Marcacci M. Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy—a systematic review. Musculoskeletal Surgery. 2015.
13. de Jonge S, de Vos RJ, Weir A, van Schie HTM, Bierma-zeinstra SMA, Verhaar JAN, et al. One-year Follow-up of Platelet-Rich Plasma Treatment in Chronic Achilles Tendinopathy: A Double-Blind Randomized Placebo-Controlled Trial. Am J Sports Med. 2011;
14. Gaweda K, Tarczynska M, Krzyzanowski W. Treatment of achilles tendinopathy with platelet-rich plasma. Int J Sports Med. 2010;
15. J. L, J. K, A. G, J. P, S. O. Surgical treatment of overuse injuries to the Achilles tendon. Clin J Sport Med. 1994;