Achilles Tendinopathy

Achilles Tendinopathy2018-02-20T12:32:18-05:00

The problem with Achilles Tendinopathy

achilles-pdf-1-web Approximately 50% of people, mostly runners and jumpers, will experience Achilles Tendinopathy during their lifetime. Though many runners and jumpers experience Achilles Tendinopathy, not all of those who are affected live an active lifestyle. About 33% of those affected by Achilles Tendinopathy report living a sedentary lifestyle. Those who have Achilles Tendinopathy experience pain, stiffness, and loss of function with daily and recreational activities. Originally, this condition was thought to involve inflammation but recent evidence shows that it has to do with the presence of degenerative tendinopathy. Remodeling and healing the achilles tendon has shown to be helpful along with appropriate loading in exercise.

Achilles Tendinopathy Interventions

In order to determine the source of the symptoms and figure out what exactly has caused the achilles tendon to become overloaded, it is important to conduct a physical therapy exam. Common physical therapy interventions include manual therapy (spinal/extremity joint mobilization/manipulation, soft tissue interventions (such as dry needling), education, and exercise. These interventions are implemented in order to help reduce load on the tendon to allow for adaptation and healing. Gradually the interventions will include increasing the load on the tendon to prepare for returning to normal activity levels.

Alfredson et al. initially showed the positive effects of eccentric loading on pain and disability with recreational athletes. All of the athletes who practiced eccentric loading through a 12-week program of strengthening were able to return to the same levels of activity they had prior to their injuries.

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Evidence

Systematic reviews of the medical evidence report strong support for using Alfredson et al.’s eccentric loading program, but further studies show success with other loading programs. These loading programs have documented histological changes in the tendon consistent with remodeling and healing including increased stiffness, decreased thickness, and increased Type I collagen formation. These changes suggest the tendon is plastic and able to adapt to imposed loads through exercise. Physical therapy was also superior to a corticosteroid injection for treatment of Achilles Tendinopathy. Authors noted a 43% recurrence rate in the steroid group compared to a 16% rate in the PT group at long term follow up.

Refer

In order to clinically diagnose Achilles Tendinopathy, research suggests identifying presence of pain on palpation of the Achilles tendon, location of pain 2-6cm above the tendon insertion, and pain during heel raise testing. Patients who report ankle pain which limits daily and recreational activities should be referred to a physical therapist. The physical therapy should include a manual therapy and ankle strengthening program.

References

  1. Kvist M. Achilles-tendon injuries in athletes. Ann Chir Gynaecol 1991; 80: 188–201.
  2. Kingma JJ, de Knikker R, Wittink HM et al. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007; 41: e3.
  3. Roos EM, Engstrom M, Lagerquist A et al. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up. Scan J Med Sci Sports 2004; 14: 286–95.
  4. Rees JD, Lichtwark GA, Wolman RL et al. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology 2008; 47: 1493–97.
  5. Bohm, S. et al. Human Achilles tendon plasticity in response to cyclic strain effect of rate of duration. J Experimental Biology. 2014. 4010-4017.
  6. Ohberg, L. et al. Eccentric training in patients with chronic Achilles tendinosis: normalized tendon structure and decreased thickness at follow up. Br J Sp Med. 2004. 38:8-11.
  7. Alfredson, H. et al. Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinopathy. Am J Sp Med. 1998.
  8. Habets, B et al. Eccentric exercise training in chronic mid portion tendinopathy: A systematic review on different protocols. Scand J Med Sci Sports. 2015. 25:3-15.
  9. Malliaras, P. Achilles and Patellar Tendinopathy Loading Programs. A systematic review. Sports Med. 2013. 43:267-286.
  10. Stevens M. et al. Effectiveness of the Alfredson protocol compared with a lower repetition- volume protocol for mid-portion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014;44:45-57.
  11. Hutchinson, A. et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013. 19:112-117.
  12. Cantin D. et al. Corticosteroid injections and the treatment of Achilles tendonitis: A narrative review. Research in Sports Medicine. 2003. 11(2)79-97.