Concepts in Achilles Tendinopathy Treatment
There is a difference between the different types of Achilles pain. They differ in location between posterior heel pain at the back of the foot (insertional tendinopathy) which is pain at the rear of the foot where the tendon inserts, and pain in the tendon itself(non-insertional tendinopathy) located at the back of the leg.
Patients with non-insertional tendinosis will usually present with a bump in the tendon itself. .These patients will describe it as a sprain, overdoing it or jumping back into strenuous activity without easing into it.
insertional heel pain, the patient will usually have pain in the back and this can be due to shoe gear. This pain is aggravated by physical activity. The pain can be present after activity and those in the later stages will not be able to tolerate sporting activity.
for both conditions include:
-Inflammation of PT/Plantaris tendon
-Exertional compartment syndrome
-Rheumatological conditions (Arthritis, Reiters, Seronegative arthropathy)
Histologically is if one looks at the Achilles tendon. We see both inflammation and structural changes. Those in the later stages will see mostly structural changes. Studies have shown that 90 percent of biopsies were positive for abnormal fiber structures, increased vascularity, and increased presence of fibrinogen/adhesions.
The initial treatment plan for this type of tendinopathy is rest and activity modification. This allows not only for the tendon to heal but also helps to decrease the inflammation in the area. This is done by placing the patient in a cam walker boot with a heel lift. This can last up to two weeks. Anti-inflammatory (NSAIDs) are used as adjunctive therapy for pain and inflammation.
Of Course, the main goal is long term pain relief. This then focuses on physical therapy with a concentration on eccentric exercises rather than concentric exercises. A randomized study was done comparing eccentric and concentric exercises. After the 12 week program, 82 percent in the eccentric group return to normal activity as compared to only 36 percent in the concentric group.
Insertional Achilles Tendinopathy
An initial treatment plan is similar to noninsertional. First focusing on decreasing inflammation and pain. This again is accomplished with decreased activity, Cam walker boot, heel lift, and NSAIDs.
Now for long term relief, we have to address the biomechanical issues. Orthotic therapy can help by correcting the excessive eversion and pronation at the rearfoot. Equinus (tight Achilles tendon) is often the cause of this problem. Eccentric stretching does not provide the same benefits as it does with non-insertional Achilles issues. Instead, a stretching regime showed an 88 percent success rate in return to activity.
This is a powerful tool used by many health care professionals. Shockwave therapy work by delivering high energy sound waves to the damaged tissue. This not only helps with breaking down damaged tissue but also helps with healing by bringing new blood flow and growth factors. This non-invasive measure should be attempted by all practitioners before going down the surgical approach. Multiple studies have shown great efficacy with the use of shockwave therapy. Please read the blog on shockwave therapy to learn more on how it works.
This is a controversial topic like the use of this can lead to tendon rupture. This treatment modality is reserved for patients who for whatever reason have exhausted all conservative treatment and can’t undergo surgery. In these cases, a small amount may be used but the patient has to be placed in a cam walker boot to prevent rupture.
Once all conservative measures have been failed, surgical approach is the next treatment modality. Just like conservative, there is a difference in approaches for treatment of insertional and non-insertional Achilles tendinopathy.
The repair mainly focuses on the debridement of all degenerative portions of the tendon. This not only gets rid of the inflamed and damaged portion of the tendon but also causes vascular ingrowth speeding up the healing process.
The surgeon will then assess the quality of the remaining tendon. If greater than 50 percent of the tendon has been resected then the tendon will need to be augmented with a tendon transfer. This is usually done by harvesting Flexor hallucis longus tendon.
Success rates of 75 to 100 percent have been reported in the literature.
Another procedure that is now being favored is Gastroc lengthening by cutting the fascia just distal to the junction of the 3 calf muscles bellies.
Non-insertional surgical repair focuses on debridement of all tendinosis or non-viable tendons. Authors believe this debridement initiates vascular ingrowth and healing response.
Surgical intervention will usually involve the removal of the calcaneal bone spur and the inflamed retrocalcaneal bursa. The surgeon depending on the quality and the amount of calcification may or may not detach/reattach the Achilles tendon to the calcaneus. The tendon may be reattached using anchors that tie the tendon down to the bone.
Minimal incision approach:
Minimal incision has been gaining popularity in the literature with good results. The minimal incision approach is done through a small 2-4 mm incision on either side of the tendon just proximal to its insertion. Through this incision, the calcaneal spur can be shaved down using specialized burrs along with the removal of the retrocalcaneal bursa. This again requires surgeons who have been trained in this technique. Initial data shows promising results. An Arthroscopy technique can be employed to get direct visualization during the spur and bursa removal.
For both non-insertional and insertional repairs. The trend has been that of early weight-bearing and mobilization. This not only helps patients get a range of motion back but also allows for faster healing. Physical therapy must be employed to help with patient recovery.
For most procedures patients are placed in a cam walker boot with a heel lift for up to 2 weeks while being weight-bearing. Then the heel lift is taken out and patients are allowed to weightbear in the cam walker for 4 weeks. Patients are then transferred to physical therapy for rehab and range of motion exercises. Patients will eventually transition to regular shoe gear from 5-6 weeks range.
Return to activity/sports is different for each patient and must be eased into after the 6 weeks mark. But can take up to 2 months before regaining strength and mobility.