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Achilles tendinopathy

Achilles tendinopathy  is a clinical syndrome characterized by three elements , pain , swelling and functional impairment , corresponding to the histological pattern of ” tendinosis ” , a term that indicates a degenerative non- inflammatory process with a disorganized collagen structure ( Maffuli et al ) Achilles tendon is the most frequently injured tendon in the human body Common problem- prevalent in athletes involved in running sport
also common among athletes in racquet sports , volleyball , soccer ,dancers , gymnasts Incidence has risen in last 3 decades – greater participation in recreational and competitive sports Non-athletes are also affected- 1/3rd of affected people are non athletes More common in men Mean reported age of onset 30-50 yrs ( Carcia 2010 ) Affects 2 % of the general population and may have a lifetime prevalence of 42 % in more active groups

anatomy-Achilles tendon is the strongest tendon in the body Confluence of gastrosnemius and soleus muscle Has no true synovial sheath of its own but has a paretenon which is a sheath of flexible connective tissue that allows for a gliding action ( paratenon can stretch 2-3 cm with movement ) Nerve supply from attached muscles and small fasciculi from cutaneous nerve , especially sural nerve Blood supply from 3 regions ( myotendinous junctions , osteotendinous junctions and paratenon ) Achille tendon is subjected to tremendous forces – during running the loading can be as high as 9 kilonewtons ( up to 12.5 times body weight ) Two bursae at the calcaneal insertion a S/C bursa lies superficial to the tendon and the skin and a retrocalcaneal bursa lies between the tendon and calcaneum 

What causes AT is not fully understood – overuse is considered to induce the condition but the 
etiology and pathogenesis have not yet been scientifically clarified. It is most likely that the
 etiology is multifactorial including both intrinsic and extrinsic factors

Repetitive strain and microtrauma leading to injury and degeneration No evidence of inflammation hence tendinopathy or tendinosis rather than tendinitis to describe the condition Impaired and failed healing response → haphazard proliferation of tenocytes , some evidence of degeneration in tendon cells abd disruption of collagen fibers and subsequent ↑ in non-collagenous matrix
 Types – important as management can differ

Impaired and failed healing response → three stages have been noted ○ reactive tendinopathy ○ tendon disrepair and ○ degenerative tendinopathy

risk factors- Advancing age Obesity Gender Recent injuries Previous lower limb tendinopathy Muscle power strength Family history Reduced ankle dorsiflexion Rheumatoid arthritis Dyslipidaemia type 1 and 2 diabetes Hypertension Steroid use Antibiotics treatment eg fluroquinalones – reported in 6 % of people who have taken fluoroquinolone antibiotics
Inhibit fibroblast metabolism → reduced cell proliferation and ↓ collagen & matrix synthesia Change in loading Poor training tech Activity levels Footwear Training surface Cold weather Examination-R/O symptoms suggestive of rupture eg
○ sudden pain back of leg
○ inability to walk or continue following the event
 Location and nature of pain Symptom behaviour eg
morning pain
pain during training
night pain Activity limitations Alleviating and exacerbating factors Medication use and medical hx

Typically
 Gradual onset of pain in back of leg or heel
worse in morning Stiffness – in morning ( common ) or after a period of immobility Pain may improve with heat or walking and worsens with strenuous activity / exercise Pain is worsened with push-off activities like
walking uphills or stairs , running and jumping

RICE Analgesia – paracetamol or NSAIDs Weight bear as tolerated If taking fluroquinolones- discontinue Stop activity which precipitated the event If no improvement within 7-10 days —> eccentric loading exercises 
( supervised ) Comparable results can be obtained with eccentric loading or low energy SWT ( Shockwave therapy ) Some evidence to recommend topical GTN ( eg GTN patch ) No definitive evidence whether Low level laser therapy ( LLLT ) may lead to better clinical outcome in patients undergoing a program of eccentric exercises

Quality of the available studies on management of AT is generally low

 

Eccentric loading exercises
♦ muscle is lengthened while contracting
♦ aim is to ↑ the tensile strength of the tendon by subjecting it yo active lengthening and high tensile forces
♦ these exercises also prepares the tendon for rapid unloading
 Extracorporeal shock wave therapy ( ESWT ) may be used as an adjunct to eccentric exercises
 Low level laser therapy ( LLST ) thought to ↑ collagen production and ↓ blood flow in new vessels and suppress the expression of proinflammatory markers such as IK-6 and TNF alpha in gene level
 Most people with improve with conservative management In general significant improvement in functions occur after 12 weeks of intervention
 Corticosteroid injections – evidence to support use is insufficient and high rate ( up to 82 % ) of adverse affects as tendon atrophy , tendon rupture and decreased tendon strength 
 Surgery ( open or minimally invasive ) is reserved for patient who do not improve after 6 months of conservative treatment
○ several techniques have been developed
○ complications are common ( 11 % Paavola et al ) for e.g wound necrosis , superficial infections , sural nerve injury , haematoma and thrombosis
○ reoperation rate was 3 %

 

Comparable results can be obtained with eccentric loading or low energy SWT ( Shockwave therapy ) Some evidence to recommend topical GTN
( eg GTN patch ) No definitive evidence whether Low level laser 
therapy ( LLLT ) may lead to better clinical outcome in patients undergoing a program of eccentric exercises

Quality of the available studies on management of AT is generally low

Best evidence supports use of eccentric exercise regimens and shock wave therapies Measures with conflicting or insufficient evidence include
○ platelet rich plasma ( PRP )
○ intratendinous hyperosmolar dextrose ( prolotherapy )
○ high volume injections
○ GTN patches
○ Cryotherapy
○ sclerosing agent
○ deep friction massage ( DFM )
○ Aprotonin ( broad spectrum serine protease inhibitor ) injection
 Regardless of treatment approach functional deficit may persist for up to 2 yrs
 Currently there is no gold standard of the treatments for Achilles tendinopathy because of the controversial clinical results between various studies The management of AT may also vary from centre to centre with variable results reported in literature

References

  1. Knapik JJ, Pope R. Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening. J Spec Oper Med. 2020;20(1):125-140. ( Abstract )
  2. Li, Hong-Yun, and Ying-Hui Hua. “Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments.” BioMed research international vol. 2016 (2016): 6492597. doi:10.1155/2016/6492597 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112330/
  3. Achilles tendon disorders Chad a Asplund et al BMJ 213 ; 346: f 1262
  4. Horn, A, & McCollum, G. (2015). Achilles tendinopathy – Part 1: Aetiology, diagnosis and non-surgical management. SA Orthopaedic Journal14(3), 24-31. https://dx.doi.org/10.17159/2309-8309/2015/V14N3A2
  5. Achilles Tendinopathy Longo, Umile Giuseppe MD*; Ronga, Mario MD; Maffulli, Nicola MD, MS, PhD, FRCS(Orth) Sports Medicine and Arthroscopy Review: June 2009 – Volume 17 – Issue 2 – p 112-126 doi: 10.1097/JSA.0b013e3181a3d625

  6. Common Conditions of the Achilles tendon AAFP May 2002
  7. Current Clinical Practice Guidelines for Achilles Tendinopathy An Evidence Based Approach to the Evaluation and Treatment of the Achilles Tendon Diorders Jaime L. Caillet
  8. Achilles tendinopathy CKS January 2016
  9. Achilles Tendinopathy S. Brent Brotzman MD Clinical Orthopaedic Rehabilitation : A team Approach
  10. Extracorporeal shockwave therapy ( ESWT ) for refractory Achilles tendinopathy : A prospective audit with 2-year follow up Foot , The , 2016-03-01 , Volume 26 , Pages 23-29
  11. The pathogenesis of Achilles tendinopathy ; A systematic review Bruno Magnan MD et al Foot and Ankle Surgery , 2014-09-01 , Volume 20 , Issue 3 , Pages 154-159
  12. Achilles Tendinopathy and Rupture Dr Jacquiline Payne June 2016 Patient UK
  13. Evidence-based Orthopedics- Achilles tendinopathy

 

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