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10 Articles in Volume 16, Issue #4
Achilles Tendon Injuries
Brain Trauma in Sports
Genetic Testing: Adjunct in the Medical Management of Chronic Pain
Letters to the Editor: Sleep Apnea, SPG Blocks for Migraines, Pancreatic Pain, CDC Guidelines
Pain and Weather—A Cloudy Issue
Phulchand Prithvi Raj, MD, Pioneer in Pain Management, Dies at 84
Physical Medicine & Rehabilitation
Preventing Chronic Overuse Sports Injuries
Sports-Related Pain: Topical Treatments
The “Missing Link” in the Physiology of Pain: Glial Cells

Achilles Tendon Injuries

A look at conservative therapy to reduce pain and improve function.

The Achilles tendon is among the most important functional parts of a person’s leg. According to the American Orthopaedic Foot & Ankle Society, “the Achilles tendon is the largest tendon in the body. It is formed by the merging together of the upper calf muscles [gastrocnemius/soleus], and inserts into the back of the heel bone [calcaneus].”1

The Achilles tendons, like other body tissues, become more rigid, less flexible, and more susceptible to injury as a person ages. However, injuries to the Achilles tendon are not common, affecting only 6% of inactive people. The most common cause of injury is repetitive stress on the tendon (ie, stress tendinopathy), especially during exercise. This painful condition accounts for approximately 11% of all running injuries and can be quite debilitating, preventing the sufferer from exercising and causing great difficulty walking, especially when the condition is acute.2

There are two types of Achilles tendinopathy—noninsertional and insertional—depending on which part of the tendon is affected.3 In noninsertional Achilles tendinopathy, fibers in the middle portion of the tendon have begun to degenerate, swell, and thicken. This type of injury tends to affect younger, more active patients. Insertional Achilles tendinopathy involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone. This type of injury can occur at any age, in patients who are very active and in those who are inactive.3

Repeated episodes of Achilles tendonitis can lead to the development of Achilles tendinosis, a chronic degenerative condition of the tendon that can lead to tendon tearing or rupture, which usually requires surgical repair.

Who Is at Risk?

In addition to runners, people who participate in dancing and sports such as tennis, football, and basketball are at high risk for injury. Using poor techniques while training for such sports or when running causes unnecessary pressure on the tendons. Making abrupt changes in training methods, such as an abrupt increase in the intensity of training or reducing the interval between 2 different sections of training, also can put strain on the tendon.4

There are several other factors that can put people at increased risk for Achilles tendon injuries. Some arthritic conditions, such as ankylosing and/or psoriatic arthritis, cause weakening of the tendons, making them prone to such injuries. Also, some people have genetically weak tendons, which make them vulnerable to this type of injury. Use of certain medications, such as fluoroquinolones (eg, ciprofloxacin and ofloxacin), also can increase the risk.

Diagnosis

The primary presenting symptom of Achilles tendinopathy is pain/tenderness in the posterior heel and along the tendon. Pain is usually worse when first getting up and walking following a period of inactivity. Achilles tendinopathy is usually diagnosed by taking a careful history and palpating the level of swelling and/or tenderness of the tendon to help locate the exact area of involvement—usually 2 cm to 6 cm above the calcaneus (Figure 1).2,5 Thickening of the tendon is often noted. In some cases, asking patients to perform exercises that involve putting the Achilles tendon under pressure can help to determine the level of injury. One example of this is to have the patient try to stand or walk on his or her toes.

In some cases, baseline x-ray, magnetic resonance imaging, and bone scans may be indicated. Differential diagnoses include ruling out posterior tibialis ligament injury or Achilles tendon avulsion, inflammatory arthritides, plantar fasciitis syndrome, occult lesion, stress fracture of calcaneus, or sural neuritis.6

Rupture of the Achilles tendon can be diagnosed by squeezing the calf muscle when the patient is lying facedown on an exam table; if the foot does not move, the test is positive for an Achilles tendon rupture.

Treatment

Depending on the level of injury, there are several conservative interventions that can be used to treat Achilles injuries.7 Conventional treatment usually consists of RICE (rest, ice, compression, and elevation) and nonsteroidal anti-inflammatory medication (NSAIDS), along with stretching and exercises.8 These methods are easy to perform and cost effective, with very good outcomes. In addition to facilitating repair of the injured area, the conservative methods involve identifying the etiological factors of the injury and attempting to correct them. When conservative interventions fail, there are a number of surgical options.

RICE, Self-Care

In most cases, the initial, acute treatment for Achilles tendinopathy starts with putting the tendon at rest. Exposing the patient to a lot of pressure, especially on the injured area, could worsen the injury and increase the pain felt by the patient. Therefore, patients should be advised against any exercises that expose the injured area to impact. Only light exercises are acceptable.9 Icing the injured tendon (15 minutes on/15 minutes off) is a useful way to reduce swelling, both immediately after injury and after exercise.10

The most commonly prescribed pain medications include acetaminophen or NSAIDs, such as ibuprofen. However, these agents should not be used for longer than 2 weeks because they can hinder the ability of the tendon to heal completely. Additionally, side effects such as gastrointestinal complications (stomach pain, ulcer, bleeding) and cardiac complications have been associated with these agents. Patients with pre-existing GI or cardiac issues should be advised to consult a medical specialist before taking these agents.11

Topical glyceryl trinitrate, usually used to treat angina, has been found to reduce the symptoms of noninsertional Achilles tendinopathy and improve function when used continuously for up to 12 weeks.12 In one study, 52 patients (68 tendons) treated for 6 months with topical glyceryl trinitrate therapy were followed for 3 years after cessation of therapy. Patients were asked about their pain scores, return to previous activity, the Victorian Institute of Sport Achilles tendon scale (VISA-A), asymptomatic patient outcomes, clinical assessment of tendon tenderness, and functional hop test. According to the study findings, the patients treated with glyceryl trinitrate had significantly less Achilles tendon tenderness (P=0.03), and greater improvement in VISA-A scores (P=0.04) than those in the placebo group; 88% (28 of 32 tendons) of patients were completely asymptomatic at 3 years (VISA-A score of 100) compared to 67% (24 of 36 tendons) of patients treated with rehabilitation alone (P=0.03 with Chi square analysis).13 The authors suggested that the mechanism of action of topical glyceryl trinitrate on chronic tendinopathies is more than an analgesic effect.

Exercise and Musculotendinous Training

A conservative regimen is the first line of treatment for patients with chronic painful Achilles tendinopathy. Light exercises will help ensure that the tendon does not become stiff. Exercises should be performed daily with the help of a physical therapist, to make sure that excessive pressure is not applied on the tendons (Table 1).8,9 These exercises facilitate the healing process and help strengthen the calf muscles. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort; however, it should not be unbearable.

The best evidence of a weight-loading exercise program comes from Swedish researchers Curwin and Stanish, who stressed the importance of eccentric training as a part of the rehabilitation of tendon injuries.14,15 The investigators found that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinopathy, but not in patients with chronic insertional Achilles tendon pain.16

In 1998, Alfredson et al then conducted a 12-week program of “heel drops” to strengthen the calf eccentrically.17 The authors then expanded their research and found that 89% of patients with tendons treated with eccentric training were back on their pre-injury activity level after a 12-week training regimen. In these patients, the amount of pain during activity, registered on the Visual Analogue Scale (VAS), decreased significantly from 66.8 to 10.2. By contrast, only 32% of patients with chronic insertional Achilles tendon pain had satisfactory results, with a significant decrease on the VAS, from 68.3 to 13.3.18

The exercises are initially done using the patient’s own weight as the loading weight, but once the patient has graduated to a pain-free foot-drop, 5 kg of weight is added to the exercise regimen. This slow-paced weight-bearing heel-drop exercise has replaced pain-free exercises performed at gradually increased speed.19 This regimen, however, is not recommended for patients with a partially ruptured Achilles tendon, because it can further damage the tendon, possibly causing a lengthening of the tendon.

In a 2011 study, researchers tested a modified 6-week eccentric heel-drop training regimen as the only treatment for chronic Achilles tendinopathy. The investigators found that the modified regimen resulted in a high degree of patient satisfaction, reduced pain, and a successful return to pre-morbid activity levels.20 In the study, 190 athletes were enrolled. The only treatment was a 6-week eccentric stretching regimen, with each stretch being maintained for at least 15 seconds. Of the 190 athletes, 56 (82%) completed the follow-up. “Mid-substance injuries” were diagnosed in 168 (88%), with the remaining 22 (12%) having distal insertional injuries. Pain as assessed by VAS reduced from a mean of 7.2 to 2.9 (P<0.01) after 6 weeks of stretching. Six months after the start of the of program, the mean pain score was 1.1. Patient satisfaction was rated at 7 or above (excellent) in 124 (80%) of the athletes. For noninsertional injuries, the satisfaction rating was excellent in 86%. Overall mean time to return to activity was 10 weeks.20

In a more recent study, researchers found that a combination of eccentric exercise and soft tissue treatment was more effective than eccentric exercise alone at improving function during both short- and long-term follow-up periods.21 The study, however, was small, including only 16 patients who were randomly assigned to either a soft tissue treatment (Astym) and eccentric exercise group or an eccentric exercise–only group. Outcomes included the VISA-A, the numeric pain rating scale (NPRS), and the global rating of change (GROC). The researcher found significantly greater improvements on the VISA-A were noted in the soft tissue treatment (Astym) plus exercise group over the 12-week intervention period, and these differences were maintained at the 26- and 52-week follow-ups. Both groups experienced a similar statistically significant improvement in pain over the short and long term.21

One caveat, however, is that the size of the majority of patients’ tendons was reduced after therapy, although the structure of the tendons did not change based on ultrasonography. It is advisable, therefore, that patients do other conventional exercises in addition to eccentric musculotendinous training to speed the process of recovery.19

Steroid Injections

Corticosteroid injections are often used for short-term pain relief in patients with inflammation. This approach can help reduce the pain just after injury, before other treatment is commenced. Since the injection has no healing effect on the tendon, it is necessary to initiate another method of treatment to repair the injury.22 However, according to the American Association of Orthopaedic Surgeons (AAOS), corticosteroid injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture.3

Prolotherapy

Prolotherapy is a method of injections designed to stimulate healing.23 Prolotherapy is used for the treatment of chronic musculoskeletal pain, including ligament, tendon, and joint injuries, as well as osteoarthritis. Prolotherapy is thought to work by stimulating a temporary, low-grade inflammation at the site of ligament or tendon weakness, “tricking” the body into initiating a new healing cycle cascade.24 Prolotherapy has been successfully used in the treatment of elbow, knee, and ankle injuries, including Achilles tendonitis.25-27

The use of platelet-rich plasma prolotherapy (PRP), or autologous blood injections, is based on the same theory as traditional dextrose prolotherapy; however, the formula used is a high-density concentration of the patient’s circulating platelet levels isolated and concentrated by bidirectional centrifugation. Enhanced healing capability is possible when platelet concentrations are increased within injured or damaged tissue.28

For treatment of Achilles tendon injuries, PRP injections are guided by ultrasound. A recent retrospective review of the literature found that while PRP was helpful in treating Achilles ruptures, it was less beneficial in treating tendinopathies.29

For treatment of tendinosis, a literature review examined a number of injectable treatments for noninsertional Achilles tendinosis, including platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). The researchers found that the studies “have variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of [injectable treatments’] effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies.”30

Extracorporeal Shock-Wave Therapy

Extracorporeal shock-wave therapy (ESWT) involves passage of sound waves through the skin into the injured Achilles tendon to stimulate healing. ESWT can be considered a treatment option when all other conservative therapies have failed and as a less invasive option before surgery in patients with chronic Achilles tendinopathy.31-33 There is evidence that ESWT can reduce the amount of pain while rehabilitating the ruptured or injured tendons; however, there have been only a handful of studies listed on PubMed on the use of ESWT for Achilles tendinopathy.

Although ESWT is considered safe, there are some concerns associated with this process, such as the risk of rupturing the Achilles tendon during treatment, which is especially pronounced among the elderly. Due to these risks associated with the treatment, it is recommended that specialists make patients aware of the risks and get their consent before they continue with the process.

Osteopathic Manipulative Medicine

Minor injuries of the Achilles tendon do not necessarily call for medical management. Physical therapy techniques, such as osteopathic manipulative medicine (OMM), can be employed before embarking on drug treatment.34,35 OMM, the brainchild of American physician Andrew Taylor Still, involves the treatment of injuries through manual touching sessions. These noninvasive techniques and gentle hand movements are used to detect the affected regions, and the prime purpose is to stretch muscles and support the ligaments and to provide relaxation to muscle spasm. This technique is effective for promoting free movement and improving blood flow throughout the body. According to Ward, OMM is essential in the treatment of injuries such as Achilles tendon injuries, helping patients regain the ability to walk properly.36,37

OMM aims to remove obstructions that derail normal body movement and fosters the self-healing capability of the body, motivating the patient to work toward his or her own recovery. Using OMM, the patient must be focused on the treatment procedure and may not leave it solely to be completed by the medical professional. The treating physician initially helps the patient with the exercises, and the patient eventually continues with the exercises on his or her own, under the directions provided by the physician. The application of OMM helps the patient gradually normalize his or her movements, with minimal or no side effects.36,37 In addition, OMM is cost effective, but it takes a considerable amount of time to heal,38 and may not be appropriate for professional athletes and others requiring a more rapid return to their activities.

Orthotics

Some clinicians recommend a change in the footwear used for training or running to make sure that the heel is lifted off the ground during these activities. The main idea behind lifting the heel is to decrease tension on the Achilles tendon. This approach can be used if the injury is not very serious, or as a preventive measure in cases where the patient is prone to these injuries.

Surgical Treatment

Approximately 25% of patients experience persistent Achilles tendon pain after nonsurgical treatments and must undergo surgery to find relief. Surgery to treat an Achilles tendon injury is very effective, but should be considered only after other treatments fail. In most cases, surgery is done when the injury becomes chronic.39

There are two types of surgical treatments: surgical debridement with tendon repair, which is the treatment of choice for patients who have less than 50% damage to the tendon, and debridement with tendon transfer, which is preferred for patient with greater than 50% damage.3 During the surgery, the nodules or adhesions that can develop under the damaged tendon are removed, and the tendon is cut and repaired to stimulate healing.40

Another surgical treatment is gastrocnemius recession, which involves lengthening of the calf muscles. According to the AAOS, tight calf muscles place increased stress on the Achilles tendon.3 Therefore, this technique is ideal for patients with tight calf muscles who still have difficulty flexing their feet, despite consistent stretching.3

In gastrocnemius recession, which can be performed with or without debridement of the tendon, one of the two gastrocnemius muscles is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or endoscopically. Complication rates for gastrocnemius recession are low, but can include nerve damage.

After surgery, the patient requires rehabilitation, sometimes up to 1 year, to facilitate complete recovery.

Conclusion

The symptoms of Achilles tendon injuries are swelling in the injured tendon, pain, and difficulty walking. This injury is most frequent among people who do vigorous exercises, such as running, jumping, and playing sports such as basketball. People who are not very active, but start doing exercise abruptly, also frequently experience these injuries.

When an individual is suspected of having this injury, it is advisable that immediate treatment be initiated to reduce pain and swelling. Pain relievers can be administered, and/or ice treatments, which help relieve pain and prevent swelling. Then, a number of nonsurgical treatments can be commenced, such as exercise, OMM, acupuncture, and orthotics. If these fail, surgery can be considered.

Last updated on: May 17, 2016
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