Physical Therapy for Achilles Tendinopathy

Background

• Achilles tendinopathy refers to all disorders involving the Achilles tendon, from acute inflammatory to chronic degenerative
  • Achilles tendinitis is an inflammatory overuse injury to the tendon
  • Achilles tendinosis is a chronic degenerative condition

Achilles Tendinitis

Achilles tendinitis is inflammation of the the Achilles tendon as a result of overuse, either from an acute traumatic event or after repetitive overload. The location of the pain can either be insertional (at the insertion of the tendon on the calcaneus) or located 2 to 7 cm proximal (midsubstance). On examination, the tendon will appear swollen and edematous, tender to the touch, with occasional crepitus.

Initial management consists of rest, ice, elevation, and compression. When the inflammation calms down, an attempt is made to correct any biomechanical causes such as tight or weak calfs. If the injury is a result of a training error, the athlete’s program is reviewed and modified with a gradual return to full participation.

The effects of physical therapy on Achilles tendonitis is poorly understood, although musculotendinous strengthening appears essential. Eccentric exercises have been shown to have positive effects of Achilles tendonitis, and remains the gold standard for rehabiliation of this condition. A study by Roos et al concluded that eccentric exercises improve function and reduce pain and effects were apparent after 6 weeks of treatment, lasting for 1 year.

Achilles Tendinosis

Achilles tendinosis refers to damage to the tendon at the cellular level. It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Achilles tendinosis can be misdiagnosed as tendinitis.

Tendons are very slow to heal if injured, and rarely regain their original strength. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.

Standard treatment of tendon injuries is largely palliative. Use of non-steroidal anti-inflammatory drugs combined with physical therapy (particularly involving eccentric exercises), rest, and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinosis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment and that inflammation does not cause tendon dysfunction. There are a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months and full recovery is within 3 to 6 months. About 80% of patients will fully recover.

References

1. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130.

2. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14:286-295.

3. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the "tendinosis" myth: painful overuse tendon conditions have a non-inflammatory pathology. British Medical Journal 2002;324(7338):626–7.

4. Marsolais D, Duchesne E, Côté CH, Frenette J. Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading. J Appl Physiol 2007;102(1):3–4.

5. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. American Family Physician 2005;72(5):811–8.