Achilles Tendinopathy: What Are The Best Treatment Options?

By Edward G. Blahous Jr., DPM

Top Tips On Managing Achilles Tendinosis

     Treatment, of course, is customized for each patient. However, one can follow the same general protocol. Initially, relative rest is recommended. Depending on the intensity of the symptoms and/or their duration, relative rest may range from boot immobilization to simple activity modification. Most patients require a boot for two to three weeks. Additionally, clinicians should encourage ice massage and NSAIDs for associated peritendinitis. Keep in mind, however, that pure tendinosis often does not respond to antiinflammatory interventions.      Subsequently, the patient will begin an organized, methodic and specific 12-week physical rehabilitation program. Alfredson is credited with characterizing the heavy load eccentric calf muscle training regimen that has truly revolutionized the treatment of Achilles tendinosis.5 It would behoove the practicing physician to obtain and understand this technique as it truly is the cornerstone of the conservative treatment. Furthermore, it is important to have a close relationship with the physical therapist in order to perform the protocol correctly. The results in the literature as well as my practice have been very encouraging.5,6      It is important to warn patients that this is a “no pain, no gain” proposition. Initially, the pain will increase but should slowly resolve over time. It also warrants mentioning that the hallmark fusiform swelling may not completely resolve despite the possibility of subjective symptom resolution.      In our clinic, we distribute a home program protocol handout to the patient to share with the therapist. While eccentric rehabilitation is the cornerstone of the proactive conservative measures, adjunctive physical therapy measures such as ultrasound and deep tissue massage may complement the treatment. In the athletic and active population, it is important to encourage alternative physical activities (biking or swimming) while the patient slowly recovers with the conservative treatment.      While most will achieve adequate success without invasive treatment, recalcitrant cases will invariably present. Newer alternative therapies are continuously evolving with variable clinical success. A non-exhaustive list includes extracorporeal shockwave, pulsed electromagnetic field, low level laser and microtenotomy therapy.7-10 Currently, I use low-level shockwave therapy with variable success in this pathology. However, much of the research in this arena involves more of a subjective clinical pain response rather than pure scientific investigation.      If surgery is necessary, it is again imperative to rule out any other adjunctive pathology that may either coexist with tendinosis or may appear to be Achilles tendinopathy, and is clarified with further diagnostic investigation. I recall one patient who was referred to me for surgical consultation of a chronic case of “Achilles tendonitis.” As it turns out, the patient had profound pain with hyperplantarflexion of the ankle and we ultimately diagnosed the patient with a painful os trigonum. Excision of the accessory bone was curative.      At this point, or on occasion earlier in the workup, an MRI is indicated. This will serve to demonstrate the exact location of the degeneration. Obtaining a MRI also enables the surgeon to quantify the percentage of tendon diameter involved. While there is no scientific standard to apply, I will transfer the flexor hallucis longus (FHL) tendon if over 40 percent of the diameter is affected. The FHL tendon is the primary candidate for tendon transfer in cases of Achilles tendinopathy in so much that it is an “in-phase” transfer and is quite accessible anatomically.

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