Conservative Care For Mid-Portion Achilles Tendinopathy

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Kent Sweeting, B.Hlth.Sc.(Pod)(Hons)

   While there is no chemically mediated inflammatory process, immunohistochemical analyses of tendon biopsies have revealed that there may be some neurogenic inflammation.13,25-27 Biopsies of areas of tendinosis with accompanying neovascularization have shown nerve structures in close proximity to vessels.26 Substance P (the pain neurotransmitter that also increases vascular permeability and vasodilatation) and neurokinin-1 receptor (the endogenous receptor for substance P) were also present in the vascular wall.27 This neural pathway associated with the neovascularization of tendinosis may explain the pain associated with this problem.20

What To Look For In The Examination

Typically, a patient will present with pain in the posterior ankle region. It generally is an insidious onset or it may be related to an increase in training. Classically, patients with Achilles tendinopathy present with post-static dyskinesia.28 Pain may also be present at the beginning of exercise. Pain will usually reduce with exercises although this ability to warm up will decrease with the increasing severity of tendinopathy. Pain will often return in the hours following exercise. There will usually be a visual thickening of the tendon.13

   Mid-portion Achilles tendinopathy is usually a straightforward clinical diagnosis. A thorough history and observation of a thickened tendon should point to Achilles tendinopathy. Palpation of the tendon from proximal to distal with the patient lying prone and the ankle at approximately 70 to 90 degrees to the leg will reveal the area of tenderness. A double leg heel raise, single leg heel raise, hopping or running should also reproduce symptoms. One should also perform a thorough biomechanical evaluation including tests of calf flexibility, calf strength and gait analysis.

   The VISA-A (Victorian Institute of Sports Assessment–Achilles) questionnaire may be a quantifiable measure of pain, stiffness and disability.29 It has good reliability, validity and stability.29 While it is mainly used for research purposes, the VISA-A is a questionnaire that one can use in the clinical setting to monitor patient progress.

   The examiner should always be mindful of differential diagnoses. Significant swelling, crepitus and swelling that does not move with tendon movement are all classic signs of paratendinopathy.28 Other differential diagnoses include posterior ankle impingement, accessory soleus, deep flexor tendinopathy and referred pain.

How Diagnostic Imaging Can Be Beneficial In Ambiguous Cases Of Achilles Tendinopathy

As I mentioned earlier, mid-portion Achilles tendinopathy is usually a straightforward clinical diagnosis so diagnostic imaging is seldom required. However, imaging is useful in less clear-cut cases.

   Ultrasound with color Doppler is my preferred imaging modality. Grayscale ultrasound will show fusiform thickening with or without focal hypoechoic areas.30 Color Doppler will often demonstrate neovascularization in the thickened part of the tendon. This usually occurs both inside and outside the ventral part of the tendon. However, in more severe cases, vessels can be visible through the entire thickness of the tendon.30

   The disappearance of the neovessels may correlate to improvement in pain.31-33 Detection of neovessels, more so than detection of abnormalities in tendon structure with grayscale ultrasound, is operator dependent. Magnetic resonance imaging (MRI) will demonstrate tendon thickening and increased signal intensity.20,34 Signal intensity on MRI has been correlated with clinical outcome.34

Pertinent Treatment Considerations

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crstuartsays: November 14, 2010 at 11:40 am

Excellent explanation and recommendation on the technique of "no concentric contraction on the affected side."

I have a patient who has suffered with chronic post-static dyskinesia in the Achilles tendon mid-substance area for 2 years. He has slight discomfort before running, the pain subsides with running and then the pain returns about 1 hour after running.

X-rays show a large Os trigonum and MRI is negative for inflammatory changes around the OS, Achilles or FHL. Is it possible that this Os is just an incidental finding and that the focus should be on eccentric stretching? This large Os somewhat limits his ability to raise onto his toes and plantarflex his foot. Surgical excision of the Os may allow more plantarflextion but is it worth the risks of painful scar tissue formation, neuritis, etc.? Five weeks of physical therapy helped relieve the pain but within 3 weeks of easing back into a jogging routine, the insidious onset of pain returned.

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Anonymoussays: December 7, 2010 at 4:29 pm

Certainly, the patient history sounds like Achilles tendinopathy. Did the MRI or physical exam demonstrate thickening of the Achilles tendon? Is the Achilles tendon tender to palpate (see '"What to look for in the examination" section)? The os trigonum could be a red herring. Perhaps you could try the eccentric program +/- a corticosteroid injection around the os trigonum. Good luck!

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Trent Perringsays: May 1, 2011 at 4:26 am

Great work Kent!

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