Conservative Care For Mid-Portion Achilles Tendinopathy

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

What The Research Reveals About Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) is usually categorized as either low-energy (2) or high-energy (> 0.2 mJ/mm2).46 Low energy ESWT such as the EMS Swiss DolorClast (EMS Electro Medical Systems) requires multiple treatments but is well tolerated and does not require anesthesia. High-energy ESWT devices such as the Dornier Epos lithotripter (Dornier MedTech) are more painful (often requiring anesthesia) although less treatments are required.48,49

   Shockwave may work by inhibiting pain receptors and causing local cell death, stimulating new tissue formation.48-50 A randomized controlled trial comparing low energy ESWT to eccentric loading exercises and a control group showed that ESWT was comparable to eccentric loading exercises.49 No randomized controlled trials examining high-energy ESWT have been published although a case control study demonstrated that the treatment group had favorable results in comparison to the control group.48

In Conclusion

Mid-portion Achilles tendinopathy is common in middle-aged athletes. Patients usually present with activity-related Achilles pain and post-static dyskinesia. A thorough patient history and clinical examination will often negate the need for diagnostic imaging. Achilles tendinopathy is a degenerative process. It is not an inflammatory process. Anti-inflammatory treatments may assist with pain but will not treat the underlying tendinopathy so one should avoid these treatments. Physical therapy including eccentric loading exercises and load modification will be a successful first-line treatment for most patients.

   There are many adjunctive treatments that may assist those patients who fail to respond to physical therapy. More clinical trials are required to determine if some patients are better suited to one of these treatments over another. Surgery is seldom required and should be reserved for patients who fail to respond to conservative measures.

   Dr. Sweeting is in private practice at Performance Podiatry and Physiotherapy in Queensland, Australia. He is a research fellow in the School of Medicine at the Logan and Gold Coast campuses of Griffith University in Australia and a lecturer the School of Podiatry at Queensland University of Technology.


crstuart's picture

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.

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!

Great work Kent!

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