Conservative Care For Mid-Portion Achilles Tendinopathy

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Author(s): 
Kent Sweeting, B.Hlth.Sc.(Pod)(Hons)


1. Paavola M, Kannus P, Jarvinen TA, Khan K, Jozsa L, Jarvinen M. Achilles tendinopathy. J Bone Joint Surg Am 2002; 84-A(11):2062-76.
2. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001; 35(5):335-41.
3. Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26(3):360-6.
4. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med 2007; 41(4):211-6.
5. Langberg H, Ellingsgaard H, Madsen T, et al. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 2007; 17(1):61-6.
6. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med 2003;13(1):11-5.
7. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of Achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005;15(3):133-5.
8. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of Achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005; 15(3):133-5.
9. Paoloni J, Appleyard R, Nelson J, Murrell G. Topical glyeceryl trinitrate treatment of chronic non-insertional Achilles tendinopathy. JBJS 2004; 86-A(5):916-22.
10. Sayana M, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2007; 10(1):52-8.
11. Astrom M. Partial rupture in Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand 1998; 69(4):404–7.
12. Khan KM, Cook JL, Kannus P, et al. Time to abandon the "tendinitis" myth. BMJ 2002; 324(7338):626-7.
13. Alfredson H. Chronic mid-portion Achilles tendinopathy: an update on research and treatment. Clinical Sports Med 2003; 22(4):727-41.
14. Alfredson H, Forsgren S, Thorsen K, et al. Glutamate NMDAR1 receptors localised to nerves in human Achilles tendons. Implications for treatment? Knee Surg Sports Traumatol Arthrosc 2001; 9(2):123-6.
15. Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not protoglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc 1999; 7(6):378-81.
16. Alfredson H, Lorentzon M, Backman S, et al. cDNA-arrays and real-time quantitative PCR techniques in the investigation of chronic Achilles tendinosis. J Orthop Res 2003; 21(6):970-5.
17. Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc 2003; 11(5):334-8.
18. Alfredson H, Lorentzon R. Intratendinous glutamate levels and eccentric training in chronic Achilles tendinosis: a prospective study using microdialysis technique. Knee Surg Sports Traumatol Arthrosc 2003; 11(3):196-9.
19. Alfredson H, Bjur D, Thorsen K, et al. High intratendinous lactate levels in painful chronic Achilles tendinosis. An investigation using microdialysis technique. J Orthop Res 2002; 20(5):934-8.
20. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: New treatment options. Br J Sports Med 2007; 41(4):211-6.
21. Ireland D, Harrall R, Curry V, et al. Multiple changes in gene expression in chronic human Achilles tendinopathy. Matrix Biol 2001; 20(3):159-69.
22. Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scand J Med Sci Sports 2005; 15(4):2529.
23. Murrell GA, Szabo C, Hannafin JA, et al. Modualtion of tendon healing by nitric oxide. Inflamm Res 1997; 46(1):19-27.
24. Murrell GA. Using nitric oxide to treat tendinopathy. Br J Sports Med 2007; 41(4):227-31.
25. Alfredson H, Forsgren S, Thorsen K, Lorentzon R.

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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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