Current And Emerging Conservative Modalities For Achilles Tendonitis

Ryan Fitzgerald, DPM, FACFAS

Treating Achilles Tendon Pathology: What The Research Reveals

The successful management of Achilles tendon pathology is a challenge to the foot and ankle surgeon. The initial approach to care should be largely conservative in nature. Patients rarely require initial surgical intervention for the management of these conditions. Regardless, Achilles tendinopathy often requires two to three months of conservative care to fully heal and allow a full return to pain-free function.

   During that time, clinicians should encourage patients to engage in RICE (rest, ice, compression, elevation) therapy while modifying activities to reduce the forces along the Achilles tendon. Encourage patients to decrease or stop the activities that cause pain, and transition over to low-impact activities, such as cycling and swimming, to further reduce the stress along the Achilles tendon. Functional rehabilitative exercises geared toward eccentric (lengthening) exercises and training — that can train muscle groups and increase strength and resiliency with low-energy exercise — lead to faster muscle and tendon repair. Studies demonstrate that eccentric exercises often provide excellent results in the management of Achilles tendonitis to the point where many authors recommend utilizing this modality as a first-line treatment for Achilles tendinopathy.30,31

   The use of orthotic control devices is of particular value in those patients who demonstrate biomechanical instability as an underlying cause of Achilles tendonitis.32 Additionally, shoe gear modification, with the addition of heel lifts and varus or valgus wedges, can be beneficial in the management of these conditions in patients who demonstrate underlying biomechanical etiology. Functional bracing can be appropriate in cases of significant tendinopathy in which protective immobilization is indicated. This is of particular value in those patients who present with chronic Achilles tendinosis and there is a concern for potential pathologic Achilles tendon rupture.

   Clinicians may also use nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen to address pain and swelling. However, one must exercise caution with these medications in patients with cardiovascular disease, hypertension and gastroesophageal reflux disease (GERD) as these medications can exacerbate symptoms in those patients who suffer from these concomitant disease processes.33

   In many cases of long-standing Achilles tendinopathy, patient symptoms are commonly recalcitrant to simple RICE therapy. Despite these challenges, however, surgery is often unnecessary. As I previously noted, functional rehabilitation and physical therapy can often be beneficial in the management of this patient population with goals of reducing pain and swelling while improving mobility and strength.

   However, in some cases, exercise and stretching paradigms alone are inadequate to address the symptomatology of chronic Achilles tendinopathy. In these cases, rehabilitative physical therapy activities in conjunction with anti-inflammatory modalities, such as therapeutic ultrasound, electrical stimulation and low-level laser light therapy, can often break the pain-inflammation cycle and allow for appropriate healing in the Achilles tendon.34-37

Emerging Conservative Therapies

In addition to more traditional modalities in the management of chronic Achilles tendinopathy, including eccentric (lengthening) exercises, functional orthoses and immobilizing splints, a review of the current literature demonstrates an increasing number of conservative therapeutic modalities that one can utilize in the management of recalcitrant cases.

   Extracorporeal shockwave therapy (ESWT) has demonstrated promise in the conservative management of insertional Achilles tendonitis.34,38,39 The SWAAT study demonstrated improvement in both the anke-hindfoot score as well as in objective function following the administration of ESWT in conjunction with the use of dietary supplementation with arginine, ViNitrox (Nexira), collagen, methyl-sulfonyl-methane, vitamin C and bromelain.38 The theory is that ESWT creates a positive, inflammatory effect while also improving blood flow within the tendon to allow for tissue healing. Despite these apparent successes, further study is necessary.

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