Current And Emerging Conservative Modalities For Achilles Tendonitis
- Volume 25 - Issue 11 - November 2012
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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.
There has been much recent discussion in the literature regarding the efficacy of autologous platelet-rich plasma (PRP) injections in the management of chronic insertional and mid-substance Achilles tendinopathy. Some studies have shown little positive effect in the improvement of Achilles tendon symptoms but others have found greater success.40,41 In 2011, Owens and colleagues demonstrated an improvement of functional outcomes in patients suffering from Achilles tendinopathy following intratendinous injection of PRP.42 However, MRI evaluation of the same patient cohort demonstrated little to no change in the substance of the diseased Achilles tendons.
There is growing interest in the working mechanisms of autologous growth factors and how clinicians can apply them to the management of chronic tendinopathy. In 2011, a prospective, double-blind, randomized trial of patients suffering from chronic elbow tendinopathy demonstrated that growth factor-based therapies provide additional benefit beyond physical therapy in recalcitrant cases of tendinopathy.43 Several studies have demonstrated efficacy in the management of Achilles tendinopathy with intra-tendon application of recombinant human platelet-derived growth factor-BB (rhPDGF-BB).44,45 The rhPDGF-BB treatment resulted in a dose-dependent, transient increase in cell proliferation and sustained improvement in biomechanical properties. However, the exact amount and mixture of growth factors necessary to facilitate a positive response is unknown, and further study is required.46
The Achilles tendon is the strongest tendon in the body and it functions with every step people take. Achilles tendinopathy is a common lower extremity complaint that can prove challenging due to anatomical, biomechanical and activity-related considerations. While a prolonged recovery process is common for this pathology, clinicians can successfully manage many patients with conservative care modalities.
The literature demonstrates that appropriate early intervention is associated with improved outcomes as well as an earlier return to function. If left untreated or under-treated, Achilles tendonitis can progress toward degenerative tendinosis if clinicians do not adequately address the underlying etiology.
There are a variety of conservative modalities available to the foot and ankle clinician involved in the management of Achilles tendinopathy. A review of the current literature demonstrates a variety of emerging techniques and modalities — from both a conservative and surgical aspect — that show promise in the management of acute and chronic Achilles tendonitis and subsequent tendinosis. While further research is necessary, there is strong evidence to suggest that these technologies will provide numerous treatment options in the future.
Dr. Fitzgerald is a Fellow of the American College of Foot and Ankle Surgeons. He is board-certified in foot surgery and reconstructive foot and ankle surgery by the American Board of Podiatric Surgery. Dr. Fitzgerald is in private practice at Hess Orthopaedics and Sports Medicine in Harrisonburg, Va.