Essential Insights In Diagnosing And Treating Chronic Achilles Tendinosis

Bob Baravarian, DPM

The Achilles tendon is the largest and strongest tendon in the human body. As a result of its location and importance in ambulation, the tendon is associated with overuse type injuries. In a small number of Achilles tendon injuries, the acute tendonitis problem is not dealt with appropriately and the chronic microtrauma and damage to the tendon results in scar formation and bulbous partial tear damage to the Achilles tendon. This leads to chronic pain. This type of Achilles injury is chronic in nature and is referred to as an Achilles tendinosis.

   Achilles tendinosis type injuries are associated with a decrease in blood supply to the injury site, resulting in chronic and expanding scar tissue formation. The lack of blood supply to the injury site results in the body not responding to the injury and a chronic state of pain. In such cases, it is rare that rest, ice and anti-inflammation type activities will provide relief. Often, irritation of the tissue is necessary for breaking up scar tissue and increasing the blood supply for healing.

   The diagnosis of Achilles tendinosis is quite simple. Patients will often have a bulbous enlargement of the Achilles tendon in the central watershed region. The amount of damage varies but it usually affects somewhere from 20 to over 80 percent of the tendon. Although it is easy to diagnose a case of Achilles tendinosis, it is quite difficult to understand the presence or lack of blood supply to the area, and the amount of damaged tendon and scar formation. In order to provide proper treatment, it is important to understand the cause and amount of damage.

   In our institutes, we use color power Doppler ultrasound extensively in the diagnosis and follow-up of Achilles tendinosis cases. The power Doppler ultrasound allows us to check the amount of tendon damage by measuring the scar formation on a cross-sectional examination. One may also utilize the power Doppler to see the amount of blood supply to the region. The more blood supply in the region, the greater the chance you have of conservative care improving the underlying problem.

What You Should Know About Conservative Care Options

Always attempt conservative measures prior to any form of surgical intervention. Conservative treatment ranges from simple to complex treatment options. If the Doppler exam shows decent blood supply to the Achilles, patients should rest and attempt physical therapy for at least one month to see if the Achilles will respond. Often patients may use a below the knee boot with a heel raise to rest the tendon. After a month, check the amount of scar tissue and blood supply with ultrasound to see how the tendon is responding. If there is progress, start conservative care with the addition of stretching and gentle strengthening.

   If there is a lack of blood supply and/or therapy is not helping, begin complex conservative care options. These are often procedures that stimulate the tendon and increase blood supply to the tendon. The three treatments that we recommend at our institutes are shockwave therapy, platelet rich plasma therapy (PRP) and Topaz micro-Achilles tenotomy (Arthrocare). All three treatments have a place in our toolbox.

   We usually use shockwave therapy in mild cases of Achilles tendinosis. We find that three treatments are necessary at two-week increments. The tendon experiences trauma at a microscopic level, which results in the breakup of scar tissue as well as increased inflammation and blood supply.

   In moderate to severe cases, we usually attempt PRP therapy. However, if there is severe scar tissue formation, these types of treatments may not work. Platelet rich plasma works to bring the healing growth factors associated with blood products to the area of scar tissue to fool the body into believing there is a local injury and sending more blood for healing. The additional needling during PRP injection also breaks up the scar formation in the Achilles and increases blood supply to the scar region.

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