Non-insertional Achilles tendinopathy

Achilles tendon disorders: An overview of diagnosis and conservative treatment

ABSTRACT

Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.

Comparative short-term effectiveness of non-surgical treatments for insertional Achilles tendinopathy: a systematic review and network meta-analysis

BACKGROUND

The incidence of Achilles tendinopathy has risen over the past decades. Insertional Achilles tendinopathy is characterised by tissue degeneration of the Achilles tendon from its insertion in the calcaneus to up to 2 cm proximally. This clinical condition is accompanied by pain, loss of function and diminished exercise tolerance. Numerous conservative treatment modalities are available to participants with insertional Achilles tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, laser therapy, cryotherapy, therapeutic ultrasound, and orthotics. Eccentric exercise and extracorporeal shockwave therapy may reduce pain in participants with non-calcified insertional Achilles tendinopathy. However, no specific treatment is recommended over another due to the low methodological quality of trials. Given the lack of standard or preferred non-surgical treatment and the potential risks of surgical treatment, there is an imminent need to reassess different non-surgical treatments based on the newest evidence. Thus, this systematic review aims to evaluate the clinical effectiveness of the various non-surgical treatments for insertional Achilles tendinopathy.

METHODS

AMED EBSCOhost, CINAHL, EBSCOhost, EMBASE, PEDro, PubMed, Web of Science, and Clinicaltrials.gov were searched from 1992 to 14th October 2022, randomised controlled trials of adults with insertional Achilles tendinopathy investigating non-surgical treatments compared with each other or no treatment, placebo/sham control. Two reviewers independently screened and extracted the data. Random effects of network meta-analysis immediately after treatments were used to report comparative treatment effects. The surface under the cumulative ranking probabilities was calculated to assess the relative ranking of treatments.

RESULTS

Nine trials (total n = 464 participants) were included. This review recommended the combination of eccentric exercise and soft tissue therapy to manage insertional Achilles tendinopathy. With the highest SUCRA values of 84.8, and the best mean rank of 1.9, Eccentric exercise plus soft tissue treatment ranked as the most effective treatment for short-term pain.

CONCLUSIONS

This is the first NMA of non-surgical treatment focusing on short-term pain control for IAT which eccentric exercise plus soft-tissue therapy was found to be the most effective treatment combination. However, the overall confidence in non-surgical treatments from all included trials was very low. No recommendation of the best treatment option can be made from this review.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Early Outcome of a Single Peri-Tendinous Hyaluronic Acid Injection for Mid-Portion Non-Insertional Achilles Tendinopathy - A Pilot Study

AIM

The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyaluronic acid for mid-portion, non-insertional Achilles tendinopathy.

MATERIALS AND METHODS

A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed.

RESULTS

Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded.

CONCLUSION

This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.

Comparing Effectiveness of Combination of Collagen Peptide Type-1, Low Molecular Weight Chondroitin Sulphate, Sodium Hyaluronate, and Vitamin-C Versus Oral Diclofenac Sodium in Achilles Tendinopathy: A Prospective Randomized Control Trial

Background

Achilles tendinopathy, a common cause of heel pain, is primarily considered mechanical in origin, but its pathogenesis and treatment lack consensus. Molecules such as collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate and vitamin C have been shown to act as building blocks of tendon structure, and oral supplementation of these have promising results in Achilles tendinopathy.

Methods

This study was a prospective randomized control trial to compare the effectiveness of oral diclofenac sodium versus a nutraceutical combination of collagen peptide type-1, chondroitin sulphate, sodium hyaluronate, and vitamin C in the treatment of Achilles tendinopathy on pain and ultrasonographic structures. A total of 40 patients satisfying inclusion and exclusion criteria were randomly allocated into two groups and were given the nutraceutical combination in group A and diclofenac sodium in group B. The patient evaluation was done at baseline, six-week, and 12-week intervals in terms of VAS (Visual Analogue Scale) and tendo-Achilles thickness by ultrasound.

Results

Both nutraceutical combination and diclofenac reduced pain in persons with Achilles tendinopathy. The nutraceutical combination had a statistically significant better outcome in reducing pain at the end of 12 weeks. On ultrasound, both the interventions reduced Achilles tendon anteroposterior and mediolateral thickness by the end of 12 weeks. Although there was no absolute significant intergroup difference, the percentage change was more in the nutraceutical group in the case of anteroposterior thickness.

Conclusion

Combining collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate, and vitamin C is more effective than oral diclofenac in controlling pain in Achilles tendinopathy.

Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume

Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m² (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.

Short- and Intermediate-Term Results of Extracorporeal Shockwave Therapy for Noninsertional Achilles Tendinopathy

BACKGROUND

Earlier randomized controlled trials (RCTs) reported only midterm (3-4 months) results of extracorporeal shockwave therapy (ESWT) as a treatment for noninsertional Achilles tendinopathy (NAT). This study compared the effectiveness of an eccentric loading program followed by stretching exercises combined with ESWT (study group) or sham ESWT (control group) for treating chronic NAT in both the short and long term.

METHODS

This double-blind RCT was conducted between 2018 and 2020. Adult patients with unilateral NAT who failed standard conservative treatment were randomly allocated to either group. Function and pain were assessed at baseline, 1 month, and 16 months using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and visual analog scale (VAS), respectively. Mixed-design analysis of variance and nonparametric statistics were performed. Twenty-two men and 28 women aged 18 to 40 years were allocated into 2 equally matched groups.

RESULTS

Function and pain scores in the study group were not significantly different from control group scores at baseline (VISA-A: 22.2 ± 6.5 vs 21.0 ± 5.2 and VAS: 8 ± 1 vs 8 ± 1, respectively). Both groups significantly improved posttreatment (VISA-A: 85 ± 6.2 vs 53.4 ± 7.7 and VAS: 1 ± 2 vs 7 ± 2, respectively). At the 16-month follow-up, outcome scores declined slightly but significantly in the study group (VISA-A: 80 ± 5.3; VAS: 3 ± 2) and improved in the control group (VISA-A: 67 ± 5.6; VAS: 5 ± 1). However, both groups were significantly better than baseline. At both time points, the study group had significantly superior scores (statistically and clinically) than the control group (P = .0001).

CONCLUSION

Combining calf eccentric loading with stretching exercises resulted in significant improvements in the pain and functional scores in patients with NAT. Adding ESWT to this combined protocol resulted in significantly greater improvements in both the short and long term.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes

Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.

Approaching Foot and Ankle Injuries in the Ambulatory Setting

Foot and ankle injuries account for a significant volume of primary care office visits each year. Given the incidence of injury and concern for long-term sequelae, it is imperative that primary care physicians familiarize themselves with commonly encountered foot and ankle injuries. Coupling a sound understanding of key anatomic structures with an appropriately gathered history can help to quickly narrow the differential diagnosis in this clinical presentation. This article focuses on key elements from the history and physical examination as well as provides a concise review of imaging modalities and recommended treatment strategies.

Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practising physiotherapists establish the most effective intervention parameters. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations. The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

Biologics in the Treatment of Achilles Tendon Pathologies

Regenerative medicine is gaining more and more space for the treatment of Achilles pathologic conditions. Biologics could play a role in the management of midportion Achilles tendinopathy as a step between conservative and surgical treatment or as an augmentation. Higher-level studies are needed before determining a level of treatment recommendation for biologic strategies for insertional Achilles tendinopathy. Combining imaging with patient's functional requests could be the way to reach a protocol for the use of biologics for the treatment of midportion Achilles tendinopathy and, for this perspective, the authors describe the Foot and Ankle Reconstruction Group algorithm of treatment.

[Tendinopathies of the foot and ankle : Evidence for the origin, diagnostics and therapy]

Tendinopathies of the foot and ankle result in substantial impairment of the mobility of patients and have a high clinical significance. Knowledge of the origin of these diseases has been accumulated over decades from the multitude of intrinsic and extrinsic triggering factors based on biomechanical considerations with an evidence-based medicine (EBM) level 5. A high correlation between tendinopathy and hypervascularization of the Achilles tendon was found in a double-blind randomized prospective study using Doppler ultrasound (EBM level 1) but these results were not reproducible; therefore, the importance of these findings is unclear. Inspection and clinical examination supplemented by ultrasound and magnetic resonance imaging (MRI) are essential to achieve the correct diagnosis. The varying extent of load-dependent irritation of tendons and the surrounding tissues and the individual variation in experience of investigators mean that the results of clinical examinations are difficult to collate or not reproducible and cannot be investigated in studies. The expression of the varying results is difficult to assess even by the use of sonography and magnetic resonance imaging (MRI). Conservative treatment of tendinopathy is based on medical experience (EBM level 5). The effectiveness of physiotherapeutic eccentric loading and extracorporal shock wave treatment (ESWT) for Achilles tendinopathy was demonstrated in several case control studies and series (EBM level 3). Due to the high rate of healing with physiotherapy, surgery should only be performed following a minimum of 6-12 weeks of unsuccessful conservative treatment, because formation of scar tissue on the foot can result in permanent complaints (EBM level 4).