Treatment of Achilles Tendinopathy

A stubborn injury that plagues many athletes, especially runners, is achilles tendinopathy. While rest may alleviate the pain in some individuals, as soon as activity is resumed, the symptoms often return.

As with many tendinopathy pathologies, achilles tendinopathy is often diagnosed as tendinitis and treated improperly. It has been shown that neovascularization is abundant in these structures and is not necessarily an inflammation issue (a topic we will examine more closely in the near future!). As with any other injured individual, they will present with many impairments that should be treated regularly (stretching, strengthening, etc.), but there are certain interventions that have been shown to have higher evidence.

Low-Level Laser Therapy (LLLT) is an intervention that is becoming more prominent today in treating many different pathologies, one of which is achilles tendinopathy. In the study we looked at, there was no difference between eccentric exercises + placebo and eccentric exercises + LLLT (actually the placebo group performed better in one of the outcomes!). Consider this evidence when choosing your interventions.

As you might have expected, eccentric exercises have been shown to be the best treatment method for patients with achilles tendinopathy. Even after 5 years of treatment, improvements were shown; although, some pain was still present in some individuals. One of the issues with using eccentric exercises for individuals with achilles tendinopathy that has become prevalent is the effectiveness for those with insertional vs. mid-portion achilles tendinopathy. Insertional achilles tendinopathy results in the tendon being most painful where it attaches to the calcaneus; mid-portion achilles tendinopathy is proximal to that. The studies have shown high evidence in regular eccentric exercises (loading into dorsiflexion) for mid-portion pain, but not insertional pain. However, there has been recent research that shows a modification of the exercise can improve the results of insertional pain. Perform the eccentric exercise the normal way, except do not load into dorsiflexion. Approximately 2/3 of the sample showed improvements!

Another alternative treatment method that is becoming more well-known involves using autologous-combined plasma injections combined with standard treatments-wearing a pneumatic boot, receiving ultrasound, and eccentric exercises. Occasionally, you hear about professional athletes receiving this type of treatment for other joints in Europe, since it is not usually performed in the U.S. While the study is still preliminary, it's still something to keep your eye on in the future!

References:
Deans VM, Miller A, Ramos J. "A Prospective Series of Patients with Chronic Achilles Tendinopathy Treated with Autologous-conditioned Plasma Injections Combined with Exercise and Therapeutic Ultrasonography." J Foot Ankle Surg. 2012 Jul 21. Web. 09/09/2012.

Fahlström M, Jonsson P, Lorentzon R, Alfredson H. "Chronic Achilles tendon pain treated with eccentric calf-muscle training." Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. Epub 2003 Aug 26. Web. 09/09/2012.

Jonsson P, Alfredson H, Sunding K, Fahlström M, Cook J. "New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study." Br J Sports Med. 2008 Sep;42(9):746-9. Epub 2008 Jan 9. Web. 09/09/2012.

Mafi N, Lorentzon R, Alfredson H. "Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis." Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42-7. Web. 09/09/2012.

Tumilty S, McDonough S, Hurley DA, Baxter GD. "Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles' tendinopathy: a randomized controlled trial." Arch Phys Med Rehabil. 2012 May;93(5):733-9. Web. 09/09/2012.

van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A, Tol JL. "A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy." Br J Sports Med. 2012 Mar;46(3):214-8. Epub 2011 Nov 10. Web. 09/09/2012.

Verrall G, Schofield S, Brustad T. "Chronic Achilles tendinopathy treated with eccentric stretching program." Foot Ankle Int. 2011 Sep;32(9):843-9. Web. 09/09/2012.

A more developed review of the research behind these and many more interventions is located in the practice guidelines below for achilles tendinopathy!

Carcia CR, Martin RL, Houck J, Wukich DK. "Achilles pain, stiffness, and muscle power deficits: achilles tendinitis." J Orthop Sports Phys Ther. 2010 Sep;40(9):A1-26. Web. 09/09/2012.

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