ClInICAl review

Achilles Tendinopathy

Indexing Metadata/Description
      

Title/condition: Achilles Tendinopathy Synonyms: Achilles tendinosis, chronic Achilles tendinitis Anatomical location/body part affected: Posterior heel area; Achilles tendon ICD-9 codes: 726.71 Achilles bursitis or tendinitis ICD-10 codes: M76.6 Achilles tendinitis Reimbursement: No specific issues or information regarding reimbursement have been identified Presentation/signs and symptoms Nagging posterior heel/heel cord pain that reduces walking tolerance and capacity for running or jumping Warm-up reduces pain and stiffness at the beginning of the aggravating activity Tenderness and thickening in distal Achilles tendon Increased pain with stretching calf, as in heel walking or descending steps

Causes & Risk Factors



Causes: The presumptive cause is repetitive microtraumatic tendon injury that becomes degenerative because of an abnormal healing response (the appropriate term for this mechanism being tendinosis, not tendinitis) Pathogenesis: Local tissue hypoxia and impaired metabolism probably contribute to noninflammatory collagen disorientation that weakens tendon fibers.(1) The etiology of pain in Achilles tendinopathy has not been elucidated. Advanced cases show increased capillary circulation in the paratendon. This neovascularization clearly develops along with histological evidence of collagen degeneration and decreased tensile strength.(2) Eccentric exercise therapy for Achilles tendinopathy has been associated with both reduced pain and decreased capillary paratendon blood flow(3) Risk factors: Insertional Achilles tendinopathy (focal tenderness at or near calcaneal insertion) is more common in older, more sedentary individuals,(4) whereas noninsertional Achilles tendinopathy is prevalent among athletes who participate in running and jumping sports(5) Intrinsic factors weakly associated with increased risk include older age, Achilles tendon malalignment, subtalar hyperpronation, decreased passive dorsiflexion, and hyperlipidemia(6, 7) Use of fluoroquinolone antibiotics may also increase risk(8) Changing from high to low heeled shoes Training errors (i.e. rapid increase in running distance, running on sloped roads)

Author
Rudy Dressendorfer, PhD, PT

Overall Contraindications/Precautions


Reviewers
Joanne Minichillo, PT Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

 

A healthy Achilles tendon has greater tensile strength than fibers of the gastrocnemius and soleus muscles.(5) Current opinion is that Achilles tendinopathy predisposes to weakening of the calf muscle-tendon complex.(1, 2, 6, 7) To reduce the risk of exercise-related partial and complete tears, gradually introduce and slowly progress calf muscle eccentric training(9) Similarly, avoid intense Achilles tendon stretching in early rehabilitation Periods of immobilization should be minimized to prevent further weakening

Examination


Editor
Sharon Richman, MSPT Cinahl Information Systems

July 18, 2008

History History of present illness/injury: Patients usually report 4 weeks or more of sharp, nagging pain above heel, especially with first steps after sitting; initially pain and stiffness localized to distal Achilles tendon; limited ankle flexibility in heel walking; inability to stand on heels Mechanism of injury or etiology of illness: Inquire about whether regular activities involve stair climbing, uphill walking, running, or jumping

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 Course of treatment

 Medical management: Conservative treatment (including physical therapy interventions) is usually attempted before surgical

consult  Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken? Steroid injections are not recommended for this condition(10)  Diagnostic tests completed: Ultrasonography and MRI supplement the clinical assessment and may influence the treatment plan by disclosing partial tears of the Achilles tendon  Home remedies/alternative therapies: Document any use of home remedies (e.g. ice or heating pack) or alternative therapies (e.g. acupuncture) and whether they help or not  Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and what specific treatments were helpful or not helpful Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased). Patient may report pain with first steps after sitting, with standing on their heels, with climbing stairs, running, jumping, walking. Pain is commonly eased with warm-up prior to activity. Body chart: Use body chart to document location and nature of symptoms. Pain is commonly located above the heel, on the distal Achilles tendon. Nature of symptoms: Document nature of symptoms (constant vs. intermittent, sharp, dull, aching, burning, numbness, tingling). Patient commonly reports sharp, nagging pain and stiffness. Rating of symptoms: Use a visual analog scale or 0-10 scale to assess symptoms at their best, worst and at the moment (specifically address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day, PM, night); also document changes in symptoms due to weather or other external variables. Pain is usually related to activity rather than time of day Sleep disturbance: Document # of wakings/night Other symptoms: Document other symptoms patient may be experiencing which could exacerbate the condition and/or symptoms that could be indicative of a need to refer to physician (dizziness, bowel/bladder/sexual dysfunction, saddle anesthesia) Barriers to learning: No  Are there any barriers to learning? Yes  If Yes, describe ________________________________________ Medical history Past medical history:  Previous history of same/similar diagnosis: Past history of Achilles trauma? Prior treatment for Achilles pain or general lowerextremity injuries and outcome of treatment  Comorbid diagnoses: Ask patient about other problems including diabetes, cancer, heart disease, pregnancy, psychiatric disorders, orthopedic disorders, etc. Hyperlipidemia increases the risk of Achilles tendonitis  Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken (including over-thecounter drugs). Use of fluoroquinolone antibiotics may increase risk of Achilles tendonitis  Other symptoms: Ask patient about other symptoms he/she may be experiencing that may necessitate immediate referral to physician such as bowel or bladder dysfunction, saddle anesthesia, or dizziness Social/occupational history Patients goals: Document what the patient hopes to accomplish with therapy and in general Vocation/avocation and associated repetitive behaviors, if any: (e.g., does the patient participate in recreational or competitive sports?) Insertional Achilles tendinopathy (focal tenderness at or near calcaneal insertion) is more common in older, more sedentary individuals,(4) whereas noninsertional Achilles tendinopathy is prevalent among athletes who participate in running and jumping sports.(5) Functional limitations/assistance with ADLs/adaptive equipment: Common functional limitations include stair climbing, walking, running, and jumping. Patient may report use of assistive device for ambulation. Functional limitations may include stair climbing, running, and jumping Living environment: stairs, #floors in home, with whom does patient live, caregivers, etc.; Identify if there are barriers to independence in the home; any modifications necessary? Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Assistive and adaptive devices: Assess need for (and proper fit) of crutches, cane, or walker, if applicable, for protected ambulation Circulation: Pedal pulses should be equal bilaterally Cranial/peripheral nerve integrity: Sensation in the distribution of the sural nerve should be intact. Assess talocrural joint proprioception Gait/locomotion: Inspect walking gait for reduced push-off and lack of full knee extension at mid-stance Joint integrity and mobility: Assess passive accessory movement of the talocrural and subtalar joints Muscle strength: Assess strength of ankle plantarflexors and dorsiflexors. Compare to contralateral side. Manual muscle testing may not reveal weakness; generally the forces required to elicit pain are higher than the force used to test strength(1)

 Observation/Inspection/Palpation: Assess for thickening, adhesions, or nodules that accompany Achilles tendinosis. Crepitation (wet

leather sign) in Achilles tendon may be palpable with passive ankle motion. In noninsertional Achilles tendinopathy, tenderness is usually found 2 to 6 cm proximal to the calcaneal attachment.(5, 7) The point of maximum tenderness should move up and down the leg with ankle dorsiflexion and plantarflexion(5) Posture: Assess alignment of the leg, affected Achilles tendon and foot in barefoot standing (with side-by-side comparison to uninvolved side) and also for pelvic shift to unweight involved leg. Assess subtalar alignment for hyperpronation using navicular drop test Range of motion: Assess active and passive ROM at talocrural joint, especially the stiffness/flexibility of calf muscles in dorsiflexion and forward lunge or wall lean. Assess flexibility of the calf complex in standing with the foot in pronation and supination (using a wedge, if necessary, to evert and invert the subtalar joint), noting the pain response for each position Reflex testing: Patellar and Achilles tendon reflexes are usually intact and equal bilaterally. Changes in reflexes indicate nervous system involvement Special tests specific to diagnosis: Compare results of Thompsons calf squeeze test bilaterally to rule out rupture (see Clinical Review on Achilles Tendon Rupture; Accession Number: 5000005213). Assess for provocation of pain with passive ankle dorsiflexion. Measure pain using visual analog scale (VAS). Provocative tests to reproduce pain: 1-leg squats and drop (plyometric) jumps. Compare affected leg to uninvolved side

Assessment/Plan of Care


Contraindications/precautions A healthy Achilles tendon has greater tensile strength than fibers of the gastrocnemius and soleus muscles.(5) Current opinion is that Achilles tendinopathy predisposes to weakening of the calf muscle-tendon complex.(1, 2, 6, 7) To reduce the risk of exercise-related partial and complete tears, gradually introduce and slowly progress calf muscle eccentric training(9) Avoid intense Achilles tendon stretching in early rehabilitation Contraindications to cryotherapy include Raynauds syndrome, medical instability, cryoglobinemia, cold urticaria, and paroxymal cold hemoglobinuria. Avoid applying cold over superficial nerves, areas of diminished sensation, poor circulation or slow-healing wounds(11) Precautions for cryotherapy(11) Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue treatment if there is an elevation in blood pressure Use caution with patients who are hypersensitive to cold Avoid aggressive treatment with cold modalities over an acute wound Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote muscle relaxation and decrease in pain Contraindications to heating modalities include application over areas with decreased sensation, vascular insufficiency, recent or potential hemorrhage, malignancy, acute inflammation, or infection. Do not use heat over areas where heat rubs or liniments have been recently used. Do not use heat if unable to determine sensory deficits in patients with cognitive deficits or if a language barrier is present(12) Precautions for LLLT(12) Goggles with an appropriate optical density rating should be worn Do not use LLLT in patients with epilepsy, fever, malignancy, decreased sensation, or infection. Avoid using LLT over the epiphyseal plates in skeletally immature children, over the gonads, sympathetic ganglia, vagus nerve or mediastinum Contraindications to use of LLLT(12) Do not use laser with pregnant women Do not use over the unclosed fantanelles of children Do not use over cancerous lesions, the cornea, endocrine glands, and over hemorrhaging lesions Contraindications to therapeutic ultrasound; do not use(12) Over the region of a cardiac pacemaker Over the pelvis, abdominal and lumbar regions during pregnancy Over the eyes and testes In a area with infection or bleeding If a tumor or malignancy is present in the area In the area of a deep vein thrombosis or thrombophlebitis Over the heart, stellate or cervical ganglia Over epiphyseal plates of growing bones Precautions to therapeutic ultrasound(12) Use caution in patients with sensory deficits or in patients that are unable to communicate sensory deficits Use caution if patient has circulatory impairments Use caution over plastic or metal implants Always decrease ultrasound intensity if the patient complains of discomfort Diagnosis/need for treatment: Chronic Achilles tendon injury with antalgic gait and general impairment in functional capacity for work or sport

Rule out: Tibial stress fracture Posterior tibialis tendonitis Pre-Achilles bursitis Retrocalcaneal bursitis Plantaris tendonitis Achilles partial rupture Prognosis: Conservative treatment will likely lead to full recovery for most Achilles tendinopathy cases.(1) In an 8-year follow-up study of 83 patients treated nonoperatively, 84% had full recovery of prior activity and 94% were asymptomatic or had only mild pain on strenuous exercise. (Note: these statistics include the 29% who had surgery).(13) Patients with severe types of insertional Achilles tendinosis on magnetic resonance imaging (MRI) are more likely to be nonresponders to conservative treatment than patients with less degenerated tendons(14) Other Considerations: Current opinion is that Achilles tendinopathy should be conservatively managed for at least 3 to 6 months.(5) Initially, determine whether symptoms decrease with either complete avoidance of the aggravating activity, a trial of decreased intensity, duration and frequency, or cross-training Expected Progression
Joint and soft tissue mobilization techniques may help to decrease pain

Problem
Achilles pain on weight bearing

Goal
Minimal or no pain on unassisted ambulation

Intervention
Ice pack or cold whirlpool to control pain In a small, randomized controlled study, low-energy shock wave therapy in chronic (6 months or more) recalcitrant insertional Achilles tendinopathy was associated with better VISA-A outcomes at 4 months than eccentric loading.(15) Further research is needed to define the indications for this treatment modality The effectiveness of low-level laser therapy (LLLT) in addition to eccentric exercise has not been established. A pilot study where all patients preformed an eccentric exercise program for 12 weeks and were randomized to either LLLT (810 nm, 100 mW, applied to six points on the tendon for 30 s, for a total dose of 3 J per point and 18 J per session) or placebo. There were significant improvements in VISA-A scores and pain at 4 and 12 weeks for both groups. The study was underpowered; therefore, no conclusions can be made on the effectiveness of LLLT(16)

Home Program
Provide patient with written instructions on the appropriate use of ice, avoidance of aggravating activities and proper footwear

Problem
Antalgic gait (possibly requiring assistive device)

Goal

Intervention
Unload stress with appropriate assistive ambulatory device in cases with severe antalgic gait Correct hyperpronation with foot orthotics or motion control athletic shoes

Expected Progression
Gait training without assistive device

Home Program
Provide patient with written instructions for safe use of foot orthotics including gradually increasing time used to avoid further pain

Restricted ankle ROM

Full ankle active ROM

Initiate active and activeassistive ROM in a pain free range Warm whirlpool or heating agent to increase local tissue temperature and relax calf muscle prior to exercise therapy Continuous therapeutic ultrasound may increase tissue elasticity prior to manual therapy; however, no evidence is available to support the use of therapeutic ultrasound or other electrical modalities specifically for treating Achilles tendinopathy Night splinting for chronic midportion Achilles tendinopathy does not add any benefit when combined with an eccentric exercise program(18)

Progress as appropriate to Achilles stretches (see HEP column) Augmented soft-tissue mobilization (deep friction massage followed by passive and active stretching) may help activate fibroblastic collagen remodeling(17)

Patient sits on edge of chair with towel forming sling under ball of foot, push foot against resistance to stretch gastrocnemius when knee extended and soleus when knee flexed 30 Achilles stretch stand with legs straight on balls of feet on curb or step, drop heels down and hold stretch for 30 seconds in extended position, repeat 3x daily

Reduced lower extremity strength

Normal lower extremity strength

Introduce pool and/or lowimpact exercises during the protection phase of early rehabilitation(19)

Progress to land-based eccentric strengthening and stretching exercises for both insertional and noninsertional Achilles tendinopathy.(9, 20) Continuing Achilles tendonloading activity, such as easy running and jumping, during the first 6 weeks of rehabilitation was found to be equally as effective as active rest at 12-months follow-up(21)

Stretch-contract-relaxstretch technique works best with prolonged contractions (30 seconds) Two-legged heel raises to regain calf strength once flexibility regained (after few days to weeks) with gradual shifting of weight from uninjured to injured leg

Problem
Deficits in functional capacity for regular activities

Goal
Return to prior activity level

Intervention
Two systematic reviews suggest that high-load eccentric exercise reduces pain and restores function in non-insertional Achilles tendinopathy, although more research is needed because of methodological weaknesses in most of the studies(9, 22) Continuing Achilles tendonloading activity, such as easy running and jumping, during the first 6 weeks of rehabilitation was found to be equally as effective as active rest at 12-months follow-up(21)

Expected Progression
Introduce high-impact exercises for athletes returning to sport

Home Program
Instruct patient in total body endurance activities applicable to patients activity level

Desired Outcomes/Outcome Measures



The Victorian Institute of Sports Assessment-Achilles (VISA-A) Questionnaire is a valid and reliable outcome measure developed specifically for Achilles tendinopathy(23) It measures two factors: pain/symptoms and functional activity

Full symptomatic recovery does not ensure full recovery of muscle-tendon function in Achilles tendinopathy.(11) Studies are needed, therefore, to determine whether return to sport increases risk of further Achilles injury.

Maintenance or Prevention

Coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations

References
McShane JM, Ostick B, McCabe F. Noninsertional Achilles tendinopathy: pathology and management. Curr Sports Med Rep. 2007;6(5):288-292. (RV) 2. de Mos M, van El B, DeGroot J, et al. Achilles tendinosis: changes in biochemical composition and collagen turnover rate. Am J Sports Med. 2007;35(9):1549-1556. (R) 3. Knobloch K, Kraemer R, Jagodzinski M, Zeichen J, Meller R, Vogt PM. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic Achilles tendinopathy. J Orthop Sports Phys Ther. 2007;37(5):269-276. (RCT) 4. Aronow MS. Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy). Clin Podiatr Med Surg. 2005;22(1):19-43. (RV) 5. Krolo I, Viskovic K, Ikic D, Klaric-Custovic R, Marotti M, Cicvara T. The risk of sports activities the injuries of the Achilles tendon in sportsmen. Coll Antropol. 2007;31(1):275-278. (RV) 6. Koike Y, Uhthoff HK, Ramachandran N, et al. Achilles tendinopathy. Crit Rev Phys Rehabil Med. 2004;16(2):109-132. (RV, X) 7. Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. J R Soc Med. 2004;97(10):472-476. (RV) 8. Greene BL. Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Phys Ther. 2002;82(12):1224-1231. (X) 9. Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med. 2007;41(6):e3. (SR) 10. DaCruz DJ, Geeson M, Allen MJ, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64-65. (RCT) 11. Silbernagel KG, Thomee R, Ericksson BI, Karlsson J. Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. Br J Sports Med. 2007;41(4)276-280. (R) 1.

12. Michlovitz SL, Nolan TP. Modalities for Therapeutic Intervention, 4th edition. Philadelphia: F.A. Davis Company; 2005. (GI) 13. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long-term prognosis of patients with Achilles tendinopathy: an observational eight-year follow-up study. Am J Sports Med. 2000;28(5):634-642. (R) 14. Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 2007;28(4):472-477. (R) 15. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am. 2008;90(1):52-61. (RCT) 16. Tumilty S, Munn J, Abbott JH, McDonough S, Hurley DA, Baxter GD. Laser therapy in the treatment of Achilles tendinopathy: a pilot study. Photomed Laser Surg. 2008;26(1):25-30. (R) 17. Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc. 1999;31(4):531-535. (R) 18. de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41(7):e5. (RCT) 19. Beneka AG, Malliou PC, Benekas G. Water and land-based rehabilitation for Achilles tendinopathy in an elite female runner. Br J Sports Med. 2003;37(6):535-537. (X) 20. Hennessy MS, Molloy AP, Sturdee SW. Noninsertional Achilles tendinopathy. Foot Ankle Clin. 2007;12(4):617-641, vi-vii. (RV) 21. Silbernagel KG, Thomee R, Ericksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897-906. (R) 22. Hootman JM. High load eccentric exercise for treatment of chronic Achilles tendinopathy: a systematic review. J Athl Train. 2004;39(2):S99. (SR) 23. Robinson JM, Cook, JL, Purdam C, et al The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35(5)335-341. (R)