Pathophysiology, Diagnosis, management and Prevention of Achilles Tendinopathy

1. Achilles
Tendinopathy
D R . S O U V I K B H AT TA C H A R J E E
J U N I O R R E S I D E N T ( A C A D E M I C )
D E PA R T M E N T O F P H Y S I C A L M E D I C I N E & R E H A B I L I TAT I O N
A I I M S B H U B A N E S A R .

2. INDEX
Introduction
Types
Mechanism of injury
Pathophysiology
Risk factors
Diagnosis
Management
Prevention

3. INTRODUCTION
Achilles tendinopathy is a painful overuse
injury of the Achilles tendon. This injury is
common among athletes,
Among elite track and field athletes, 43%
reported having either current or prior
symptoms of Achilles tendinopathy. ( Highest
prevalence [83%] in middle-distance runners)
65% of injuries are found in general public
which are not sport related.

4. TYPES
Achilles tendinopathy is a clinical diagnosis and majority of the patients come with a combination of-
localized pain, swelling of the Achilles tendon and loss of function.
According to location of the pain, Achilles tendinopathy can be classified as -
1. Insertional tendinopathy ( 20-25% )
2. Non-insertional or Midportion tendinopathy (55-65%)
3. Proximal musculotendinous junction type (9-25%)
Patient can present with symptoms at the insertion and midportion concurrently.
30% patients have bilateral pain.

5. MECHANISM OF INJURY
Achilles tendon is a mechanoresponsive structure.
The most common cause of in athletes is excessive loading with inadequate recovery .
An increase work or daily activity can contribute to excessive loading.
A fixed forefoot equinus results in compensation at the ankle joint by dorsiflexion and may result an
overuse injury to the tendon.
Compensation at the subtalar joint for imbalance of foot places strain on the tendon. The subtalar
joint may compensate by everting the calcaneus with increase load over the medial side of the
tendon.
A rigid plantar-flexed first metatarsal or cavovarus places strain on lateral side of the tendon.

6. MECHANISM OF INJURY
Cook & Purdum
TENDON CONTINUUM
For staging tendinopathy based on the
and distribution of disorganisation of

7. PATHOLOGY
The main pathology is a failed healing response, with degeneration and haphazard proliferation of
tenocytes, disruption of collagen fibers and increase in non-collagenous matrix.
Histopathologically the samples show unequal and irregular crimping and loosening and increased
waviness of collagen fibers, with an increase of type iii collagen fibers.
Hypoxic, hyaline degeneration, calcification, fibro-cartilaginous and bony metaplasia can coexist.

8. RISK FACTORS
INTRINSIC
1. Tendon vascularity
2. Weakness & lack of flexibility of the gastrocnemius-
soleus complex
3. Pes cavus
4. Deficits in Hip neuro-muscular control
5. Lateral ankle instability
6. Dyslipidemia
7. obesity
EXTRINSIC
1. Excessive loading on the tendon
2. Fluroquinolone
3. Corticosteroids
4. Training load errors

9. SYMPTOMS & SIGNS
SYMPTOMS
Gradual onset of pain with activity & reduced
function
Stiffness in morning and after prolonged
sitting or after a period of inactivity
Deficit in strength & performance
SIGNS
Tenderness
Sometimes a nodular swelling can be
palpated
The ARC sign
The Royal London Hospital Test

10. CONFIRMATORY TEST FOR
MIDPORTION TENDINOPATHY
ARC SIGN
Palpate the tendon to locate any
nodule
Pinch the nodule and ask the
patient to actively dorsiflex &
plantarflex the ankle
Movement of the thickened
nodule
ROYAL LONDON HOSPITAL TEST
Identification of the most
symptomatic location of the
tendon with foot at rest
Ask the patient to actively dorsiflex
the foot and and again pinch the
area
Reduction of pain on dorsiflexion

11. DIAGNOSTIC TESTS
Blood Investigations:
CBC, ESR, CRP
LFT
Uric acid
FBS,PPBS, HbA1c
Lipid Profile

12. DIAGNOSTIC TESTS
1. Radiographs : To look for any associated bony abnormalities, intratendinous calcific deposits and ossification.

13. DIAGNOSTIC TESTS
2.Ultrasonography :
 Correlates with histopathological finding, doppler to detect neurovascularity
 UTC ( ultrasound tissue characterization)- to quantify tendon structure.
 Shear-wave elastography : To assess the mechanical properties of the tendon

14. DIAGNOSTIC TESTS
3. MRI :
Extensive information about the internal morphology of the tendon , surrounding bony and soft
tissue structure.
Can differentiate paratendinopathy and tendinopathy.

15. FUNCTIONAL IMPAIRMENTS
1. Range of motion : Decreased dorsiflexion ( Non-weight bearing- Goniometer, Weight bearing-
Ankle-lunge test), limitation of plantar flexion, inversion and eversion.
2. Calf muscle endurance : Decreased . Assessment done by Heel-Rise test. The Limb symmetry index
can be calculated to compare the degree of functional deficit between limbs.
3. Calf Muscle strength : Strength deficit is seen due to reduced palntar-flexor strength.
Dynamometry can be used to measure isometric and dynamic strength. Isokinetic dynamometry is
used to assess ankle palntar-flexor and dorsiflexor strength .
4. Jumping ability : Single-legged hopping and drop-countermovement jump can be used to measure
function and degree of pain during activity.

16. MANAGEMENT
Achilles tendinopathy is difficult to treat . Management of AT lacks evidence-based support, and
patients are at risk of long-term morbidity with unpredictable clinical outcome.
Non-operative care should be implemented for a minimum of three to six months prior to
considering surgery.

17. CONSERVATIVE MANAGEMENT
PHARMACOLOGICAL:
1. NSAIDS Commonly used and shows modest efficacy. Effective in only acute cases . Analgesic effect
effect of NSAIDS can impose further damage to the tendon and delay definitive healing.
2. NITRIC OXIDE Can be administered by an adhesive patch (in case of midportion AT). Topical GTN is
is effective in chronic cases of non-insertional AT and treatment benefits upto 3 years.
3. INJECTIONS Several substances have been used for AT injections. Steroid , Dextrose, aprotinin,
sclerosing agents, Local anaesthetic or PRP can be given. Helps in reducing pain, improving activity
level and reducing tendon thickness. High volume injections are found to be more efficacious than
platelet rich plasma in short term.

18. ULTRASONOGRAPHY
GUIDED TECHNIQUE
PREPARATION: Patient is placed in prone position . A pillow or towel is placed under the distal tibia or
hung off the side of the table to allow the foot to hang freely in neutral position. Skin is properly
cleaned and prepared in sterile manner. Topical spray or jelly is used.
SURVEY SCAN : Soft tissue & tendons of the hind foot are visualized along with the posterior surface of
calcaneus.

19. ULTRASONOGRAPHY GUIDED
TECHNIQUE
NEEDLE INSERTION & INJECTION : 25-gauge 1.5 inch standard needle is used
1. Dextrose prolotherapy 2 ml mixture of 1 ml 1% lidocaine and 1 ml of 50% dextrose is given
2. PRP 2-3 ml of platelet rich plasma

20. CONSERVATIVE
MANAGEMENT
NON-PHARMACOLOGICAL:
1. REST It is considered to be a first line of therapy
2. CRYOTHERAPY To reduce metabolic rate of the
tendon, decrease extravasation of blood and protein from
newly formed capillaries.
3. ORTHOTICS Widely used in conservative management.
Heel pads are most commonly used. Air heel brace can be
used in patient who can not tolerate exercise. Night splints
can also be used.

21. CONSERVATIVE MANAGEMENT
4. ECCENTRIC EXERCISES  Promote collagen cross linking.

22. CONSERVATIVE MANAGEMENT
5. Low-energy shock wave therapy and ESWT  Promotes soft tissue healing & inhibit pain
receptors. Combination of shock wave therapy and eccentric exercise is beneficial.
6. Hyperthermia Stimulate repair process, increase drug activity, allow more efficient relief from
pain, removal of toxic wastes, increase tendon extensibility and reduce muscle & joint stiffness.
7. ULTRASOUND THERAPY Insufficient evidence to support a beneficial effect.
8. OTHERS low-level LASER therapy, Taping (antipronation), Iontophoresis and dry needling.

23. SURGICAL INTERVENTION
In 24-46% of patients requires surgical intervention.
Types 1. Simple Percutaneous tenotomy
2. Minimally invasive stripping of the tendon
3. Open procedures

25. SURGICAL INTERVENTION
After surgery rehabilitation is focused on early motion and avoidance of overloading the tendon in
the initial phase.
Initial splinting (CAM walker) and crutch walking
After 2 weeks patient is advised to start active and passive ankle range of motion exercises and early
weight bearing is encouraged.
Extensive debridement and tendon transfer may require protected weight bearing for 4 to 6 weeks
post-operatively.
After 6-8 weeks strengthening exercises are started which gradually progressing polymetric
exercises .

26. EXERCISE REHABILITATION
Rehabilitation can be divided into 4 phases
1. Symptom management & load reduction phase
2. Recovery phase
3. Rebuilding phase
4. Return to sport phase
Exercise to promote tendon recovery is initiated immediately in the symptom-management & load
reduction phase
Sport-specific loading is generally introduced in later phases.

27. SYMPTOM MANAGEMENT & LOAD
REDUCTION PHASE (Wk1-2)
Pain and difficulty with all activities (difficulty in performing 10 one-legged heel raises)
Progress loading with up to 100% of BW with slow, controlled motion
Treatment program: Perform exercise once a day and to use pain-monitoring model
1.Circulation exercises
2. Two-legged heel rises (3 * 10-15 rpt)
3. One-legged heel rises (3*10 rpt)
4. Eccentric Heel rises(3*10 rpt)
5. Sitting heel rises(3*10 rpt)

28. RECOVERY PHASE (WK 2 – 5)
Pain with exercise, morning stiffness and pain while performing heel rises.
Load on the tendon is increased by increasing speed of movement and additional external resistance
Treatment Program : Perform exercise once a day
1. Two-legged heel rises standing on edge of a step (3*15 rpts)
2. One-legged heel rises standing on edge of a step (3*15 rpts)
3. Eccentric heel rises standing on edge of a step (3*15 rpts)
4. Sitting heel rises (3*15 rpts)
5. Quick-rebounding heel rises (3*20 rpts)

29. REBUILDING PHASE (WK 3-12)
No pain at the distal insertion site, decreased morning stiffness.
Continue external resistance exercises and initiate plyometric exercise
Treatment Program : Perform exercise everyday and with heavier load 2-3 times a week
1. One-legged heel rises standing at the edge of a step with added weight (3*15 rpts)
2. Eccentric heel rises standing at the edge of a step with added weight (3*15 rpts)
3. Sitting heel rises (3*15 rpts)
4. Quick-rebounding heel rises (3*20 rpts)
5. Plyometrics training (sport specific)

30. RETURN TO SPORT PHASE (MO 3 -6)
Minimal symptoms, can participate in sports with difficulty
Loading increased from previous phase to include sport-specific loading speed and movement
patterns on high-intensity days.
Treatment Program : Perform exercise 2-3 times a week
1. One-legged heel rises standing at the edge of a step with added weight (3*15 rpts)
2. Eccentric heel rises standing at the edge of a step with added weight (3*15 rpts)
3. Quick-rebounding heel rises (3*20 rpts)

31. ASSESSMENT
Severity of symptoms and participation in activity are assessed using pain scales and outcome
measures and questionnaires.
1. Numeric pain rating scale
2. VISA-A ( The Victorian Institute of Sport Assessment – Achilles questionnaires)
3. FAOS (Foot Ankle Outcome Score)
4. FAAM ( Foot and Ankle Ability Measure)
5. LEFS ( Lower extremity functional scale)
6. CSIM ( Client-specific impairment measure)

32. VISA-A
Evaluate pain & symptom severity
with activity in patients with
Achilles tendinopathy

33. FAOS
Arranged in 5 subclasses:
Pain
Symptoms
Activities of daily living
Sport & recreation function
Foot & ankle related quality of life

34. FAAM
Evaluates changes in functional
ability using 2 subscales:
Activities of daily living
Sports

35. PREVENTION
1. Overloading of the tendon should be avoided
2. Check for early symptoms
3. Monitoring of training load, sport participation and recovery sessions.
4. Periodic monitoring of performance
5. Ultrasound monitoring routinely

36. DIFFERENTIAL DIAGNOSIS
Paratenonitis of Achilles Tendon
Retrocalcaneal bursitis
Sever’s disease
Achilles tendon ossification
FHL tendiopathy
Posterior tibialis tendinopathy
Peroneal tendinopathy
Osteomyelitis of tibia and calcaneus
Neoplasm of tibia and calcaneus
Ostrigonum syndrome
Plantar fasciitis
Ankle Osteoarthritis
Lumbar radiculopathy
Posterior ankle impingement

38. REFERENCES
Delisa’s Physical medicine & rehabilitation
Achilles tendinopathy-Nicola Maffuli, Umile Longo, Filippo Spiezia
Current Clinical Concepts: Conservative Management of Achilles Tendinopathy, Karin Silbernagel
Outcomes of prolotherapy for intra-tendinous Achilles tears, Otto Chan, Ben Havard
Ultrasound-guided Prolotherapy Injections for Insertional Achilles Calcific Tendinosis: Benjamin
Buchanan, Jesse Deluca, Kyle Lammlein

39. THANK YOU