Achilles Tendinopathy
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achilles tendonitis
achilles tendinopathy
achilles tendinitis
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achilles tendinopathy and diagnostic procedures
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Definition and mechanism of injury
Achilles tendinitis is a common overuse injury caused by an excessive stretching or tearing of the Achilles tendon in an acute context. This can lead to a sudden injury, or in the worst case, can cause a rupture of the Achilles tendon. In both cases, a lack of flexibility or a stiff Achilles tendon can increase the risk of these injuries. Clain, Michael R., and Donald E. Baxter. "Achilles tendinitis." Foot & Ankle International 13.8 (1992): 482-487. Level 2A
A lot of descriptions are given concerning Achilles Tendinopathy. Usually a difference is made between the insertional and the mid portion form. The difference is in the localisation. The insertional form is situated at the level of transition between the Achilles tendon and the bone. The midportion form is located at the level of the tendon body. It is described as the gradually emerged of pain 2-6 cm above the calcaneal insertion of the Achilles tendon, associated with degenerative changes and often with thickening of the tendon (Alfredson, 2003; Jozsa et al., 1997; Movin et al., 1997; Paavola et al., 2002a). VAN DER, Arnt, and Liselot VAN DE WALLE. "HET EXCENTRISCH TRAINEN VAN DE KUITSPIEREN." Level 1B Surgical specimens show a range of degenerative changes of the affected tendon, such as in the tendon fibre structure and arrangement as well as an increase in glycosaminoglycans, which may explain the swelling of the tendon. T E O Schubert, C. W. (2005). Achilles tendinosis is associated with sprouting of substance P positive nerve fibres. Ann Rheum Dis , 1083-1086.fckLR Level 3B The precise cause of tendonitis remains unclear. Even though tendonitis of the achilles tendon is often connected to sport activities, the ailment is also often found with people who do not practice sports. The biggest cause is the excessive overburdening of the tendon. A light degeneration of the achilles tendon can be latently present, but pain only appears when the tendon is overburdened. It is also noted that the ailment is usually not preceded by a trauma. John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A, MIKA PAAVOLA, M. P. (2002). Current Concepts Review Achilles Tendinopathy . THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED , 2062-2076.
The terms “tendinose”, “tendonitis” or “tendinitis” and “tendinopathy” are commonly used. (Paavola et al., 2002a). The definitions of those terms are often described in a different manner. Because of that, it's difficult to evaluate articles and to compare them (Alfredson, 2003). Van Sterkenburg, M. N. (2006). Achilles tendinopathy: new insights in cause of pain, diagnosis and. Foot Ankle Clin, 11(2), 421-7. Level 1B Tendinitis is the inflammation of the tendon and is caused by micro-tears that happen when the musculotendinous unit is acutely overloaded with a tensile force that is too heavy and/or too sudden. Evelyn Bass. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters Int J Ther Massage Bodywork. 2012; 5(1): 14–17.fckLRPublished online Mar 31, 2012. Achilles tendonitis is commonly seen in athletes who sustain an increase in training load, and is most often due to overuse. Tendons respond poorly to overuse, therefore healing is slow. This can leave a tendon pathologically defective, which decreases tendon strength and leaves it less able to tolerate load, thus vulnerable to further injury Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130. or tendinosis. Extrinsic factors contributing to this condition include training errors and inappropriate footwear. Intrinsic factors include inflexibility, weakness and malalignment. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy - a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14:286-295. In other situations, there will be clinical inflammation, but objective pathologic evidence for cellular inflammation is lacking, and in these conditions the term tendonitis is more appropriate. Tendonitis is a degeneration of the tendon’s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury. Even tiny movements, such as clicking on a mouse, can cause tendinosis, when done repeatedly.
Achilles tendonitis is a degenerative change of the Achilles Tendon associated with pain and often with the thickening of the tendon. It is common in athletes, but it also occurs in non athletes. Surgical specimens show a range of degenerative changes of the affected tendon, such as changes in tendon fibre structure and arrangement as well as an increase in glycosaminoglycans, which may explain the swelling of the tendon. T E O Schubert, C. W. (2005). Achilles tendinosis is associated with sprouting of substance P positive nerve fibres. Ann Rheum Dis , 1083-1086.fckLR Level 3B The precise cause of tendonitis remains unclear. Even though tendonitis of the achilles tendon is often connected to sport activities, the ailment is also often found with people who do not practice sports. The biggest cause is the excessive overburdening of the tendon. A light degeneration of the achilles tendon can be latently present, but pain only comes into being when the tendon is overburdened. It is also noted that the ailment is usually not preceded by a trauma. John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A, MIKA PAAVOLA, M. P. (2002). Current Concepts Review Achilles Tendinopathy . THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED , 2062-2076. Tendonitis is often confused with tendonitis, but it is important to understand the difference between these two pathologies. Tendonitis is an inflammation of the tendon. This inflammation causes micro-tears in the tendon when it is acutely overloaded. This diagnosis is often mistakenly used when the patient actually has tendonitis. Tendonitis is a degeneration process in which no temperature rises occur, as opposed to tendonitis. It is very important to distinguish between these disorders, to discover which treatment is required, and what the expected duration of the treatment will be. The healing time for tendonitis is generally shorter, and commonly takes several days to 6 weeks. For tendinosis, the expected duration is variable, this can be 6-10 weeks, but it might also take 3-6 months, when the tendonitis has become chronic. K M Khan, a. p. (2002). Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology . BMJ , 324:626.fckLR Level 2A, Evelyn Bass, L. (2012). Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. Int J Ther Massage Bodywork. , 5(1): 14–17.fckLR Level 2C
Clinically Relevant Anatomy
<img src="/images/thumb/7/76/Achilles_tendon.jpg/200px-Achilles_tendon.jpg" _fck_mw_filename="Achilles tendon.jpg" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_type="thumb" alt="Achilles Tendon" class="fck_mw_frame fck_mw_right" /> The achilles tendon is the biggest and strongest tendon in the human body. The tendon has the capacity to resist large tensile forces. It stems from a distal confluence of the gastrocnemius and soleus muscle and inserts at the bottom of the calcaneus. Like other tendons, Achilles has a hierarchical structure. Freedman, Benjamin R., Joshua A. Gordon, and Louis J. Soslowsky. "The Achilles tendon: fundamental properties and mechanisms governing healing." MLTJ Muscles, Ligaments and Tendons Journal 4.2 (2014): 245-255. Level 2A The M. soleus is a prime mover plantar flexor of the ankle and the m. gastrocnemius is a flexor of the knee. A typical tendon structure consists of thin, cylindrical cells and an extracellular matrix. The cells of the tendon, respectively tenocytes tenoblasts, are responsible for the synthesis of all of the components of the extracellular matrix. Inside the matrix we find bundles of type I collagen and elastin. This type-I collagen is responsible for the strength of the tendon. Between the collagen there is a ground substance located which is made up of proteoglycans and glycosaminoglycans. VAN DER, Arnt, and Liselot VAN DE WALLE. "HET EXCENTRISCH TRAINEN VAN DE KUITSPIEREN." Level 1B The achilles tendon is surrounded by parthenon and not by the common known synovial membrane. The parthenon works as an elastic sleeve around the tendon which allows the tendon to move freely between surrounding tissue. The parthenon consists out a layer of cells and is responsible for blood transportation of the tendon. The layers that are formed under the parthenon are in chronological order: the epitenon which is a thin membrane and the endotenon wichon his turn surrounds the collagen fibers which results in bundles. Kiewiet, Nathan J., et al. "Gastrocnemius recession for chronic noninsertional Achilles tendinopathy." Foot &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; ankle international (2013): 1071100713477620. Level 4
Epidemiology / Etiology
The etiology of Achilles tendonitis is still unclear. Straining the tendon during physical exercise has been seen as one of the biggest pathological stimulus. Systematic overloading of the Achilles tendon above his physiological limit can cause a micro-trauma.
Repetitive micro-traumas that are linked with a non-uniform tension between the M. gastrocnemius and M.soleus, cause frictional forces between the fibers and abnormal concentrations of the loading in the achilles tendon. This has consequences such as the inflammation of the tendon sheath, degeneration, or a combination of both. Without the minimum time for recovery, this can lead to a tendinopathy. Young, Jonathan S., and N. Maffuli. "Etiology and epidemiology of Achilles tendon problems." The Achilles Tendon (2007): 39-49. Level 2B
In acute trauma, the external factors dominate , while injuries caused by overuse generally have a multifactorial origin. The acute phase of Achilles tendinopathy is caused by acute overload, blunt trauma or acute muscle fatigue, and is characterized by an inflammatory reaction and edema formation. If the treatment of the acute phase fails or if they overlooked it, it can cause a fibrin and form adhesions off the tendon.
Often, tendon degeneration is found in combination with peritendinous adhesions, but this does not mean that one condition causes the other one. Decreased arterial blood flow, local hypoxia, decreased metabolic activity, nutrition, and a persistent inflammatory response have been suggested as possible factors that could lead to chronic tendon overuse injuries and tendon degeneration.
In epidemiological studies, various alignments and biomechanical faults are claimed to play a causative role in two-thirds of the athletes with an Achilles tendon disorder.
The most common and perhaps the most important malalignment is the one of the ankle caused by hyperpronation of the foot. Increased foot pronation has been proposed to be associated with Achilles tendinopathy.
So we can say that the effects of overuse, poor circulation, lack of flexibility, gender, endocrine or metabolic factors can lead to tendinopathies. The structure of the tendon is disturbed by this repetitive strain (often eccentric nature) and collagen fibers go along together, break the crosslinks and the slide denaturation cause tissue, causing inflammation. This cumulative microtrauma is assumed not only weaken collagen cross-linking, but also the collagenous matrix and the vascular elements of influencing the tendon, which ultimately leads to tendonitis. Paavola, M., Kannus, P., Järvinen, T. A., Khan, K., Józsa, L., &amp;amp;amp;amp;amp;amp;amp;amp;amp; Järvinen, M. (2002). Achilles tendinopathy. J Bone Joint Surg Am, 84(11), 2062-2076. Level 2B
Clinical representation
Morning pain is a hallmark symptom because the achilles tendon must tolerate full range of movement including stretch immediately after getting up in the morning. Symptoms are typically localized to the tendon and the immediate surrounding area. Swelling and pain are less common. The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130. With people who have a tendinopathy of the achilles tendon that has a sensitive zone, combined with intratendinous swelling, that moves along with the tendon and of which sensitivity increases or decreases when the tendon is put under pressure, there will be a high predictive value that in this situation there is a case of tendinosis. KL. Luscombe, P. S. (2003). Achilles tendinopathy. Trauma , 215-225.fckLR Level 2C The affected side of the tendon shows a larger diameter, higher stiffness and lower strain in comparison to the non affected side. Patients with an insertion Achilles tendinopathy (IAT) have lower echogenicity, correlated with a higher severity of symptoms. Chimenti, Ruth L., et al. "Altered tendon characteristics and mechanical properties associated with insertional Achilles tendinopathy." Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy 44.9 (2014): 680-689. Level 3B
Symptoms and differential diagnose
Heel pain is a common symptom. There are many causes, but mechanical etiology is the most common. The location of the pain can be a guide to establish the correct diagnosis. The most common diagnosis is plantar fasciitis, a condition that leads to medial plantar heel pain. Other causes of pain can include a plantar heel calcaneal fracture stress. Heel pad syndrome (deep, bruises and pain in the center of the heel). Achilles tendinopathy is a common condition that causes posterior heel pain. This pain is localized to the site of insertion of the affected tendon. Posterior heel pain can also be attributed to an <a href="http://www.physio-pedia.com/Haglund's_deformity">Haglund deformity</a>. This is a prominence of the calcaneus that can cause bursitis between the calcaneus and the Achilles tendon (also called Sever's disease). To differentiate between the causes of pain in the heel can be achieved by a history and physical examination, with the right imaging studies (if indicated). Tu, Priscilla, and Jeffrey R. Bytomski. "Diagnosis of heel pain." American family physician 84.8 (2011). Level 2A Posterior Ankle Impingement, Medial Tendinopathy, <a href="http://www.physio-pedia.com/Retrocalcaneal_Bursitis">Retrocalcaneal Bursitis</a>, Sural Nerve, <a href="http://www.physio-pedia.com/Lumbar_Radiculopathy">Lumbar Radiculopathy</a>, Ankle OA, DVT, Haglund Deformity, Partial Achilles Tendon Rupture. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130.
Diagnostic procedures
Outcome measures
Research
The four cornerstones of tendon histopathology are: 1: cellulaire activation and an increase in cell numbers, 2: an increase in ground substance, 3: collagen disarray and 4: neovascularization. An achilles tendinitis is primarily not seen as an inflammatory condition. However the signs of inflammation are real and irreversible. Research confirms that the inflammation is neurogenic.
The presence of neuropeptides such as ‘substance P’ and of calcitonin genes related to peptides indicate an inflammation in the tendon.
Medical Management
Corticosteroid injections
Sclerosering injections
Rehabilitation after a sclerosing injection consists in 1 - 3 days of rest; then tendon-loading activity increases gradually avoiding maximum loading. After 2 weeks tendon loading activity is allowed (jumping, fast runs, heaving strength training). This research suggests a clinical role for sclerosing therapy for those who fail to respond to eccentric exercise. Alfredson, Håkan, and Jill Cook. "A treatment algorithm for managing Achilles tendinopathy: new treatment options." British journal of sports medicine 41.4 (2007): 211-216. Level 3A (level 3A)
Plateled-rich Plasma injections
Operative surgery
In 75% of subjects who underwent tenotomy experienced a positive result after 18 months. An open procedure of the achilles tendon resulted in better outcomes of tendons without a focal lesion. Alfredson, Håkan, and Jill Cook. "A treatment algorithm for managing Achilles tendinopathy: new treatment options." British journal of sports medicine 41.4 (2007): 211-216. Level 3A (level 3A)
Physical management
==== Active rehabilitation ====
It was shown that strength training, that is stimulated externally and is linked to a motion expert task, not only helps reduce tendon pain but modulate excitatory and inhibitory control of muscle, and thus potentially tendon load. Rio, Ebonie, et al. "Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review." British journal of sports medicine 50.4 (2016): 209-215. Level 3A (level 3A) A popular and effective option is the eccentric strength training. John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A (level 1A)
Eccentric exercises have been shown to have positive effects of Achilles tendonitis. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130., Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy - a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14:286-295. In the past decade, an eccentric training (ECC) has become the main non-surgical choice of treatment for achilles tendinopathy Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286. Level 2A (level 2A) and remains as the gold standard for rehabilitation of this condition. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Manual Therapy 2002;7(3):121-130., Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy - a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14:286-295. But there is no convincing evidence that the most effective exercise regimen. In fact, a recent systematic review concluded that there is little clinical and mechanistic evidence that supports the use of the eccentric component and compare that well-conducted studies of different load programs are largely lacking. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286. Level 2A (level 2A) New loading based exercise regimes such as insulated concentric exercise, heavy slow resistance training (HSR), and eccentric-concentric becoming ECC proposed but lack solid scientific evidence for their effectiveness in achilles tendinopathy. The results of a study suggest that HSR and ECC improve the symptoms and physical activity as well in patients with chronic mid-portion achilles tendinopathy. Beyer, Rikke, et al. "Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy A Randomized Controlled Trial." The American journal of sports medicine (2015): 0363546515584760. Level 1A (level 1A) A study by Roos et al concluded that eccentric exercises improve function and reduce pain and effects were apparent after 6 weeks of treatment, lasting for 1 year. Robinson JM, Cook JL, Purdam C et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British J of Sports Med. 2001;35:335-341. An active exercise program mostly includes eccentric exercises. This can be explained by the fact that eccentric muscle training will lengthen the muscle fibres, which stimulates the collagen production. This form of therapy appears successful for midportion tendinosis, but has less effect with insertion tendinopathy. The sensation of pain sets the beginning burdening of the patient and the progression of the exercises. Bleakley C, M. S. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med , (1):251-61.fckLR Level 1A (level 1A), Brett L Woodley, R. J.‐W. (2007). Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med , 41(4): 188–198.fckLR Level 1A (level 1A), John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A (level 1A) Thorough management guidelines for achilles tendinopathy is covered in detail in the Achilles Tendinopathy Toolkit. A treatment with a combination of 4 weeks of laser therapy prior to 6 weeks of eccentric exercise therapy gives significantly better results than eccentric exercise therapy without laser therapy. Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial. Level 1A (level 1A)
Passive rehabilitation
Nevertheless patients will always have to be encouraged to execute less burdening activities, so that the burden on the tendon decreases as well. Complete immobilisation should however be avoided, since it can cause atrophy. Alex Scott, R. P. (2011). Conservative treatment of chronic Achilles tendinopathy. CMAJ , 183(10): 1159–1165.fckLR Level 1A (level 1A), ohn J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A (level 1A)
Mobilisations
Previous studies have shown that Rocker shoes are able to internal plantar flexion related they have conducted research on the Achilles tendon to people who walked with the rocker and without shoes. People who walked with the rocker shoes cause a significant reduction in plantar flexion moment in the late stance phase of walking. Sobhani, Sobhan, et al. "Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy." Journal of Science and Medicine in Sport 18.2 (2015): 133-138. Level 2A (level 2A)
Soft tissue treatment (Astym) plus eccentric exercise appears to be a beneficial treatment program that clinicians should consider incorporating into the management of their patients with insertional AT. McCormack, Joshua R., et al. "Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy A Randomized Controlled Trial." Sports Health: A Multidisciplinary Approach (2016): 1941738116631498. Level 2 (level 2)
Recently, the use of Extracorporeal Shock Wave Therapy was proven. John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A (level 1A), Dykstra JH, H. H. (2009). Comparisons of cubed ice, crushed ice, and wetted ice on intramuscular and surface temperature changes. J Athl Train. , (2):136-41.fckLR Level 2A (level 2A), Sten Rasmussen, M. C. (2008). Shockwave therapy for achilles tendinopathy. A double-blind, randomized clinical trail of efficacy. Acta Orthopaedica , 249-256.fckLR Level 1B (level 1B)
Besides that, the application of ice can cause a short decrease in pain and in swelling. Even though cryotherapy 2, 5 was not studied very thoroughly, recent research has shown that for injuries of soft tissue, applications of ice through a wet towel for ten minutes are the most effective measures. Bleakley C, M. S. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med , (1):251-61.fckLR Level 1A (level 1A), Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286. Level 2A (level 2A), John J. Wilson, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. University of Wisconsin Medical School, Madison, Wisconsin , 1-8.fckLR Level 1A (level 1A)
Nitroglycerin patches have a firming impact on the achilles tendon when applied. [28] (level 3A)
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