ACHILLES TENDINOPATHY

Transcription

1 ACHILLES TENDINOPATHY Review Article: The Specialist Forum, Sept 2013 The Medical Chronicle, Sept 2013 Dr. Gavin Shang Sports Physician MBBCH (WITS) MPHIL SPORTS MED (UCT/SSISA) Achilles tendinopathy is defined as an overuse, chronic, degenerative condition of the Achilles tendon; essentially representing a failed adaptation to imposed repetitive overload stresses in weight- bearing activities (running, jumping). It can be a difficult condition to treat, as no individual form of treatment seems to benefit every patient, especially if chronic. It is important to address extrinsic (changes in training duration, frequency, type, volume, intensity, gradient or surface; improper technique, inappropriate footwear with poor shock absorption; improper transition into minimalist running) and intrinsic factors (pes cavus, over- pronation, lateral ankle instability, musculo- skeletal inflexibility, loss of collagen fibre elasticity with age, limb length discrepancies) to ensure symptom reduction and resolution; and minimize the risk of recurrence. Histo- pathologic changes include: collagen fibre disruption and disarray; poor intra- tendinous demarcation of normal fibre structure; intra- substance tears; areas of discoloured mucoid degeneration; and especially areas of neo- vascularization. Neo- vascularization or in- growth of new blood vessels into the degenerate area most probably represents an attempted healing response. It has been postulated that the in- growth of new vessels and nerve endings associated with them, contribute to the symptoms of Achilles tendinopathy. This histo- pathologic description applies to the chronic tendinopathy stage. Reversibility of the condition is more probable when symptoms are present without much pathologic intra- substance change (tendinosis stage). In the acute stages of Achilles tendon injury there can be an inflammatory component in the paratenon (paratenonitis) and possibly the tendon (tendinitis) itself.

2 It is classified into insertional and mid- portion (non- insertional) Achilles tendinopathy. Mid- portion tendinopathy is localized to a relatively hypo- vascular watershed region ±5cms from the calcaneal insertion site. Insertional Achilles tendinopathy is more resistant to treatment due to traction effects and possible calcification at the insertion site. Presents typically with gradual pain, swelling and impairment of function that may have a relapsing and remitting course with improvements during periods of rest from aggravating activities. Morning pain and/or stiffness are common complaints. Initially symptoms are apparent at the onset of activity but resolve with continued activity. As the condition progresses, symptoms are present after activity; then become associated with the entire duration of activity; and eventually leads to the inability to perform the desired activity. Severe cases may present with pain at rest. Clinically the tendon is intact but tender to palpation and resisted plantar- flexion. A palpable thickening of the tendon compared to the other side and even a nodule of scar tissue may develop in chronic cases. X- rays are used to demonstrate any tendon calcification or Haglund s deformity (associated with retro- calcaneal bursitis). MRI scans are rarely needed but can be used to assess surrounding soft tissue pathology if suspected. Imaging modalities should be taken in context and should not dominate the clinical decision- making. Musculo- skeletal ultrasound is the most useful and practical investigative modality as it can demonstrate real time imaging of tendon thickening, fibre disruption, paratenon or bursal involvement as well as Doppler visualization of areas of neo- vascularization. Management is through a multimodal approach for the purpose of alleviating symptoms and promoting functional recovery is tailored specifically to the individual s presenting symptoms and signs. Many complementary treatment options exist as no single method of treatment has been shown to be effective when used in isolation. Training errors (mentioned previously) are the most common and modifiable extrinsic risk factor. Relative rest with avoidance of aggravating activities and cross- training modalities are advised. Education, advice and planning on resumption of activity will help prevent recurrence. Heel raises or cushioned lifts are advocated to help offload the Achilles tendon and should be worn bilaterally to avoid gait asymmetry. Night- splints and immobilizing boots/braces are also advocated in some circumstances. Physiotherapy modalities including therapeutic ultrasound, interferential treatment, dry needling and kinesio- taping combined with cryotherapy and oral analgesics are all used to help symptoms. Non- steroidal anti- inflammatory drugs

3 (NSAIDs) should only be used where inflammatory changes are present (retro- calcaneal or retro- Achilles bursitis or paratenonitis). Topical anti- inflammatory preparations can also be considered for symptom relief. Animal studies have shown that tendon healing improves with the addition of nitric oxide or endothelial derived relaxing factor. Paoloni et al demonstrated this beneficial effect (increase in objective tendon strength measures) and subjective symptom relief with topical glyeryl- trinitrate in a randomized controlled clinical trial. The effects are attributed to the local analgesic effect, an effect on global tendon blood flow or an effect on the areas of neo- vascularization. Contra- indicated in patients with known cardiovascular disease (angina pectoris) due to the potential development of tolerance to its vasodilatory effects. Any restricted range of movement disrupts the balance of the kinetic chain and allows for poor force distribution that in turn can be transferred to the Achilles tendon. Assessment and mobilization of the 1 st metatarsal- phalangeal joint; mid- tarsal and sub- talar joints; ankle, knee and hip joints is advised under the guidance of the physiotherapist. Notable associations: certain antibiotics (flouro- quinolones as mentioned above) have been implicated as having a detrimental affect on tendon metabolism; anabolic steroids increase the forces through the tendon due to rapid increases in muscle mass, before the tendon is able to adapt to these changes. Patient education (if possible) is key in both these circumstances. Heavy- load eccentric tensile loading (Alfredson et al) of the musculo- tendinous units, stimulate tendon healing along appropriate lines and allows for gradual adaptation to loading during weight- bearing activities. High frequency oscillations were found to occur more commonly during eccentric than concentric loading. This has been proposed to achieve a greater therapeutic benefit by providing a greater stimulus within the tendon for remodeling. This involves heel- drop exercises with only the forefoot on a raised step. Performed (twice daily, 3 sets of 15 repetitions in a slow and controlled manner) with the knee flexed and then with the knee straight. This allows for both the soleus and gastrocnemius components to be loaded in turn. The heel reaches below the horizontal level of the step for non- insertional compared to not reaching below this level for insertional Achilles tendinopathies (minimizing the traction effect on the Achilles tendon insertion site for insertional tendinopathies). Extra- corporeal shockwave therapy, laser therapy and micro- current therapy have all been shown to be effective when used in conjunction with an eccentric loading program and more efficacious than an eccentric loading program or therapeutic modality being used in isolation. Frequency, duration, dosage; access to specialized equipment as well as practitioner training; and consistency of protocols for clinical and research use, are areas that still need to be addressed.

4 Corticosteroid injections may be useful only where retro- calcaneal or retro- Achilles bursitis is present. These infiltrations are best performed under direct ultrasound guidance to minimize the risk of intra- tendinous injection. There is a potential documented Achilles tendon rupture association with corticosteroid intra- substance infiltrations, due to the catabolic effects of the corticosteroids themselves or the associated pressure necrosis with intra- substance infiltration into an already degenerate tendon. Doppler ultrasound guided sclerosing agent (polidocanol) infiltrations have been shown in some studies to be an effective treatment modality and are presently used in some centres. The agent is infiltrated under guidance, directly into the areas where neo- vascularization is present (at the tendon surface interface to avoid intra- substance pressure necrosis). Glucose, lidocaine, phenol, normal saline, glycerine or Traumeel (a homeopathic preparation) have all been used as forms of prolotherapy or proliferation therapy. The infiltrated substance acts as a local irritant to stimulate intra- substance change. Autologous blood, platelet rich plasma (PRP) or isolated growth factors (platelet derived growth factor (PDGF), transforming growth factor- beta (TGF- B), insulin- like growth factor (IGF), vascular endothelial growth factor (VEGF) and fibroblast growth factor 2 (FGF- 2)) have all been tried in some form as intra- substance infiltrations. Their therapeutic application (type, volume and timing of infiltration post- injury; single or multiple infiltrations) and efficacy for specific musculoskeletal injuries are still being debated. PRP preparations were previously prohibited for competitive athletes under the World Anti- Doping Authority (WADA) code January, However, despite the presence of some growth factors, platelet- derived preparations were removed from the List as current studies on PRP do not demonstrate any potential for performance enhancement beyond a potential therapeutic effect ( ama.org/en/world- Anti- Doping- Program/Sports- and- Anti- Doping- Organizations/International- Standards/Prohibited- List/QA- on Prohibited- List/). The risks and benefits of all these intra- substance infiltrations need to be questioned before their use. The side- effect profile is low, with post- infiltration discomfort being most likely. Open or minimally invasive surgical procedures (FAST technique fasciotomy and surgical tenotomy for failed conservative management may include: tendon debridement (longitudinal intra- substance with or without curettage of degenerative areas and use of PRP); tendon surface and paratenon debridement only. Surgical excision of a Haglund s deformity or bursal resection will be performed if indicated.

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