Refractory Achilles Tendinopathy Mark R. Hutchinson MD Professor of Orthopaedics & Sports Medicine University of Illinois at Chicago
Disclosures No personal corporate support Department occasionally receives corporate support for resident research and education Editorial boards: AJSM, BJSM, MSSE, Phys & Sportsmed
Doc, my heal still hurts Despite Rest Home stretching Home massage Ice OTC NSAIDS Prescription NSAIDS Topical NSAIDS Taping 4 weeks in a boot
Natural History At 5 years 80% improved with conservative tx, OTC medications, and home exercises 24-47% go on to sx Silbernagel KG, Brorsson A, Lundberg M. AJSM (2011) Kader D, Saxena A, Movin T. BJSM (2002) Paavola et al. AJSM (2000)
Clinical Predictors Poor prognosis Palpable nodules Hx of prior rupture Hx of oral quinalone use Hx of steroid injections Chronicity Bony deformity (pump bump) Insertional worse than midsubstance
176 tendons MRI as a predictor 53% NonOp, 47% Op MR classified by tendon size & involvement 12.5% of Type 1 need sx 90.8% if Type 2 need sx 70.4% of Type 3 need sx Nicholson C, Berlet GC, Lee TH. Foot & Ankle International April 2007 vol. 28 no. 4 472-477
Evidenced Based Treatment Options Yes No Maybe
Customized Foot Orthoses? Yes No Maybe
Customized Foot Orthoses Effectiveness of customized foot orthoses for Achilles Tendinopathy: A RCT Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook J, Hylton B, Menz B. BJSM 2015 EBM Level II
Topical Glyceryl TriNitrate Yes No Maybe
EBM Level I Topical Glyceryl TriNitrate Treatment (6 months) still positive effect at 3 years post treatment when compared to placebo. (Pro/RCT) Paaloni JA, Murrell GAC. Foot & Ankle International October 2007
Manual Tx Techniques Yes ART, Graston, ASTYM, Cupping No Maybe
Manual Therapy Techniques ART, Graston, ASTYM, Cupping Increased cross-sectional area Better microscopic quality of tendons (less type III) Better recovery of biomechanical function K, Chen Q, Zhao C, An K, Gay RE. J Manipulative Physiologic Therapeutics, 2015 Miners AL, Bougie TL. J Canadian Chiro, 2011. EBM Level IV
Eccentric Training Yes No Maybe
Eccentric Training Eccentric programs are effective at short & long term (5 yr) follow up. Lorenz D. J Strength Cond Res. 2010; 32(2): 90 98. A, de Jonge S, de Vos RJ, van der Heide HJL, Verhaar JAN, Weir A, Tol JL. Br J Sports Med 2012 EBM Level 1 & II
Night Splints Yes No Maybe
Night splints NO additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy (RCT). devos RJ, Weir A, Visser RJA, DeWinter THC, Tol JL. Br J Sports Med 2007 EBM Level II
Dry Needling Yes No Maybe
Dry Needling Immediate increase local RBC saturation & oxygenation by red light laser Systematic lit review: 20% Achilles improve 50% tennis elbow improve Krey D, Borchers J, McCamey K. The Physician & Sportsmedicine, 2015. Kubo, K., Yajima, H., Takayama, M. et al. Eur J Appl Physiol 2010 EBM Level IV
Yes Injectable Agents Prolo, RBC, PRP, Mesenchymal cells No Maybe
Injectable Agents Prolo, RBC, PRP, Mesenchymal cells Less promising with prolo (EBM III) No additional benefit of RBC + eccentric compared to needling + eccentric (EBM Level I) Maayke N. van Sterkenburg, Milko C. de Jonge, Inger N. Sierevelt, C. Niek van Dijk. AJSM 2010 Bell KJ, Fulcher ML, Rowlands DS, Kerse N. BMJ 2013
Yes Injectable Agents Prolo, RBC, PRP, Mesenchymal cells No Maybe
Injectable Agents Prolo, RBC, PRP, Mesenchymal cells Improved VISA scores, decreased hypoechoic areas at 6 months (EBM level II) Beneficial at 3-6 mos, may decrease over time (EBM 1) Metanalysis (EBM level III) supportive of PRP Ferrero, G., et al. J Ultrasound 2012 Dragoo JL, Wasterlain AS, Braun HJ, Nead KT., AJSM 2014 Fitzpatrick J, Bulsara M, Zheng MH. AJSM. 2016
Injectable Agents Prolo, RBC, PRP, Mesenchymal cells No difference at 1 yr (EBM I) Cochrane: low support for athletes, low support at long term, complication if simultaneous steroid (EBM III) De Jonge S et al. AJSM 2011 Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Cochrane Database Syst Rev. 2014 Kearney RS1, Parsons N, Metcalfe D, Costa ML. Cochrane Database Syst Rev. 2015
Radiofrequency Coblation Yes No Maybe
Radiofrequency Coblation 90% patient satisfaction at 6 months 15/17 complete pain relief VAS 8.7 to 1.6 Nirschl pain scores improved p<0.0001 No complications Yeap EJ, Chong KW, Yep W, Rikhraj IS. J Orhop Sx 1999 Liu YJ et al. Chinese J Sx, 2008 Sarimo J, Orava S. Scand J Sx, 2011 EBM level IV (case series)
Surgical Debridement Yes No Maybe
Surgical debridement 91% excellent / 9% good outcomes in elite track and field athletes tx with retrocalcaneal exostectomy, peri-tenolysis, mucoid degeneration debridement. Saxena A. Foot & Ankle International 2003. EBM IV
Sx debridement / repair 35 patients with insertional tendinopathy tx with takedown, debridement, and suture bridge repair 97% satisfaction, 1 revision to FHL transfer Greenhagan RM et al. Foot & Ankle Specialist, 2015 EBM Level IV retro case review
Debridement + Augmentation Decreased pain, improved heal rise, increased functional scores in non athletes (EBM IV) Slight increased strength with augmentation (EBM I) but not necessary in all! Schon LC et al JBJS Am, 2013 Hunt KJ et al Foot & Ankle International 2015
My EBM approach Good exam/imaging 1 st non-op Eccentric training OTC heal lift but not custom orthotic Rx PT to include manual tx +/- dry needling PRP > Prolo or RBC if resistant Rarely use Nitroglycerin or Radiofreq but OK to try 2 nd line surgery (failed 4-6 months) Location & involvement guides approach
Thank you