Chronic Achilles Tendinopathy



Chronic Achilles Tendinopathy

Introduction

Achilles tendinopathy is a combined presentation of pain and swelling in and around the Achilles tendon leading to impaired performance. We will discuss the biomechanics causative of Achilles tendinopathy, and the physiological processes occuring within the pathological tendon itself. We will then design a podiatry-based rehabilitation programme for a patient.

The Achilles tendon is the tendinous extension of the soleus and the gastrocnemius, inserting into the superior part of the tuber calcanei in the calcaneus bone. It is the thickest tendon in humans, and with normal biomechanics bears up to 3.9 times body weight while walking and 7.7 times while running (Giddings, Beaupré, Whalen, & Carter, 2000).

Given the difference in stress levels on the tendon between walking and running, it is not surprising that most cases of Achilles tendinopathy occur in athletes who engage in middle to long distance running. Intrinsic factors for tendinopathy include poor biomechanics such as limb malalignments and hyperpronation, while extrinsic factors include form, posture, footwear, and environmental conditions (Maffuli & Almekinders, 2007).

Two thirds of athletes with Achilles tendinopathies also have malalignments, while morphological changes are rarely present in asymptomatic Achilles tendons in active young adults (Joseph, Anderson, Trojian, & Crowley, 2012). Excessive movement of the hindfoot in the frontal plane, especially a lateral heel strike with excessive compensatory pronation, is thought to cause a "whipping action" on the Achilles tendon, predisposing it to tendinopathy". hyperpronation leads to excessive movement, and the whipping action leads to high compressive forces on the tendon.

Achilles tendinopathy most frequently occurs in the mid-portion of the tendon, as opposed to the site of insertion (Lawrence, 2012). Achilles tendinopathy is degenerative and may eventually result in tendon rupture (Joseph, et al., 2012). Thus, it is imperative to treat early.

Shock wave therapy for Achilles tendinopathy

Often medical attention will not be initiated until athletes have attempted to “run through” the pain but have had to stop or severely modify sports activities. Initial treatment of Achilles peritendinitis and tendinosis always is conservative and focuses on control of pain and inflammation, correction of functional malalignment, and rehabilitation of the gastrocnemius-soleus muscle-tendon complex(Alfredson, 2010). In athletes who present within 1-2 weeks of the onset of symptoms, a short course (7-10 days) of oral, nonsteroidal anti-inflammatory medications and 2 weeks of rest usually will allow them to return to running, symptom free. n addition, they should be counseled about the extrinsic factors (e.g., errors in training) that may have caused their problem and about prophylactic measures (proper shoes, stretching) that can prevent Achilles tendonitis. Table 1 outlines a common conservative treatment regimen. Immobilization of the ankle for a period of 7-10 days may be indicated in individuals with severe acute symptoms.

Steroid injections, however, should be limited to the area of the retrocalcaneal bursa and should be employed only in patients with recalcitrant retrocalcaneal bursitis. There is a growing amount of evidence that steroid injections in and around the Achilles tendon may increase the risk of tendon rupture(Grigg, 2012). The most recent Cochrane review reported insufficient ...