Achilles Tendinopathy 【Study Note】

Achilles Tendinopathyのコンディションマニュアル
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参考ブログ・動画

Evidence Based Guide to Achilles Tendinopathy for Physical Therapists | Treatment | FPF Show E:37

https://fitnesspainfree.com/2022/06/evidence-based-guide-to-achilles-tendinopathy-for-physical-therapists-assessment-and-treatment-fpf-show-episode-37/

Introduction

• The episode covers an evidence-based guide to Achilles tendinopathy for physical therapists, focusing on assessment and treatment.

• Host: Dan Pope, a physical therapist, coach, personal trainer, and fitness enthusiast.

Definition of Tendinopathy

• Tendinopathy is not primarily an inflammatory condition; it's a degenerative condition characterized by pain and loss of function related to mechanical loading. (The term - TENDINOPATHY was defined at ICON 2019 International Scientific Tendinopathy Symposium) Some pro-inflammatory cytokines - but not the major cause of pain

• Patients and GPs still use a term "tendinitis". Sometimes we need to talk in their language. But educate them progressively. (My idea)

• Prevalence

  • Rotator Cuff tendinopathy 5.5%

  • Gluteal Tendinopathy 4.2%

  • Achilles Tendinopathy 2.4% (~20% are symptomatic, 80% are asymp)

  • Achilles tendinopathy is common in both athletes and non-athletes.

    • 52% lifetime incidence in runners.

Anatomy of Achilles Tendinopathy

• Key structures involved: gastrocnemius and soleus muscles, Achilles tendon (mid-portion and insertional), and calcaneus (heel bone).

• Tendinopathy involves changes in the tendon’s microstructure, such as disorganized collagen fibers and increased microvasculature.

• 2 Categories

  • Mid-portion achilles tendinopathy 2-7cm from insertion

  • Insertional 0-2cm from insertion

• Tendon structure

  • Normal - highly arranged, collagen fibres with sparse cells (mostly tenocytes) aligned along the lengthe of collagen fibre

    • Metaphor - un-cooked spaghetti in a box

  • Tendinopathic - Fragmented collaged fibres, disorganised, accumulation of glycosaminoglycans

  • Increased microvacculature and neoinnervation (new blood vessels and new nerves formation) —> higher sensitivity to pain

Prevalence and Risk Factors

• Risk factors: quinolone antibiotics, weak plantar flexion strength, training in cold weather, and abnormal gait patterns.

• Unclear / Mixed evidence for foot shape (stiff, flexible, pron) as a risk factor.

Prevention

• Nothing has strong scientific evidence on achilles tendinopathy prevention

  • Stronger plantar flexion does not lower the risk

• Gradual increase in load on the Achilles and calf muscle strengthening.

• Wearing warm clothes during cold weather may help, although research is limited.

• Tailor strengthening programs to the type of sport.

  • Runner vs Soccer - Runners linear, same speed. Foot ball players require to rehab in different speed, changing in directions, deceleration, jump

Diagnosis

• No gold standard for diagnosing AT

• Diagnosis involves assessing localized pain in the Achilles, pain with increased loading, pain on palpation, and potential tendon thickening.

• Imaging (ultrasound preferred) used when diagnosis is uncertain or symptoms progress abnormally.

• Mid-portion tendinopathy shows thickening, altered echogenicity on ultrasound, and altered signal intensity on MRI.

• Imaging usually not necessary - can get success without a scan in most cases

• Differential Diagnosis

  • Enthesitis - Rheumatic disease, psoriatic disease. --> refer out

  • Tendon Xanthoma - Family Hx of high cholesterol/ cardiovascular disease at a young age, LDL values --> refer out

  • No progression --> refer out

Treatment

• Active treatments are superior to a "wait and see" approach.

• Education is critical: explaining the condition, prognosis (12wks/ pain reduction but often residual pain), addressing psychosocial factors, and pain education.

• Progressive loading programs involving isometrics, heavy slow loads, and eventually plyometrics.

• No differences between different types of calf training (eccentrics, isometrics, heavy slow)

• Differentiate between mid-portion and insertional tendinopathy.

  • Insertional - start heel raises on a flat surface

• Sport can be continued under 5/10 in pain scale

Additional Treatments

• If conservative treatment fails:

  • shockwave therapy (at least three sessions)

  • PRP injections  - no side effects, painful, costly

• Other treatments with mixed evidence: night splints, inlays, collagen supplements, ultrasound, friction massages, laser, and light therapy.

Treatments to AVOID

• NSAID - interfere with pain monitoring, gastrointestinal complications

• cortisone injection - not effective, weakens tissue, increases risk of rupture

• Surgery as a last resort after 6-12 months of no progress with conservative treatment. No scientific evidence to support.

  • Mid-portion - Debridement of pathological tendon

  • Insertional - Excision of retrocalcaneal bursa/ Haglung deformity (abnormal bony growth of insertion)

Prognosis

• 12 weeks - manual therapy + progressive rehab

• Majority of patients recover over time, but symptoms may persist long-term.

• Up to 23-37% of patients have persistent symptoms at the 10-year mark.

• Most athletes return to sport, but long-term performance levels are unclear.

• Age, BMI, gender, duration of symptoms, presence of ultrasound abnormalities - do not affect prognosis

• No identified prognostic factors for long-term outcomes.

Recurrence

• Returning to sport too quickly (e.g., within 10 days) increases the risk of recurrence.

• Strengthening programs for the Achilles may help prevent recurrence, but research is lacking.

Conclusion

• Patients need education on the realistic expectations of recovery. - 12 wks + not complete pain elimination

• Rehabilitation should be progressive, sport-specific, and account for individual patient needs. 

• Encourage continued exercise and gradual loading to improve prognosis.