DIAGNOSIS

mobility and decreasing the strain of the Achilles tendon with nor- mal motion. Eccentric training is superior to concentric training in decreasing pain in chronic Achilles tendinopathy, and promising results have been obtained using an intensive heavy-load eccen- tric muscle training regimen (18). If there is a foot alignment problem, orthoses that place the hindfoot in neutral may prove beneficial. A heel lift of 12-15 mm is classically used as an adjunct to the management of Achilles tendon pain. Orthotic correction can alter the biomechanics of the foot and ankle and relieve heel pain. In runners, orthotics have demonstrated up to 75% success (19).

Several drugs, such as low dose heparin, wydase and aprotinin, have been used in the management of peri- and intra-tendinous pathology. Although widely used and promising, evidence of their long term effectiveness is still unclear. Peritendinous injections with corticosteroids are still controversial, evidence for their effec- tiveness is missing, and there are no good scientific reasons to support their use. In 24-45.5% of patients with Achilles tendinopathy, conservative management is unsuccessful, and surgery is recommended after exhausting conservative methods of management, often tried for at least six months (12). However, long-standing Achilles tendinopathy is associated with poor post- operative results, with a greater rate of re-operation before reach- ing an acceptable outcome.

The objective of surgery is to excise fibrotic adhesions, remove degenerate nodules and make multiple longitudinal incisions in the tendon to detect intratendinous lesions and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. Recent investigations show that mul- tiple longitudinal tenotomies trigger neoangiogenesis at the Achilles tendon, with increased blood flow (20). This would result in improved nutrition and a more favourable environment for heal- ing. Patients are encouraged to weight bear as soon as possible after surgery.

Most authors report excellent or good results in up to 85% of cases, although this is not always observed in routine non-spe- cialised clinical practice. It is difficult to compare the results of studies as most do not report their assessment procedure. Also, no prospective randomised studies comparing operative and conserv-

12

ative treatment of Achilles tendinopathy have been published, thus most of our knowledge on treatment efficacy is based on clin- ical experience and descriptive studies.

CONCLUSIONS Although Achilles tendinopathy has been extensively studied, there is a clear lack of properly conducted scientific research to clarify its aetiology, pathology and optimal management. Most patients respond to conservative measures if the condition is recognised early, while continuing the offending activities leads to chronic changes which are more resistant to non-operative man- agement. Teaching patients to control the symptoms may be more beneficial than leading them to believe that Achilles tendinopathy is fully curable. Surgery usually involves removal of adhesions and degenerate areas, and decompression of the tendon by tenotomy or measures influencing the local circulation. It is still debatable why tendinopathic tendons respond to surgery. For example, we do not know whether surgery induces ordered re-vascularisation, denervation or both, resulting in pain reduction. It is also unclear how longitudinal tenotomy improves vascularisation. As the biolo- gy of tendinopathy is being clarified, more effective management regimens may come to light, improving the success rate of both conservative and operative management.

THE AUTHORS Prof Nicola Maffulli MD, MS, PhD, FRCS (Orth), Professor of Trauma and Orthopaedic Surgery, Department of Trauma and Orthopaedics, Keele University School of Medicine, Stoke-on-Trent, United Kingdom.

Mr Pankaj Sharma MRCS is a specialist registrar in trauma and orthopaedic surgery, Severn and Wessex Deanery, Highcroft, Romsey Road, Winchester, SO22 5DH, United Kingdom.

References 1. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. Journal of Bone and Joint Surgery (British version) 1989;71(1):100-101 2. Kirkendall DT, Garrett WE. Function and biomechanics of tendons. Scandinavian Journal of Medicine and Science in Sports 1997;7(2):62- 66 3. Shadwick RE. Elastic energy storage in tendons: mechanical differences related to function and age. Journal of Applied Physiology 1990;68(3):1033-1040 4. James SL, Bates BT, Osternig LR. Injuries to runners. American Journal

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