ACHILLES TENDINOPATHY PART 2 – MANAGEMENT OF ACHILLES TENDINOPATHY

BY NAMITA ACHARYA, ROYCE CHAN, TOM CRISP, NAT PADHIAR, ET AL*

INTRODUCTION The management of Achilles tendinopathy is currently undergoing significant review. The condition is degenerative and difficult to treat. Recently, however, with improved understanding of its pathophysiology and increased availability of accurate imaging modalities, a number of new treatment options have been developed, each demonstrating some degree of success. These are predominately conservative measures that include eccentric exercises, sclerosant injections, high-volume image-guided injections, extracorporeal shockwave therapy, and ultrasound therapy, and application of topical glyceryl trinitrate patches. However, the scientific evidence

underlying some of these newly developed treatments is modest. The ability to compare the studies about them is difficult because of variability in the imaging of Achilles tendons and interpretation of those images. This relates particularly to the recent findings of neovascularisation in symptomatic tendons (1), especially as there is currently no standard system for grading the degree of neovascularisation. Furthermore, there are variations in the outcome measures used to assess changes in clinical function after an intervention. Many

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This is the second of two reviews about the degenerative condition, Achilles tendinopathy. The first appeared in the July issue and explored its pathology and investigation, but this part focuses on the management of this complex disorder. There are particular difficulties in the treatment of Achilles tendinopathy, which all practitioners should be aware of, and the results of new research on the underlying pathology have an impact on the approach both to imaging and treatment. The best clinical approach is often conservative, and there are many targeted options, which this review emphasises, as well as the surgical approach for recalcitrant cases.

BOX 1: TREATMENT OPTIONS FOR ACHILLES TENDINOPATHY

CONSERVATIVE n Autologous

blood injections

n Eccentric exercise programme

n Extracorporeal

shockwave therapy n Glyceryl trinitrate patches

SURGERY n Minimally invasive stripping

n Cryotherapy n Dry needling

n Electrocoagulation n High-volume image- guided injections n Laser therapy

n Sclerosant injections n Open tenotomy n Percutaneous tenotomy

studies do not use validated measures specific for Achilles tendinopathy, such as the Victorian Institute of Sports Assessment–Achilles (VISA–A) questionnaire (2). Heterogeneity within the populations studied and variations in their methodologies also limit the

ability to compare the efficacy of available treatments.

CONSERVATIVE TREATMENT Eccentric exercises Eccentric exercises are currently the most commonly used intervention in the treatment of Achilles tendinopathy. These exercises actively lengthen the muscle–tendon unit, with the aim of obliterating any neovascularisation and thus reduce pain. Eccentric exercises have been used for around 30 years and are effective for treating the symptoms of 60–90% of patients. They produce significant positive results when compared to control groups in randomised controlled trials (3,4). Eccentric exercises have been

shown to be most effective when the Alfredson protocol is used (5). This comprises three sets of fifteen

sportEX medicine 2010;46(Oct):6-10